Family Practice Advance Access originally published online on June 21, 2006
Family Practice 2006 23(5):605-606; doi:10.1093/fampra/cml029
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Beyond depression: a new approach to understanding and management. Christopher Dowrick. (240 pages, £21.50.) Oxford Medical Publications, Oxford University Press, 2004. ISBN 0198526326.
University of East Anglia, School of Medical Health Policy and Practice Earlham Road, Norwich NR4 7TJ, UK Email: amanda.howe{at}uea.ac.uk
Doctors can feel that depression just doesn't fit the box they have been taught to put it in. They can feel cynical, frustrated or irritated by their inability to make sense of this multifaceted problem in conventional medical terms. At best, they may construe it as a complicated and difficult clinical challenge to which conventional diagnostic reasoning and treating don't do justice. If this rings any kind of bell, read on.
This book can help clinicians to think differently about the problems which depressed patients present, and offers some reflections to inform that thinking. It is hard to pigeonhole: not a textbook, nor an introductory or conventional overview. It is well and clearly written, but the argument is complex, and it bears more than one reading. It is written by a UK family medicine practitioner with a lifelong interest in mental health issues, who is also a leading researcher in the field. This text represents a consolidation of his expertise, going beyond the narrow scope of original research to apply his accumulated wisdom to a more scholarly review.
Ultimately this is a patient-centred book, and its purpose is to encourage those who work with patients with mental health problems to reconsider the assumptions behind their daily practice. It includes ‘pen sketches’ of patients whose care has clearly meant a great deal to the author, and which are used to reference his developing themes in a way that I found meaningful and sympathetic. The chapters move from an overview of the orthodox medical views of depression, through a brief critical discussion of the roles of pharmaceutical and professional agencies in defining depression as biomedical in nature, and then to a more original section where the whole concept of depression is questioned. The author defines his current understanding of depression as a life crisis, seeing the defining resolution as whether or not an individual can retrieve meaning within their lives' traumas, and the crucial role of clinicians as assisting in such search for meaning. To do justice to the arguments is very difficult in a short review, and any shortcomings in this are the responsibility of the reviewer. However, reviews are meant to help others decide to read the book itself, and to do this you must taste the core argument.
The author suggests that depression, while reflected in biological processes and potentially influenced by pharmacological agents, is predominantly a highly individualised response to failure to create and retain meaning in one's life. He outlines some predisposing factors: early life experiences which mitigate against good coping mechanisms and resilience in the face of life's inevitable knocks; the strain of living in a culture where happiness, success, economic security, and communal belonging is the apparent norm, if you are unhappy, out of work, poor, and seen as a social outsider; a learned self-perception of inadequacy and negativity: or life opportunities of relative tedium and mediocre stimulation. This certainly sounds like a recipe for unhappiness, loss of pleasure, withdrawal and self-doubt—a depressive reaction. If those from whom help is sought endeavour either to make a ‘diagnosis’ based on the symptoms not the causes, prescribe a drug, dwell on the past and those personal, cultural and familial factors which are not able to be changed, or become despairing themselves ... then perhaps a new drug from the ever present pharmacopeia is the only option.
The evidence base for all this is strongly made, with some context from major historical figures marched on in support: Buddha, Marx, Spinoza, Sisyphus and Sartre are names not generally on the lips of everyday GPs, and this can feel indigestible, albeit mind broadening. They do, however, add important weight when one starts to try to consider the implications of the author's conclusions, which are radical. The author argues that there is one intervention which family practitioners practise again and again that matters in depression—meeting with the patient and hearing their story from their perspective; hearing it, and helping patients to see their experience in the context of their broader life, and indeed the lives of others—helping them to find ‘some meaning and purpose out of seemingly undifferentiated suffering and distress’ (p. 195). This is the therapeutic principle which Dowrick, drawing both on the multidisciplinary literature and his own experience, sets out, and which has wonderful resonance for many others working in primary care. He argues that the key principles which may both dispose to, but also remedy, ‘depression’ are in the patient's narrative, which is core to their own sense of being. The role of the clinical practitioner is construed as primarily to strengthen the identity and abilities of the person whose life is temporarily threatened with disintegration, and to encourage engagement with others to make sense of, and move through, the problems in our lives.
For those with major illnesses that make daily life and such engagement difficult or impossible (psychoses, profound catatonias, deep personal damage) this argument may have its limitations, but for most practitioners and patients this interpersonal construction of meaning lies at the heart of the therapeutic encounter, regardless of the specific treatment modalities chosen. Readers may be surprised by this ‘punch line’—many of us have been accepting just such a principle for many years. The originality of Dowrick's treatise lies in its message coming from a GP rather than an ‘specialist’ mental health therapist in its timely reminder that the forces of biomedical business still dominate training and service provision, and in its demonstration that many cultures and ages see psychological problems as phenomena that can be survived, reinterpreted, and used creatively to overcome life's difficulties—providing either we ourselves or loving others can support us in this reconsideration.
Many readers might benefit from this book, but I would suggest it may be most valuable for novices in training who are interested in the problems of depression, or for those in service feeling overwhelmed or unsuccessful in managing depressed patients. Those who find treating depression a bore, and are happy to hand out pharmacological treatments without further involvement may not enjoy it—if their defences are so high then how could they? But for the rest let's do it—though perhaps not in 10 minute appointments.
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