The enemy within

The head of the firm where I was a trainee family doctor was a lovable eccentric and mettlesome lay preacher invariably clad in a black jacket and striped trousers bequeathed to him by a grateful head waiter with cirrhosis. He told me to read Dr Watts's Depressive Disorders in the Community, adding that a medical audience once stood and applauded Dr Watts for the lonely studies in family practice that helped him describe the many masks worn by this painful and sometimes dangerous disease[1]--dangerous in that some sufferers end their lives, unable to bear the mental pain of depression.

I think of a chief surgical resident I knew. He was handsome, blond, and celery-thin with a puckish grin and a refreshing lack of self-importance. He would startle me by unexpectedly appearing and murmuring, "How super, doctor," as I performed a minor procedure like pushing a trochar trembling home or wrestling with a drip. I asked him how he maintained his cheerfulness.

"Oh, if you knew," he said. "If you only knew." Years later I read his obituary in the British Medical Journal. It ended: "He always had a cheerful exterior and even in his last days . . . showed no sign of the depression that led to his death."

I also remember a young nurse at an asylum by the sea who told me, "I'm back. I tried to commit suicide." I looked at her perfect petal face, set off by her crisp cotton cap, but was too callow to do more than say, "Now we must teach you to love yourself." It was a sentence stolen from a Reader's Digest that I barely understood back then. A paternalistic National Health Service saved her.

The NHS went the extra mile with Bill, an elegant older doctor from the Duchy of Cornwall. He had lost his marriage, his orchards, and a wealthy practice from misfortune. He hid his "malignant sadness"[2] behind a front of humorous banter, a British relish for the ridiculous, and running jokes. He sought salvation and a diploma in psychological medicine at the same asylum as I did, where several of us lived in residence. We didn't know he was depressed or that, twice a week, his psychiatrist, an anesthesiologist, and a nurse clambered up to his bedroom to give him electroconvulsive therapy.

Years later I worked at a mental health clinic with a middle-aged child psychiatrist, an Everest of erudition, who affected a faintly military attire. He was like an encyclopedia in battle dress. He was tolerant and avuncular with his small patients and happily frolicked with them on the floor, but he could be tart and taciturn with the rest of us. We did not realize he was depressed and missed several clues. One day he shot himself.

I dare say you can match these personal experiences with your own.

Recently, three young hockey players ended their lives. They were healthy, rich, and one at least had a good sense of humor and could set the table in a roar. Was he a smiling depressive? Did he laugh, like Abraham Lincoln, to stop himself from crying? Was his the gallows humor beloved of Henry VIII, Stalin, and many depressives? A fatal illness was missed in three men who were not waving but drowning. They may not even have realized they were ill; insight goes fast in depression. Every day a doctor commits suicide in North America. They all knew that depression is treatable.

Depressive illness and a risk of suicide are easy to miss. The sufferer, invariably weighed down by shame and inappropriate guilt, often spurns enquiries and attempts to befriend and assist. However, at least in the office, two questions may unlock the diagnosis: in the past month have you been bothered by little interest and pleasure in doing things, and in the past month have you been feeling down, depressed, or hopeless? If the answer is yes to one or both questions, a careful assessment is indicated.[3] Then the work begins, restoring vitality to those who need a better life and persuading them, who are often the dedicated and the good, to love or at least tolerate themselves enough to want to live and give.

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This article has been peer revewed.

References

1.    Watts, CAH. Depressive disorders in the community. London, UK: John Wright; 1966.
2.    Wolpert L. Malignant sadness: The anatomy of depression. London, UK: Faber and Faber; 1999.
3.    Lam R, Mok H. Depression. Oxford, UK: Oxford University Press; 2008.

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Dr Morrant is a psychotherapist in Richmond with an interest in literature, history, and gardening.