This week saw the release of an interesting study Click Here for Lancet Journal which provided clinical evidence that all the major commercial antidepressants outperformed patients who were treated with a dummy dose known as a placebo. The researchers collected their data from multiple studies that used the gold standard of clinical research of randomised controlled trials. These type of experiments use control and treatment groups to provide evidence that the treatment group are being directly affected by the drug under investigation, and attempt to eliminate any biases that could influence results. The published review showed that all the 21 drugs they examined had positive effects on alleviating the symptoms of major depressive disorder. They showed that the drugs varied in their effectiveness but the graph below illustrates the most commonly prescribed drugs. Anything to the right of 1 is positive result and shows between 50% to over 100% improvements over non-treatment.
What contributes to the depression?
I see many men who are diagnosed with depression and they often complain of feeling disinterested, exhausted, trapped, avoiding social relationships, unpredictable in mood, angry and full of anxiety. Chronic cases can be crippling and can effectively leave sufferers housebound, isolated, prone to self medicate with alcohol or drugs, destructive within relationships and work life, and can eventually lead to attempting suicide. My feelings are that depression is a psychic reaction to feeling trapped within your life. This can be literally within an unfulfilling career, relationship (or lack of one), or by unresolvable financial problems. It may also be more abstract with feelings of being constrained by thoughts of failure, lack of self-worth, or one that I often see in men is the loss of tangible identity and a lack of purpose within life. The quote below is one man’s sentiment of how he struggles;
My biggest difficulty about being a man is that I often do not know my purpose or feel that I am not making a success of myself.
I also believe that the myth of the perfect social media life is a huge problem for many men. Endless celebrities and entrepreneurs are shown as physical adonises, wealthy playboys and all round happy successes, who do jobs they love for vast sums of money, all whilst they flex their chiselled torso. This creates an unrealistic expectations of oneself as when compared to the reality of being an average employee, partner or parent, we will often fall short of an unattainable ideal. This causes perception of our own lives to be downgraded and for us to feel somehow substandard and lazy for not achieving more or looking better.
Men have explained in the treatment room that this existential unfulfillment is difficult to fully comprehend and can occur when one has embarked on a career and family life, and something just suddenly feels missing. At this stage men will sometimes became obsessed with outside interests such as fitness, social clubs/pubs or online worlds, they can also be vulnerable to temptation of extra marital affairs. Men will often say that they feel unloved, unnecessary and invisible, as they work long hours and feel excluded from their families, as partners and children function with little input from themselves. It can be tempting to have the fun and excitement of a new romantic liaison, the result often being a wounding to the relationship that can leave men guilt ridden and shamed, and the relationship to potentially fail.
This man has consented to his views of his mental health challenges being shared, this highlights the pressure of just trying to be functional for others;
Even if people don’t say or think that we should just get on with it, I still feel that it is expected. When my brain just cannot process everything expected of my role as father, husband, and employee, no one will spend time to walk alongside; they just want to say some ‘magic words’ and me to leave them ‘fixed’ in order to meet their needs.
I have never felt so alone, despite family and colleagues trying to help.
Off to an NHS mindfulness course now; let’s see if that helps unlike everything else.
Should I take Medication?
This accompanying piece in the Guardian The Guardian Online Article suggests that more than a million people in the UK should have access to antidepressants. This is on top of around the 11 million regular prescriptions already dispensed. Men often ask me if they should go on medication and I always advise to talk to their GP, but we will discuss the process of using antidepressants.
My thoughts are that medication can be helpful, especially when used alongside talking therapy. My main problem is that although drugs can alleviate the feelings of despair and hopelessness, allow better functioning and an opportunity to see things differently, they cannot fix all our real world problems. They allow us to be more proactive in changing parts of their lives they are unhappy about. However, without additional support and introspection, making meaningful change can be difficult, especially around careers or relationships. Men can feel stuck as they have to earn a wage and have responsibilities which they feel force them to stay in roles they do not like. Likewise, the reality of leaving the family home is often impossible, as few people are financially secure enough to afford to find a home by themselves. The resulting separation can often be acrimonious and fears of not seeing children all adds to the depressive environment of having no choices. My experience is that these type of difficult problems are not simply resolved through just taking pills.
Another common fear is whether I will be medicated forever and how will life be when I am not taking the pills? This can be difficult, but working with a good GP should allow a treatment plan that allows for a safe withdrawal process when symptoms alleviate. In some respects we see the paradox of change we discussed earlier, as unless someone has made significant changes then it is likely the depression may reappear after the treatment ends, my main argument for accompanying therapy with medication. Something that also often prevents ending medication is both the psychological reliance that I cannot cope without the pills, and the effects of withdrawal. Even when managed well and clinically weaned off the drugs, withdrawal can last for weeks and often mimics depressive symptoms, making the patient panic and resume treatment.
The final issue that many men complain of is the side effects. Reading the information leaflet that comes with medication can easily induce terror, as side effects can be physical symptoms such as cramps, yawning and nausea, or further mental health issues such as paranoia and anxiety. Many men often suffer libido loss and erection problems, especially on popular SSRI (Selective Serotonin Reuptake Inhibitors) such as Citalopram and Sertraline. This can impact the very essence of masculinity and heighten feelings of being a failure who is unable to perform. I have had couples who have reported that they ceased sex after taking medication, leading struggling relationships to have further losses of intimacy and causing partners to blame themselves or each other for why they cannot have intercourse. Another paradox, as even though the medication can elevate mood, the crumbling relationship can counteract this effect and cause relapse as marital tension rises.
This man generously allowed me to share his journey which demonstrates the complex nature of his own relationship with his mental health and treatment. I feel this shows how hard work, medication and support can help combat depression, but also shows that we can often be taken unexpectedly by our illness…
I certainly feel things have improved socially since I was first diagnosed with ‘nervousness & depression’ in the late 70s. [generalised anxiety disorder – as it later became known] Attitudes are more sympathetic and people less likely to judge or discriminate against you these days. It’s easier to find and get help.
However, on the inside I still see my condition as a failure, as a weakness. My partner is incredibly supportive and understanding but in spite of her help and love I’m especially hard on myself. Despite and the rational arguments and evidence to the contrary I still feel the need to be masculine, strong and silent. The brave protector and stoic provider for my family. Not the dark, uneasy, tormented shell I currently am.
At 53 I am able to look back on over 30 years of this behaviour pattern, something which in itself I find particularly upsetting. I often fear that if I’ve 30 years of this to look back on, I’ve therefore another 30 years of mental health issues to look forward to.
I’ve always found these winter months especially difficult and this year is no different. I know it’ll pass and I have a great many tools and techniques picked up over years of therapy and learning which help me function on a day to day basis. But still, here I am …again.
I am pleased to see that medication has been shown to be effective and can be a lifesaver for those who cannot cope with what life throws at them. However, I am not sure if a nation of people taking psychopharmaceuticals for the rest of their lives is a measure of public health progress. I think that there needs to be more done to treat the causes of why so many of us feel depressed, rather than just fixing our symptions by changing out brain chemistry temporarily. I have some thoughts and may share them in my next blog.
Thank you to the men who allowed their voices to be used in this article.