Stigma of depression – a personal view

Abstract

Depression is a serious illness of which I and other patients should not be ashamed but this is hard to avoid. The stigma of depression is different from that of other mental illnesses and largely due to the negative nature of the illness that makes depressives seem unattractive and unreliable. Self stigmatisation makes patients shameful and secretive and can prevent proper treatment. It may also cause somatisation. A major contributing factor is that depression for those who have not had it is very hard to understand and so can be seen as a sign of weakness. Openness by depressives and education in schools could help.

My first serious depression occurred 6 years ago¹. I had never before experienced so terrible a set of feelings and was hospitalised because of my suicidal intentions. When I recovered, due to antidepressants and cognitive therapy, I found out that my wife, Jill Neville, had not told anyone that I had been depressed. She said that she was embarrassed about my being depressed and told friends and colleagues that I was exhausted and was suffering from a minor heart condition. She was also very worried that if the truth were known it would have a serious effect on my career. This was my first experience of stigma and I found it upsetting as I believed that I had had a serious illness and it was nothing to be ashamed of. But my position was not that straight-forward.

I was convinced that my depression had a purely biological cause and was induced by the drug flecanide which I was taking to control my atrial fibrillation. I did not think that there was any psychological basis for my depression though my wife thought otherwise. I very much preferred a biological explanation. This is probably because then I was not really responsible for the condition, it was like a physical rather than a mental illness. It was not unlike having a diagnosis of post-traumatic stress disorder, which carries no stigma because the cause is so clearly an external one. But what then was my problem with a psychological basis for the depression? I have had to come to accept that I too stigmatise depression when the basis is psychological and that my public declarations that depression is a serious illness and should carry no stigma are not as honest as I would like them to be.

In trying to understand stigma, it is essential to recognise the effect that depression has on those associated with the depressed individual. Depressives are both negative and self involved. For the carer it can often be extremely difficult to understand why their partner should be in such a condition. My wife found it incomprehensible that I should be depressed as we were happily married, I had a fine job at the University, and I had no serious physical illness. Worse still, depressives are almost totally negative in all their attributions and also obsessively self-involved which makes them unattractive company. In an experimental study, subjects were asked to speak on a telephone with a patient who, unknown to them, was depressed. Their reports on their conversation were, not surprisingly, negative.

Other studies confirm that depressed individuals have a negative impact on those with whom they interact, for example, at work. When in a position of power, they tend to exploit their position and in subordinate roles tend to blame others. I recall, now with some guilt, that before my own experience with depression, I had employed on a temporary basis an assistant to work in the laboratory who turned out to be very good at her work but was on the edge of a severe depression. Her effect on the group in the laboratory was so bad that they had great difficulty working, not only with her but even near her, and so I had to let her go. I hope I would now handle it better but it would still not be easy.

There can be no doubt that there is considerable stigma associated with depression. I am repeatedly congratulated for being so brave, even courageous, in talking so openly about my depression. I, in fact, am a 'performer' and there is no bravery, but these comments show how others view depression and that it is highly stigmatised. An example of how stigma can present a particularly difficult problem for sportsmen is provided by the case of a professional footballer, Stan Collymore² who played for England. He had a severe depression and his career went into a rapid decline. He says that he can never forgive the Aston Villa manager for the way he reacted to his depression. He told him to pull his socks up and that his idea of depression was that of a woman living on a 20th floor flat with kids. The Sun newspaper said that he should be kicked out of football as how could anyone be depressed when he is earning so much money. He bitterly remarks that if you suffer from an illness that millions of others suffer from, but it is a mental illness which leads many to take their own lives, then you are called spineless and weak.

Just as important, perhaps more so, is the self stigmatisation of those with depression as it can have serious effects on how individuals deal with their illness. My experience in talking to others who have had a depression has provided me with numerous accounts of just how much those with depression see it as something to be ashamed of, and so kept secret³. One young woman cannot even tell her father who is a psychiatrist and another woman could not confide in her brother or sister who knew nothing of her suicide attempts. While I have no difficulty talking about my depression when I have recovered, when I am in it I must admit I hesitate. One reason is that whoever you tell is embarrassed and does not know quite what to say. There is also a sense of failure in not having handled it. That is why depressives can talk so openly to each other about their experience.

The shame and stigma associated with depression can prevent those with the illness admitting they are ill. It is remarkable how it is sometimes possible to conceal one's depression. It was chilling to hear a mother relate to me how she could talk cheerfully to her son while at the same time composing, in her own mind, the suicide note that she would leave him. There is also the stigma of taking antidepressant medication which is perceived as mind altering and addictive. Stigma may also cause somatic symptoms as it is more acceptable to talk of stomach ache and fatigue than mental problems.

A major difficulty in overcoming stigma, and indeed probably one of the causes, is that it is very hard, perhaps impossible, for those who have not experienced depression to understand what the individual with depression is experiencing. I have colleagues who openly admit that they just cannot understand what I am talking about. As Styron⁴ wrote ‘the pain of severe depression is quite unimaginable to those who have not suffered it’. The experience is almost impossible to describe and the situation is not helped by the almost total absence of good descriptions of depression in English novels – I know of none. Writers have described their own depression but none in novels; Virginia Woolf, herself a depressive, never does. Perhaps it is just too difficult. It may be that if you can describe your severe depression you have not really had one.

In more general terms, there are many attempts to account for stigmatisation of mental illnesses. Mental illnesses are perceived as different as they express themselves through those very characteristics that make us human – cognitive and affective and behavioural – and thus differ from physical illnesses⁵. Mental illness is thus seen as embodying the core of the person and not just affecting some organ like the heart or lungs. But different mental illnesses each have their own characteristics in relation to stigma. For example, unlike depression, people with schizophrenia or addictions are perceived as being dangerous. But depressives are seen as unpredictable people who, if they really tried, could pull themselves together. I am not persuaded that the stigma in relation to depression has a major evolutionary biological component other than that of avoiding undesirable company⁶.

What can be done to reduce the stigma associated with depression? There is no easy answer not least because acutely ill depressives are not attractive company. Perhaps the most important aim would be to publicise just how wide-spread depression is and that it is a serious illness. Most important is that it can be cured. It could help a great deal if those individuals with depression who are well known public figures were to support such a campaign; Collymore is an obvious example. That they do not make their condition public is itself due to stigma which will make their co-operation hard to get.

A neglected area is health education in schools. This is odd as one of the illnesses that children will suffer from when adults is depression and yet they are given no information about its nature. One positive venture is the play for schools by Y Touring, Cracked, which not only deals with depression but also has a debate at the end of the play in which the actors remain in character and have a discussion with the audience. In Northern Ireland there is a booklet produced by Aware that explains depression very clearly to children⁷. But the success of such programmes needs careful evaluation.

Correspondence to: Dr Lewis Wolpert, Department of Anatomy and Developmental Biology, University College London, Gower Street, London WC1E 6BT, UK