Managing depression – Lucas Managing depression – analytic, antidepressants or both? Richard Lucas* INTRODUCTION severe of psychopathology, Freud and Abraham’s seminal papers remain as clinically In this paper, the analytic contribution to relevant, today, as when they were first the understanding and management of written.1,2 depression will be considered, together with Clinical material, taken from a patient who clinical illustrations, within the context of every had been in analysis, will be used to illustrate day general psychiatric practice. how psychoanalysis informs on the Patients with major depression cover the psychopathology of depression. Material will spectrum, in terms of severity of the then be presented from patients not amenable psychopathology, between those who receive a to analysis, but showing how analytic insights purely analytic approach, those who may take help both to understand the process through medication while having analytic which the patient is undergoing and in providing psychotherapy, and those seemingly not a supportive framework to the professional amenable to other than a physical approach. carers and relatives, while they are having to The latter group features largely in endure very difficult periods, where the everyday psychiatry, where general depression appears to be unremitting in psychiatrists have to run large supportive character. Appreciating the dynamic of a outpatient clinics, where many patients are pathological superego in depression, taking prescribed antidepressant medication. over the driving seat, and the need to unseat it However, even in these cases, it does not and foster a more benign superego that exclude one from thinking analytically. When strengthens ego development, is a key issue trying to understand and relate to the most when relating to patients with depression, whether treating with antidepressant medication, psychotherapy or both3. In order to understand depressive illness, we also need to * Psiquiatra e Psicanalista, St Ann's Hospital, London. distinguish it from other causes of low mood and recognise its special psychopathology. Freud’s seminal paper, Mourning and 274 Melancholia, helps us to go beyond ordinary R. Psiquiatr. RS, 25'(2): 274-282, mai./ago. 2003 Managing depression – Lucas empathy, through recognising the underlying friend. An initial supportive response from the narcissistic structure1. However, his insights are carers’ deals with the immediate crisis and usually not incorporated within general medication is not indicated. In contrast, patients psychiatric training and practice, nor in contrast with features of psychotic depression are do psychoanalytic therapists think enough about typically older, there was a real intention to kill depression in terms of a psychotic disorder and themselves, and the treatment typically would how medication might be thought about, when involve medication and admission to a needed, in this context. psychiatric hospital.6, 7 DIFFERENT MEANINGS TO DEPRESSION GRIEF REACTIONS The first thing we need to do is to be clear In Mourning and Melancholia, Freud about four quite different ways that we may talk movingly described the process of mourning. about depression. Edith Jacobson, in her How, we try to turn away from reality and cling studies on depression, referred to them as onto the lost object through a hallucinatory normal, neurotic, psychotic and grief reactions4. wishful psychosis e.g. hearing the voice of our lost loved one. However reality gains the day NORMAL DEPRESSION and we have to relinquish the external object and reinstate its memory inside us and to do What Jacobson referred to, as normal this we have to go through the work of depression, is akin to what Melanie Klein mourning.1 referred to as the depressive position. It is Freud interestingly contrasted mourning essentially a state of health, a capacity to bear with melancholia; the latter would now be guilt, stay in touch with mental pain and referred to as a severe depressive episode8. In emotional problems and bring thinking to bear melancholia, Freud surmised that there must on situations. In Kleinian terms, we oscillate have also been a loss for the patient; however between our ability to stay with painful situations one could not see the loss. He concluded that it or seek temporary relief through splitting and therefore must have been an internal projection, returning to the paranoid-schizoid narcissistic loss, occurring at an unconscious position, or flight into manic idealisations5. level, and requiring a separately considered understanding in its own right.1 NEUROTIC DEPRESSION PSYCHOTIC DEPRESSION Neurotic depression or reactive depression can be understood, simplistically speaking, as In modern day terminology, Jacobson’s an exaggerated response to stress due to a psychotic depression would be termed a severe weak state of ego strength combined with a depressive episode with psychotic symptoms8. failure of the external support system and Depression is, in fact, a very common condition. basically is a cry for help. Some 3% of the population are seeking help at any one time, while another 3% remain For example, an asylum seeker was undetected struggling on their own in the admitted to hospital after running in front of community. 10% also undergo manic episodes. cars. A flat mate reported how he had tried to In manic depression, there is a 15% risk of jump out of a window until restrained and then suicide, and up to 50% of patients may have took a few paracetamol tablets. He clinically visited their General Practitioners in the few presented in a withdrawn and retarded state, as weeks preceding suicide (Gelder et al., 2001). if undergoing a severe depressive episode, but Clearly, it helps to be familiar with the was fine the next day after we indicated that, if clinical presentation, as the patient may not contacted by his solicitors, we would write a complain of depression but only emphasise one supportive asylum appeal letter. of many commonly experienced symptoms and Two conditions, where the differentiation one may miss realising that the symptom is part of the underlying nature of the depression is of an underlying syndrome. The following are important is in the assessment of suicide and well known typical symptoms familiar to all with puerperal depression.. the young and is practicing psychiatrists: seen as a wish for temporary oblivion and a cry Diurnal mood variation, early morning for help in relation to clear external precipitants, wakening, and psychomotor retardation – a such as a family row or break up with a boy slowing up of all physical and mental processes 275 R. Psiquiatr. RS, 25'(2): 274-282, mai./ago. 2003 Managing depression – Lucas – with resulting loss of appetite and weight, As Freud put it “an object loss was transformed decreased libido, amenorrhoea, constipation into an ego loss”1. So, when the patient and retardation (stupor). announces to the world that they are useless, Other features include agitation (a they are not really criticising themselves, but a ceaseless roundabout of painful thoughts), poor purported ideal that has temporarily let them concentration (depressive pseudo-dementia), down. The self-tormenting is then a tormenting agoraphobia, depersonalisation and of the ideal object that had abandoned them at a derealisation, a loss of energy (mimicking time of need. The sadomasochistic process of anaemia) and hypochondriacal features self- criticism, that so dominates depressive including headaches, chest pain, stomach pains episodes, goes on in a relentless fashion until it with associated cancer phobia, and atypical has run its course. facial pain (depressive equivalents) and suicidal Some experienced nursing staff will have thoughts.9 no difficulty in intuitively understanding the need There are compelling reasons why general to let this process run its course in hospital, psychiatrists regard depressive illness as a without demanding excessive physical biological disorder. They see the symptoms of a interventions. slowing up of psychological and bodily No true mourning, with relinquishment of processes as indicative of a medical disorder the object, can occur because of the unresolved requiring physical treatment. Also in depression, ambivalent dependence on an ideal object. One common neurotransmitters in the brain are is left struck how, after months of self-berating, depleted, and anti-depressants work by raising the patient then recovers their former their levels, supporting the view of a biochemical composure without showing the slightest disorder. According to traditional psychiatric curiosity about their whole recent experience in teaching there is no place for psychotherapy, hospital. other than of a supportive kind, while the patient The following serves as an amusing takes his medication and recovers from the example of recovery from a major depressive episode. episode and how we can be fooled into thinking However, the author’s perspective, in that we have been dealing with a neurotic writing this paper, is from the position of a disorder. After months in hospital in a withdrawn practising psychoanalyst, seeing some patients depressed state, a woman started to recover. with depression for individual analytic therapy, She then complained that her husband worked whilst also working in general psychiatry, which all day and then went to the pub in the evening includes prescribing medication. In such a leaving her on her own. We felt incensed on her position, one is forced to give