Contrary to what you write, “depression” may been seen as a term with some utility in society to describe symptoms nad signs which can aggregate in greater or lesser number in human beings. Yes a largely phenomenological description without a molecular or pathological basis may be flawed but who ever expected psychiatry to be any different (4 thousand years of philosophy hasn’t gotten any closer to being able to provide an analysis of how qualia result form certain neusological processes). Many of us who have lived with phenomena which can be described in “mental illness” terms (persistent low mood engendering suicidal ideation, anhedonia, psychomotor retardation, ruminative or circular thought patterns), who have such phenomena aggregating in our family history, who have recovered from these phenomena and who can recognise such phenomena in historical accounts going back at least two millenia, find it trajic that qualified psychiatrics haven’t come to terms with the difciculties of false positives in diagnosis. Of course some people will state they’re persistently low in mood when they are not, they may say they feel suicidal just to provoke a response or for another reason but that can’t undermine the fact that for some people these phenomena are part of problem that can respond to medication. As a psychiatrist who has experienced bouts of “depression”, I find it a considerable divergence from the facts that some of the symptoms can be treated without medication. In my mst serious episodes, the healthiest diet, abstaining from work, daily 3-mile joggs, comedy therapy, sunshine, great films, favourite books and the company of beautiful women will not pull me out of my state. It is hugely physilogical for me. My sense of taste changes, my balance, I slow down, I have circular-repeating thoughts of only a few words. Do not be able to distinguish this from what you call regular sadness is bordering on negligent.

For symptoms which by their very nature can be faked I humbly suggest the following rules:

1) What would the person gain by faking illness? Not as easy as it sounds, some fears are only floating on the borders of our consciousness.

2) Does the person look unwell; look for palor, tiredness, anxious face, unkeptness; and are these normal for this person.

3) Does the account “hang together”. “I’m really depressed Doctor, my wife’s annoying em and I can’t sleep”, might be more anger-related difficulties than anything depressive, poor example but the meaning of words and what they point to is crucial.

4) Get a collateral history, what is this person’s best functioning level and when were they last there. Do they enjoy life when well (I certainly do!)

5) Family history, especially any family members spent time in psychiatric institutions and suicides and suicide attempts.

6) Look at the response to antidepessants or ECT, it can be quite dramtic in people with genuine symptoms.

Please don’t give up hope of being able to genuinely treat symptoms with meidcation and compassionate psychotherapy. Yes we’ll get it wrong and have false positives but it’s certainly better ethically than undertreating.

Nick

The condition of ‘melancholia’ is an ancient thing, alas across all cultures.

The problem is the drugs that are given for mental illness. Anti- depressants can actually mimic illicit drugs, such as speed or so- called ‘ecstasy’. Prozac was an example of a SSRI that transformed itself from a medical treatment into some sort of unsafe ‘lifestyle’ monster.

Mental illness is probably a spectrum, ranging from the average to the extreme. The difficulty for a GP or consultant is judging where depression has become something that is beyond everyday sadness and turned into a sinister thing.

Back to your blog. Although you initially suggest that ”we” -GPs, ITUs and stroke wards and hospital physicians - are somehow like cowboys describing these ”anti-depressants”. Not sure were your evidence is for it. We do a HAD score, as do many hospital doctors. and a limited psychiatric evaluation. True, with increasing pressures of day-to-day life in the 21st century and the decreased social, family and community sense - not to mention decrease of religious involvement, we GP’s are becoming more and more the new priests and pastors for the community. And we don’t give absolution or communion but counseling, relaxation tapes and indeed sometimes anti-depressants.

I suggest you spend some time in my surgery and trying to solve societies problems by saying no to them and then see how tough they - and perhaps you as well are…