Medical Matters:"At the centre of the human heart is a longing for the absolute good" - Simone Weil, Swiss philosopher.
We all want to be well. If we have a problem, we want to overcome it. So why, if we are depressed or have a psychological difficulty, are we so reluctant to go to the doctor about it?
A new study, carried out by Khan and colleagues and published in the British Journal of Psychiatry, has looked at the reasons people give for avoiding going to their GP for help when they become depressed. The study was qualitative, that is, it focused on the person's own story or personal experience of feeling depressed and trying to deal with it. The results of the review are surprising.
Firstly, it seems that external things, such as family problems or lack of money, are seen by many people as being responsible for their depression. They don't see depression as being caused by some internal trigger.
They also view being unable to cope at work or with friends as a much bigger problem for themselves than the actual feeling of being depressed. After all, you can hide how you feel.
At first when someone becomes depressed they usually try to "fight" and "conquer" the feeling. So before a person goes to their GP they can spend a long time worried and distressed.
During this time they often try out different ways of coping with depression. Eventually, however, the individual comes to realise that their own ways of coping are not working. The study highlighted that admitting this can naturally be quite difficult and can slow up the process of finding help.
Deciding to get help is not simple. Making the decision to seek advice is a complex action and then, having done so, actually finding this help is not at all straightforward. The study emphasised that going to a GP raises all kinds of issues, including the acceptability of having a non-physical problem.
Physical health worries are seen as acceptable and legitimate reasons for visiting a doctor. Not so psychological difficulties. This is probably why so many people go to their GP and present with symptoms that are difficult to explain physically.
Most importantly, the study indicated that looking for help for low mood is often viewed as a "moral action". By going to the doctor, the person often has a feeling of giving up personal control of their health and this can be seen as a morally suspect thing to do.
The individual may feel that they somehow have let themselves down. Issues of personal control then are an important part of the patient's own personal experience of depression. The need to regain control of our lives is often more important than the actual, unpleasant symptoms of depression.
Whatever about the difficulties in making the decision to walk into a GP surgery, what happens when you get there can again raise significant personal issues.
Serious personal concerns can be raised when confronted with the choice of accepting some form of treatment for low mood.
There is a stigma associated with depression. There is also a stigma associated with treatment. The depressed patient who is offered treatment now has to deal with a double stigma. So it is understandable why someone would be reluctant to go to a doctor for help.
This study suggests that always seeing the unwillingness to accept treatment as being due to a fear of side effects is incorrect. As Albert Einstein said, "Behind every complex problem is a simple solution, which is usually wrong."
Taking medication, for many people, is not about side effects, but is actually a "moral problem" involving personal responsibility. It is only when the GP or family friends offer advice to reduce or solve this moral difficulty that the person may be willing to consider treatment. Even then the help will be accepted only if it is seen as short term and temporary.
The introduction of a treatment, psychological or otherwise, needs to be discussed in detail with the individual. They will want to be reassured that there will be no changes to their personality as a result of the help offered.
It also needs to be understood that the wish to be able to cope at work or socially is often more important to the person than simply getting rid of the unpleasant symptoms.
In life we all develop ways of dealing with low mood. It may be of value to build on these ways of coping rather than abruptly introducing external forms of treatment such as psychological therapy or medication. Treatment for depression needs to be seen as an addition to our own initiatives and our own ways of handling low mood, methods that we have found useful in the past.
The authors of this important research suggest that any form of help should take into account the individual's own way of viewing depression and their own methods for dealing with it.
In this way treatment can be based on the latest research evidence but it can also be patient-centred, with the patient as the primary active ingredient.
John Wallace is a clinical psychologist and consultant psychiatrist.
Dr Muiris Houston is on leave.