Shoot the Damn Dog: A Memoir of Depression

by Sally Brampton

  Far from being a panacea, psychopharmacology is a ludicrously inexact science. Its reputation as a modern miracle is based on the thirty per cent for whom antidepressants effect an almost magical cure of near remission. For the next thirty to forty per cent of people suffering from depression, it is touch and go. They may need to try two or three or even four antidepressants to discover the one that works for them. Then, for the last thirty per cent, for people like me, antidepressants have no effect at all.

  ‘Why,’ I asked my psychiatrist, ‘don’t you tell us that?’

  He shrugged. ‘Because I am in the business of bringing hope to my patients.’

  I applaud his sentiment, but I also know that there is nothing more hopeless than the depressive who believes they are beyond all help and who does not know or understand why.

  When I first became depressed, all my trust was in modern medicine. Like most people, I believed the myth of happy pills. You get depression, you take drugs, you get better.

  When that remedy failed, I thought, in some obscure way, that it was my fault—that it was me who was failing modern medicine and not the other way around.

  Sadly, I am not alone in this. According to research published by the Clinical Neuroscience Research Centre in Dartford:

  Around 5 million people in the UK experience depression at any one time. Whilst many people make a full recovery about thirty to forty per cent are resistant to conventional therapies. For them their depression is an enduring, debilitating disease and for some, the only treatment options left include psychosurgery and ECT.

  I recall a day in my psychiatrist’s office. I am slumped on the sofa, shaking and crying. My psychiatrist’s expression is severe. More than that, he seems uneasy. The prognosis, he says, is bad. I have been severely depressed for an unusually long time, around eighteen months, which is long enough for my condition to be regarded as ‘chronic’.

  He suggests that we try ECT (Electro Convulsive Therapy) but I saw a friend I made in the first psychiatric unit I was in suffer its consequences with apparently little benefit. Her memory, she complained, was shot to pieces. I am set against it, and say so. I want my memories, good and bad. He frowns, a tiny jolt of impatience framing his eyes. He is a scientist. He wants to make me well, not whole. At least, that is my interpretation and I wonder, for a moment, what the whole of me is. If depression is a part of me, perhaps I must simply accept it as it is. Except that I know that I cannot go on like this. He knows it too. He is trying to help.

  ‘How does ECT work?’ I ask.

  ‘We don’t know. We just know that, usually, it does and that the memory loss, usually, is short term and short-lived.’

  I sigh. There are far too many ‘usually’s in his sentence. ‘But there are no guarantees?’

  ‘No,’ he says, avoiding my gaze.

  Then he tells me a story, about being on a train journey with a friend with whom he attended medical school. The friend is a heart surgeon. My psychiatrist is trying to explain his work, and some of the difficulties he daily encounters. I suspect that I am one of those difficulties. After a while, his friend the heart surgeon exclaims, ‘It must be like being in an operating theatre, preparing to make the first incision and somebody shouts, “No, make the cut over here.” Then another calls, “No, over here.” Then a third voice joins in, “Over here!”

  ‘In cases like this,’ my psychiatrist says, ‘it is trial and error.’

  I am a case. I am a trial. And I am an error.

  ‘Poor you,’ I say, when what I really mean is, poor me.

  There is, he says, another treatment for the chronic, a lobotomy. Not the ancient hacksaw version of Hollywood myth but a modern refinement, involving needle-fine wires. These days it goes by the more reassuring title of psychosurgery. But the success rate, among the chronic, is only twenty per cent.

  I say nothing. I think he must be joking. I hope he is joking even though I can see that he is not. We return to the subject of my medication. So far we have tried five different varieties and two combinations of others. I feel like I am in a sweet shop. Let’s try some of the blue ones. No good? Well, how about some blue with some pink? Or how about a few of the yellow?

  My psychiatrist, in a desperate attempt to break the pattern of resistance, loads me with more and more drugs. He is nothing, if not an optimist. I think that all psychiatrists must be optimists. They could not stay in their profession if they were not.

  At one time, I am taking the top dose of the SSRI antidepressant Venlafaxine which is often given to treatment-resistant patients. On top of that I take 1,000 mgs of lithium daily. Lithium is usually prescribed for bipolar depression (manic depression) from which I do not suffer. The reason I am taking it is because a body of research from the States suggests that loading lithium on top of a mega dose of an SSRI might, in some cases, break the resistance.

  It does nothing for me, other than make me so physically ill I think I might die. I shake so badly I can scarcely stand. My mouth is filled with a sour taste so repulsive I cannot eat. Even water tastes foul. The depression does not shift.

  I am sicker than ever and it is two years since I took my first antidepressant, prescribed by my GP. She stuck a pin in a book. ‘Let’s try this one,’ she said. Ten months later, I was hospitalised with severe clinical depression. In the hospital, the doctor took one look at the level of antidepressant I was taking and laughed out loud.

  It was not my GP’s fault. She was doing, in a limited time and with a limited knowledge of the new drugs that constantly appear on the market, the best that she could. The hard-pressed GP will be confronted with one new case of depression at every surgery session. One in every three people attending a GP’s surgery has significant psychological symptoms. Even so, our understanding of major depressive disorder is so limited that only sixty per cent of those presenting with it will be detected and only ten per cent of those diagnosed are referred on to specialist services.

  It is not that science is failing us. It is simply that the solution is as complex and multifaceted as the illness itself. For every theory of its causes, there is another to contradict it; for every new treatment, there is another that dismisses it as ineffective. This is not deliberate obstruction. Depressive illness, as well as being complex, is highly individual. What works for one person does not work for another. And often there is no explanation why this is so. Scientists do not know why one method or drug might work, where another does not. They know that, for some people, SSRI antidepressants work, but they have no real idea how. Or what the long-term effects might be.

  But there is hope. It is just that we need to look further for it than in a handful of pills. We need to see depression holistically, as an illness of mind, body and soul (I hesitate to use that word but I can think of no other) and treat it accordingly.

  John F. Greden, MD, the Rachel Upjohn Professor of Psychiatry and Clinical Neuroscience in the University of Michigan Medical School calls depression the ‘under’ disease—as in underdiagnosed, undertreated and underdiscussed. As for its treatment, he is on record as saying,

  If by ‘cure,’ you mean totally eliminating the condition for ever, I would suggest that’s not the way we should think about it. Indeed, it is probably inaccurate for most. If you’re asking, can you bring people with depression to a state of remission, well-being and normal functioning, and can they remain there, then the answer is a resounding yes.

  I believe that, just as I believe that there is no one theory or therapy or drug that can make you, or me, better. Or keep us better. There is no simple cure or magic remedy and there are no happy pills, much as we would like to believe in them. And we do like to believe. I have lost count of the number of people who have said to me, as if it is both an admission of defeat and the end to all their problems, ‘I suppose I had better go on antidepressants.’

  Well, why not? If they work, then wonderful. Every weapon in the fight against depression is worth considering and there may come a day when a d
aily pill is all that’s needed. Until then, for those like me who find that antidepressants are of little or no help there is a different path.

  It is not easy, but it is possible. It embraces the various talking therapies and the daily disciplines of walking, yoga and meditation. It uses love and trust and faith—not purely spiritual faith, but faith in life itself. It requires acceptance, humility and a willingness to be open as well as constant self-examination and lacerating honesty. Those are all the tools that I have used to get better and I know that they work. Not just on me but on the others who use them too. Even those who find that antidepressants are an answer to their prayers may find some of the methods in this book useful.

  The relapse rate for depressives relying on medication alone is eighty per cent. Nobody knows quite why. Some schools of thought believe that the brain becomes habituated to a particular drug, which then loses its efficacy. Still others believe that the illness mutates or that it is not a singular illness but a cluster of conditions that, at any one time, need different treatments. The illness, like the cure, remains a mystery. When I said to my psychiatrist that it seemed to me that we were no further along than bedlam and leeches, he said that at least we knew what leeches did.

  It was that, more than anything, which brought me to the writing of this book. I may have, as the scientists put it, ‘an enduring, debilitating disease’ but I prefer to think of it as an illness that never entirely leaves us but can, with full knowledge and attention, be managed with some degree of grace.

  Nigel got his test results back and they were OK. His liver is fragile after many years on a great deal of medication. He still swears by it to control the depression he has suffered since he was in his teens. I don’t, but anything that keeps him away from those sharp corners is fine by me too.

  Throat Monsters and Other Terrors

  Where am I? Who am I? How did I come to be here? What is this thing called the world? How did I come into the world? Why was I not consulted? And If I am compelled to take part in it, where is the director? I want to see him.

  Søren Kierkegaard

  I am walking down the corridor in my flat. The monster is at my throat, claw stuck fast. I cannot eat. I can scarcely breathe. It is ten months since I was diagnosed with severe clinical depression, months without beginning or end. Time moves like treacle, running thick and heavy through my days.

  I hate this flat. It is beautiful, a mansion flat two floors up with high ceilings and ornate fireplaces, but I know that behind the façade, the walls are running with tears. My tears. Pain has seeped into the plaster.

  The flat is laid out in two parts, with a long, narrow corridor connecting the two. At one end there is a large, light-filled sitting room and two bedrooms, Molly’s and mine. The rooms are painted cream and white, testament to an earlier time when I tried to decorate myself out of the dark.

  My bedroom is small; kept dark by the linen curtains which I made myself and which I keep shut fast against the day. The white duvet cover has scorch marks in it from the cigarettes I smoke in the dead of night when I am dragged from sleep by some unknown, unseen terror, but too dazed with sleeping pills to know what I am doing.

  At the other end of the corridor is the kitchen, and my study, where I rarely go. Sometimes I venture in to sit at my computer in front of the dead, blank screen and flick idly through my piles of books. They are dusty and sad, with a long neglected air. I never stay in there for long.

  The kitchen is huge and half finished, as if somebody has abandoned it in despair. They have. It was me. I decorated half of the flat and then I simply gave up. There are no units, just a few rudimentary cupboards; the fridge is ancient and most of the shelves in it have collapsed. The hot water tap is stuck fast. I haven’t the energy to call a plumber. I’m not sure that I even know how. Sometimes this strikes me as odd. I used to head up a staff of forty and handle a budget of millions. Now, I can’t even call a plumber so I wash up by boiling a kettle for hot water. I no longer think that’s strange. I think it’s normal. When they come to visit, I see the way my friends look at the kettle and then at me. I don’t know how to explain, so I say nothing.

  As I walk down the corridor, I keep my hands pressed to the wall because I am shaking so hard I can hardly stand. The next thing I know, I am flat on the ground, my face pressed into the carpet. I think, how did this happen? Did I stumble and fall? I have no recollection of it. It was as if some great hand took me by the throat and flung me to the ground. If I hadn’t been here, I wouldn’t have believed me. I tear at my throat, uselessly, trying to pull the monster away. I think, I will die now. There is no other way.

  Or, just one. Vodka. When the pain is this bad, I know of no better anaesthetic than vodka. No prescribed tranquilliser comes close. Believe me, in the past few months I’ve taken them all, with my psychiatrist’s blessing.

  He does not bless alcohol but then he’s not in the state I’m in. Nor, oh lucky man, has he ever been. Sometimes I think only those who have suffered severe depression should be allowed to treat those with severe depression. I am sick and tired of theory. I have put on a stone in six weeks. My body feels spongy and heavy, weirdly unfamiliar. It is as if my flesh has been pumped full of a thick viscous liquid. I complain about this to my psychiatrist.

  ‘You should not put on weight on these particular pills.’

  ‘Well, I have. And I hardly eat.’

  ‘There is no evidence to suggest that this medication affects the metabolism.’

  I say, ‘I am the evidence.’

  Just as I am the evidence that antidepressant medication does not work. Or at least, it does not appear to work on me. We have tried four different types; nothing seems able to lift this dark despair. The most recent makes me shake so badly that at times I can’t hold a cup of tea or a pen. I cannot even write my own name. It also, if that is possible, makes the throat monster worse.

  ‘It may be the illness reasserting itself,’ says my psychiatrist.

  ‘Perhaps it’s the medication,’ I suggest. ‘I think it’s poisoning me.’ I don’t show him my tongue, which is coated a deep, dark brown from all the chemicals I daily ingest.

  My psychiatrist frowns. Paranoia is a symptom of extreme depression. I hate my medication. I am never happy.

  Once the irony of that thought would have made me laugh.

  He says, ‘The shaking and the throat may be symptoms of anxiety, which often comes with depression.’

  ‘I don’t suffer from anxiety. It’s the side-effects of the medication.’

  I have been in two psychiatric units. I have seen severe anxiety disorder at first hand. I have, at least, been spared that.

  He says nothing.

  ‘This is all bollocks,’ I say.

  I am not a patient patient.

  I stumble to my feet and inch along the corridor, hands pressed fast to the wall to steady myself, and knock a framed photograph askew. I collect black and white photographs. There are Norman Parkinson’s women, serene, glacial and unaccountably chic and Andrew Macpherson’s modern girls, smiling and sexy. There is Matt Dillon, from an early photo shoot I did with him on Vogue, when he was just another handsome boy and not a famous movie star. And there is Bruce Weber, photographer, filming in Cannes.

  I love them. They are beautiful. Now, I knock past them clumsily, as if they do not matter.

  My kitchen looks peculiar, as if it is both intensely familiar yet a room I scarcely know. I scrabble in the freezer, pull out a bottle of ice-cold vodka and pour a measure into a glass. My hands are shaking badly. Some of the vodka spills on the wooden table, which I used to polish weekly, with beeswax and soft cloths. I leave the wet puddle, allow the ethanol to eat into the wood. I haven’t the energy to find a cloth.

  The vodka burns at my throat but gradually, the heat penetrates and the claw lessens its grip slightly. What time is it? A little after ten in the morning. I try to remember what ten in the morning means, how it feels. But I cannot. Time means nothing t
o me any more. I stagger back to bed, and try to sleep. Try to pass out. I don’t want sleep. I want oblivion.

  There’s a pounding in my ears. It’s muffled as if somebody has put a sack over my head. I open my eyes. My bedroom is dark, the curtains drawn to block the sun, which is shining merrily. I hate the sun. When the sun is shining, I should be happy. I should. I should.

  The darkness gathers in my head. It is black, this day. Blacker than black, heavy and suffocating. And the monster is still at my throat. Its form is that of a serpent, with a thick, muscular tail covered in scales that wraps round and around my neck, pulling tight. At its head there is no mouth or eyes, just a single bird’s talon, a black claw tipped with sharp silver. The claw sinks into the front of my throat and hangs fast. I try to reduce its horror by giving it a name, the throat monster. Various therapists suggest that I go one step further and try to befriend it. I think this is facile and ignore their suggestions. I don’t want a cute cartoon, a puppy dog living in my throat. I don’t want it to be my friend. I hate it. I want it to go away. I want drugs, to stop it. Where is modern science when I need it? Why is so little known about mental illness? What is it I am suffering from?

  Grief, said a therapist. Unexpressed grief. It’s got you by the throat.

  Don’t be absurd, I said at the time. Don’t be so fanciful.

  But when I am alone and the monster is tearing at my throat, I think that, whatever it is, it’s going to kill me.

  According to my psychiatrist, the monster is not real. He tells me this apologetically, as if I know it already. Which I do. Of course it is not real. It’s not even a monster, but a somatic manifestation of my illness, a mere, clinical symptom of major depressive disorder. The throat monster has a proper psychiatric name, he says, but not a name I’ll like. It is called Globus hystericus, a psychological term for ‘lump in the throat’ given to it by Freud. Of course, it must be Freud. Of course, it must manifest most often in women. My psychiatrist’s expression is grave. He knows that I resent that association of hysteria and women.