Issue link: https://maltatoday.uberflip.com/i/364850
12 LET'S talk about depression. Not perhaps the jolliest topic for a mid- summer afternoon on a beach, I'll admit. But an important one, for very often it is precisely our own fear of depression that may prevent us from detecting warning signs which may otherwise conceivably save lives. That, at any rate, is what psycho- therapist Malcolm Tortell has just fin- ished explaining to me at his Naxxar clinic. In a curious reversal of roles he tells me this from the patient's couch, while I sit in the therapist's chair: an arrangement that has more to do with the photographer's lighting require- ments [and with me having a surface on which to take notes] than with any sudden career change on my part. But it is a useful illusion to maintain for a while, if we are to take a look at depression from a clinical perspec- tive. This week we were all in a sense forced to do this because of the very public death of US actor and come- dian Robin Williams, who committed suicide at 63. Williams had evidently made a deep impression on the millions around the world who followed his career from their infancy. I myself found the news strangely saddening, and Mal- colm Tortell felt the same way. He admits his own reaction took him by surprise. "My first reaction was, oh, wait, it's another hoax. But then [when it was confirmed] I really felt it. I thought of all the times I'd seen his movies… Good Morning Vietnam, Dead Poets' Society… so it felt almost as if I had a personal connection with this guy …" At the same time, there was a poign- ant irony in his death. The same Rob- in Williams who made us all laugh had also struggled for years with depression: a revelation which elic- ited mixed reactions the world over. Some made public observations of the link that seems to exist between comic mania and depression; others interpreted his suicide as a symptom of the jaded lifestyle of the impossibly rich and famous. Yet none of us (us lay people, I mean) have very much real knowl- edge about what depression is and what it does. Let's start with reactions such as: what did Robin Williams have to be depressed about, anyway? He was wealthy, successful, loved by millions…What does this sort of re- action tell us about our knowledge of depression? "I think that's a very superficial view," Tortell begins. "Just because someone is wealthy, has a lot of fans, just because someone is admired and respected by millions – literally, in this case – it doesn't automatically mean they are happy. Otherwise, what we'd be saying is that people who don't have a certain amount of wealth should be depressed. Is that what we're saying? You have to see the flipside… and I think people would react strongly against that…" Malcolm Tortell points out that clinical depression is not 'just a frame of mind', nor even a reflection of one's circumstances: it is a medical condi- tion that has a basis in biology. "This is more a case of: his mental health was such that it led him to this act. It's not a question that the guy could wake up, look around him and say: oh, I have all these fans, I have these movies…" Tortell shakes his head. "It doesn't hit home. Another thing is that: would we say that some- one who is wealthy should not suffer from diabetes? Or schizophrenia, or a host of other diseases? There is a very strong biological component to depression. It's not the whole story: I wouldn't say that depression is just a 100% biological illness. But it makes no sense to say that because you have a certain income you're suddenly im- mune…" So what is a depression, anyway? Tortell starts out by explaining what it is not: and the first misconception to be tackled is the interchangeable use of 'depression' with 'sadness'. "We need to distinguish between a clinical and a reactive depression. A reactive depression is when you're in that state for a reason: loss of a loved one, for instance…" This, he adds, is not a medical con- dition at all: it is in fact normal. Clinical depression, on the other hand, concerns cases where the ex- ternal factors are no longer the only cause. "In a nutshell, the brain is a mixture of electrical and chemical processes. There are certain chemicals – like serotonin, dopamine, etc. – whose levels are going to affect our mood. It is a two-way process. In other words, if you go out and do something pleas- urable, like have a nice meal with friends, it's going to increase the lev- els of certain chemicals which lead to a feeling of pleasure. "So there's a feedback loop. But if the brain, for some reason, cannot produce the right amount of chemi- cals, then the person is going to go into a dark mood. In other words, if it were possible for me to 'inject' some- one with a certain chemical, it could affect their mood. And this we know from the use of even alcohol and oth- er drugs…" In the case of depression, the chemi- cals in one's brain would be out of bal- ance, so one's mood can no longer be stabilised by external circumstances. "Clinical depression is not brought about by 'thinking about life', either. You cannot think yourself into a de- pression, because the chemical imbal- ance in itself will be interfering with your thinking process…" Nor is it a case of extreme despond- ency, as the word is so often used to mean. "These people would experience feelings of emptiness, of darkness… depression is a very heavy, dark ex- perience. It's not a feeling of sadness, really. It's more of a feeling of noth- ingness. And this is the difficulty in working with it. How do you work with nothing…?" One way is through medication. There are no drugs to change life cir- cumstances, but anti-depressants can directly address the imbalance (i.e., biological) component. "What the medication does is that it resets the chemical levels in the brain, so that the mood can start to lift." Anti-depressants are successful in treating acute depression; but the Robin Williams case also illustrated that individual circumstances are very often more complex than they at first appear. "In this case there were also addic- tions. It can happen that one gets into a depressed state, and starts to self- medicate: using alcohol, drugs, what- ever makes them feel better. Then the addiction itself starts becoming a problem. Then these people start to feel bad and ashamed because they're self-medicating, and the whole thing spirals…" There are also non-biological con- siderations to consider. Robin Wil- liams was best known as a comic ac- tor, which is in itself an illusion – a role that he played for the outside world. The same basic principle – i.e., that of 'playing roles' in which one projects oneself as how one would like to be seen – is applicable to more or less everyone. "I get clients who say, oh, because everyone on Facebook is really hap- py… they're all on holiday, and there are all these smiley photos. I tell them, listen, that's an illusion. That is peo- ple picking and choosing aspects of their life… there is actually research on this, I recently read a dissertation about it. People create and market an image of themselves. No one posts a photo of the bog standard cereal they have every morning, but if it's a fancy English breakfast they'll post a photo. No one posts a photo of themselves in the morning going to work, but if they're on holiday they do. But people take that as reality, and compare it. So really and truly, I would think the big- gest danger is comparing ourselves to others. We're comparing ourselves to an illusion, to the image a person wants to project…" Meanwhile, the attention received by celebrity tragedies masks another reality. For every widely reported case, there will be countless others which never make the news. How widespread is depression, anyway, and (tentatively) what percentage of these cases would be considered at high risk of suicide? "In terms of depression, generally we are talking about roughly one per cent of the population. But that doesn't shed much light on the risk of suicide. There are other factors that may cause people to take their own life. You can argue that they were depressed at the actual moment, yes, but it wouldn't have been a direct cause. At the same time, there is another one per cent suffering from schizophrenia. One per cent OCD [obsessive compulsive disorder]; 30% of women have been sexually harassed; 30% of women have been physically abused… by the time you add it all up… and then there are the less visible cases. People suffering from OCD, minor depression, anxiety disorders…" This latter category appears to be on the increase. "Suicide can be the result of something acute: a panic or anxiety attack. It can be people fail- ing exams, it can be people breaking up a relationship, it can be all sorts of things. What we have to realise is that when you add up all the 'one per cents', and the prevalence of abuse in Malta, which a lot of people don't acknowledge, there are a lot of peo- ple suffering. Child protection and domestic violence get one new case a day. Obviously cases vary in how serious they are, but that's a lot for a country the size of Malta." Psychotherapists and social workers are on the front line when it comes to dealing with emergencies. But any- one can conceivably find oneself in that classic Hollywood cliché scene where they have to 'talk someone off the ledge'. From a professional perspective, is there an established procedure to handle such emergencies? Is there a "do's and don'ts" list for potential sui- cide cases… like there is with people asphyxiating or having an epileptic fit? There is no specific handbook, it seems, but Malcolm Tortell believes from experience that some approach- es tend to work. "I would say, address it directly. Let's take it one step back. Let's say you think someone might be suicidal: a friend or a family member, what- ever. Don't beat about the bush. Ask them: are you thinking about killing yourself? A lot of the issue is our own fear, our own reluctance to address the subject, when that person would actually be crying out for someone to acknowledge it. He might say, yes I am. That in itself can already provide a level of support. To ask the direct question is usually the best way. On the other hand, if someone comes up to us and tells us he's depressed and thinking of committing suicide, the first thing you need to do is acknowl- edge the validity of those feelings. You can't go: oh come on, you'll get over it… things will get better, and so Interview By Raphael Vassallo maltatoday, SUNDAY, 17 AUGUST 2014 The dark, downward FEAR A lot of the issue is our own fear, our own reluctance to address the subject, when that person would actually be crying out for someone to acknowledge it. ILLUSION The biggest danger is comparing ourselves to others. We're comparing ourselves to an illusion, to the image a person wants to project…"