My experience of depression and the start of antidepressant treatment is unremarkable in many ways. A middle-aged man becomes increasingly miserable and despondent over 8 months. After some persuasion by his concerned wife and long-standing friends, he discusses his condition with a general practitioner, who recommends and prescribes an antidepressant drug. However, some aspects are unusual. I offer an NHS tertiary service for patients with treatment-resistant mood and anxiety disorders, and many of those who are referred are health professionals: I became a troubled, struggling psychiatrist, looking after fellow clinicians.
Having researched and prescribed antidepressants for 33 years, I always felt prepared to seek and undergo antidepressant treatment if that course was recommended. But why should I feel impelled to write about my experience? Because I chair the Psychopharmacology Committee of the Royal College of Psychiatrists. Because I provide advice to the National Clinical Audit of Anxiety and Depression, and to the Commission which aims to enhance NHS workforce wellbeing. The main reason for my ‘self-outing’, though, is the hope this may contribute in some small way to reducing the still-lingering stigma that marks depression and its treatment.
Awake for 90 minutes in the middle of the night, and again from 5.00 a.m. Within the first minute of a 9 o’clock appointment, the doctor recognises my distress. I tell him about months of misery, endless worries in the early morning, my marked loss of weight, the persistent hopelessness. I say I can still run a clinic, supervise juniors and answer emails: but cannot write a article, prepare a talk, or develop a research protocol. When asked about suicidal thoughts, I admit the urge to drop from the ‘wobbly bridge’ into the Thames two weeks before, but conceal the more recent impulse to jump onto the M3 from a bridge near home. He seems oddly impressed by the PHQ-9 score (17, ‘moderately-severe’), and suggests an antidepressant. Before the appointment, I resolved to follow whatever a general practitioner might suggest; though do feel relieved that drug treatment will start that day. When asked which antidepressant I am prepared to take, I opt for escitalopram [a selective serotonin reuptake inhibitor (SSRI)], finding it beneficial in many patients, and having researched its effects in unipolar depression and generalised anxiety disorder.
I take the first tablet (5 mg) within 45 minutes of the consultation, and have an unpleasant mid-abdominal twisting, knotted feeling 90 minutes later. When cycling mid-afternoon, I look up and out more often, and stop to admire farm animals. I am not exasperated when trimming my beard on the 0.5 mm rather than the intended 5.0 mm setting. Could these be some of the early effects of antidepressants on emotion processing, or just the non-specific effects of seeking and receiving support? We laugh at bedtime when my wife jokes, ‘I've been waiting for you to take antidepressants for 20 years’.
Awake for 1 hour in the middle of the night, then from 5.30 a.m. Some niggly stomach tightening quite soon after taking the tablet, but two mid-morning instances of light-hearted word play. I have an odd, warm-feeling headache whilst gardening in the afternoon, though fewer negative thoughts. I decline the offer of a drink when seeing our kind neighbours in the evening, and feel fragile when quickly describing my slow slide into depression and decision to start treatment. My wife and I are the first guests to leave the party.
Again, awake in the middle of the night and for the hour from 5.00 a.m. A mixed day. Increased the antidepressant dosage (escitalopram, 10 mg). It is a relief to share experiences whilst visiting my daughter in the afternoon, and pleasing to concentrate fully whilst watching The Shape of Water once back home. However, I was pre-occupied with gloomy thoughts in the silent Meeting House, and my teeth feel ‘on edge’, as if burnt by hot coffee. The sight of a poised fox whilst in a quiet Deptford side street was not magical, but somehow sinister. Maybe these are a few of the unsettling, nervy physical and psychological effects reported by many patients during the first week of antidepressant treatment.
Poor sleep, mainly awake from 3.00 a.m. During the morning I feel peculiarly light-headed and have a sense of tilting too far forward on rising from sitting or when walking, and slight diarrhoea. In the afternoon, I worry less often and do not procrastinate, though am concerned about the safety and welfare of a probably suicidal doctor-patient. However, whilst washing-up after supper, I feel strong and enraptured, and dance to ‘Blind’ (by Hercules and Love Affair), wishing though failing to be discovered.
My sleep is disturbed in the middle and end of the night, but I feel less bothered. I finish the extraordinary Berg (Quin, 2009) though am sad to think of the author’s suicide by drowning off Brighton beach, when just 37 years old. Four weeks after the front-page headline in The Times (“Drugs adviser David Baldwin quits after being branded ‘worse than Hitler’ in online abuse row”), it feels good to attend a Wellbeing Commission meeting in Marble Arch, without anguish or suicidal thoughts. I enjoy a solitary Turkish meal and the subsequent interview with Salman Rushdie at the Royal Festival Hall, and count my blessings. I was suicidal, but am no longer: I have been serially trolled, but am not the subject of a fatwa.
Only briefly awake in the middle of the night. I sense that my bladder empties more slowly than it did before starting escitalopram. A mild headache persists much of the day. At work, I feel confident when speaking with administrative colleagues, and can resolve some unexpected challenges. I volunteer to revise the College leaflet on antidepressant drugs. Once home, I stack logs in glorious sunset, prepare an Indian meal with two unfamiliar dishes, and marvel at the clear full moon.
I have gained an hour of sleep. An outpatient brings cannabidiol from a health shop, wondering whether it might boost her response to antidepressant treatment. I have no idea. Reading about the first decade of the practitioner health programme makes me worry about the protracted struggles of many doctor-patients, but pleased to have a responsive and kind general practitioner. The platitudes and some inaccuracies in Ikigai (García and Miralles, 2017)–a self-help book given to coincide with my start of treatment–are amusing, rather than irritating. An evening phone call with my son makes me feel supported and loved.
Over 5 hours of unbroken sleep. I am delighted to appoint a new clinical academic colleague, and pleased with the second meeting of our Centre for Workforce Wellbeing. My wife and I drive into Oxfordshire with joy in our hearts. In the evening, the first session in the Society of Friends retreat is great fun. I feel less burdened and more playful. But sexual intimacy is a little unsatisfying, as I cannot ejaculate: how predictable, that I should experience this side effect of treatment, which was the subject of my doctoral degree.
Almost 6 hours of undisturbed sleep! As agreed, I increase the dosage of escitalopram to 15 mg, then experience mild ‘knotting’ of the stomach an hour later. The warm headache returns during an afternoon walk. I enjoy some group activities which I would previously have avoided, and feel at ease whilst expressing personal opinions. I am captivated by the memoir of Viv Albertine (Albertine, 2014); particularly her delayed but impressively determined move from self-defeating theoretical concerns to renewed active engagement.
The clock change in the middle of the night made it hard to judge how long I slept, but I wake feeling refreshed. No stomach discomfort during a long brisk walk before breakfast. I have a strong sense of kinship during group activities and feel almost tearful when leaving. Once home, I drink my first beer since starting treatment: it tastes good. Bedtime activities are more successful. Hooray!
I am disappointed to wake at 5 o’clock: were those 2.1 units of alcohol responsible for this backward step in my sleep? However, the circling early morning thoughts do not carry any negative emotions. I have some stomach discomfort, though only after inadvertently bolting a too-hot double espresso. Gorgeous prolonged sunshine bathes my afternoon clinic room. Later, I am again stunned, by the content and delivery of the invited lecture by Akala, during which my mind barely wandered.
‘Are you able to contemplate your death and the death of those closest to you?’ So began Advices and Queries for the day (The Yearly Meeting of the Religious Society of Friends (Quakers) in Britain, 2013). The question seems neither gloomy nor portentous. Having slept well, I enjoy working at home all day, managing down a list of pressing tasks, some with previously deferred but now looming deadlines. In the evening, I enjoy the Bulgarian film Glory, somehow identifying with its hapless, stammering railway linesman, carelessly manipulated by petty but self-aggrandising, corrupt bureaucrats.
How lovely to enjoy the views of London in bright sunshine whilst walking across Hungerford Bridge, with no thoughts or urges to jump into the river below. Part of the Council meeting of the British Association for Psychopharmacology is taken with discussing how to counter often-sensationalised stories of the adverse effects of antidepressant drugs, with dispassionate fair considerations of the balance of risk and benefit when treating depressed and anxious patients. I ponder whether to write an account of my experience. My mind wanders occasionally during a great gig at Cafe OTO, but I can attend to the music more easily. On the way home, I am not too crushed by disappointing news of the latest defeat of much-loved Crystal Palace FC.
My first disturbed sleep for some time, probably due to excess caffeine at the Council meeting and three units of alcohol in the evening. I have doubts and worries whilst lying awake, but without low mood: a thought is just a thought. A mild headache and crunchy back do not impede my morning outpatient clinic, and during the succession of administrative tasks that afternoon, I feel neither bored nor irritated.
I sleep deeply until 5.30 a.m. Two weeks into escitalopram treatment, my weight is unchanged but the PHQ-9 score has dropped markedly (to 9, ‘mild’). I feel briefly uncertain whether to increase the dosage to 20 mg, and then remember my clinical practice and research, and do so at breakfast. No stomach knotting, but my bladder definitely seems to empty slowly–or maybe I cannot sense the passage of urine through the urethra so clearly? I enjoy supervising four trainees, and then submit the response from the College about valproate prescriptions to the Independent Medicines and Medical Devices Safety Review. During an exceptionally chilled concert by the Tord Gustavsen Trio, my mind hardly wanders at all.
I awake refreshed–and enjoy the Saturday morning supermarket shop, after only a single espresso! Indecision about how to mark the end of the Great War is resolved by choosing to wear neither a red nor a white poppy, instead reading the collected war poems of Siegfried Sassoon (Sassoon, 2014) in the run-up to Remembrance Sunday. I overcome some ambivalent inertia, and gaze at the beautiful autumn leaves whilst cycling through the Itchen villages: then enjoy an evening film with no drowsy lapses.
Only brief awakenings during a long, deep sleep. I am intrigued (rather than exasperated) by the slow processes of discernment whilst Friends make and record decisions in the Meeting House: then appreciate how it is so much easier for me to see the positive aspects of all interactions in daily life. Nevertheless, escitalopram has caused some niggly adverse effects–loss of urethral sensitivity, inhibited ejaculation and more frequent defaecation. These are all bearable, but I do hope they resolve with continued treatment.
At my follow-up appointment, I greet the general practitioner with a smile, and ask about his health. He appears delighted by my account of steadily resolving symptoms and the absence of suicidal thoughts, and seems genuinely surprised by my visible improvement. We quickly agree I should continue treatment for 6 months. I feel privileged to meet two new patients in the afternoon clinic, and am nerdily (but secretly) delighted by my improved performance when answering questions during University Challenge.
Am I going high? Within 70 minutes of ending a midday meeting at the College, I have consumed a large tasty lunch, enjoyed the underground journey to Embankment station, been impressed by the new library at the Royal Society for Arts–where I guzzled coffee and savoured cake–then almost skipped across Hungerford bridge (no suicidal urges, just bright sunshine) to catch the train from Waterloo! On the way home, it feels clear that I should indeed describe my experience.
Howling winds at night, so I lie awake for 2 hours from 3 o’clock, making plans for work and at home. Advice and Queries states: ‘There is inspiration to be found all around us, in the natural world, in the sciences and arts, in our work and friendships, in our sorrows as wells as our joys’. I submit draft guidance on valproate to the Medicines and Healthcare Products Regulatory Agency for their review and participate in a teleconference about a potential study of SSRI treatment for anxiety symptoms in patients with autistic spectrum conditions. I stroll through the Butterfly Meadow at sunset and feel more ‘open’ to exchanging thoughts, feelings and experiences, more willing to share material that I would have previously judged as incomplete.
Despite sleeplessness in the early hours, I wake feeling refreshed. The morning clinic emphasises how my patients and I are growing old together. At the end of the afternoon, I again head off to Cafe OTO. My mind never wanders during the magnificent set by the Paul Dunmall Quintet, and I feel like dancing: those who know me well would be most surprised. Minimal drowsiness whilst returning from Waterloo, so I finish New Left Review (bought on the day of The Times headline, after realising I had become too ‘establishment’).
Some wakefulness in the night, but no accompanying negative thoughts. I can now lie awake without feeling bad or hopeless. Appointing two new members of the Psychopharmacology Committee is a pleasure, and I am slowly getting on top of neglected and overdue tasks. Two departmental colleagues comment on how very ‘smiley’ I have become. Listening to Radio 6 whilst driving home makes me joyful and skittish. I prepare a snack for the Friends Area Meeting tomorrow, but my baked oat bars turn out insufficiently crisp.
An excellent sleep, and the weekly shop and morning chores were accomplished in a trice. At Meeting, it feels easy to greet visitors and engage them in conversation, and I am delighted when called ‘Friend’. My social diffidence and avoidance are definitely decreasing. Although floppy, my oaty bakes proved very popular. I manage to read all of The Guardian, for the first time in many months–I can certainly keep going at tasks much longer, both in work and at home.
Remembrance Sunday. It feels better to contemplate the slaughter in silence at the Meeting House than to recite ritualised texts in a church. During a midday walk through the Butterfly Meadow, I see a pair of red kites soaring across deep blue skies. In the evening, I can at last appreciate the stillness and beauty of Musique pour le lever du jour by Melaine Dalibert, but bedtime sex has a rather disappointing non-outcome.
Fragmented sleep, but I rest without ruminations. Much joy at the news of the birth of a daughter to our married trainees, and of the national award to our AF2 doctor for her work on ‘dementia-friendly’ general hospital wards. Two new outpatients with bipolar disorder each had two deceased bipolar relatives, all of whom seem to haunt the consulting room. Once home, I start Boys in Zinc by Alexievich (2017), testimony to enduring and transgenerational consequences of a hidden and largely non-commemorated war.
Continuous sleep until 5 o’clock. I enjoy the political drama and incipient chaos of the faltering Brexit negotiations, and appreciate the glorious russet leaves during walks to and from Winchester and Southampton stations, gleefully and repeatedly singing the final couplet from Hotel California. I finish talks for a meeting in Belgrade and watch The Wound. Despite the film’s brutality, I yearn to return to South Africa.
Only briefly awake in the middle of the night (loo visit). It feels great to speak confidently about our workforce wellbeing initiative at a morning meeting on the University campus, and to pitch for additional clinical academic posts during an afternoon discussion with our Trust Chief Executive. Elsewhere, confidence in the Prime Minister, Cabinet and pound sterling seems to be dwindling, and there is more talk of my longed-for second Referendum. Is it wrong to hope for a temporary collapse in Government?
I have completed the 4 weeks of treatment and feel remarkably well (PHQ-9 score is just two). Side effects of escitalopram are now very mild. My morning clinic is shorter than normal, so I can discuss College guidance on prescribing valproate-containing medicines at a meeting in the Department of Health and Social Care, that afternoon. There are so many governmental resignations during the morning it makes me wonder if anyone will be there when I arrive. I finish Boys in Zinc, and feel nourished by the final stanzas of Sirens (Montgomery, 2005) (‘grief and pain are worse when wallowing in darkness/better bend with the oars and strain for sunshine’). Indeed, it is good to be alive.
Antidepressant drugs can be very effective in many people. The reduction in my depressive and anxiety symptoms has been similar to that in many treatment-responsive patients in my clinical practice. Early side effects such as stomach discomfort and ‘nerviness’ resolved promptly, though altered urethral sensation and sexual side effects persist (if persistence is the correct term for intermittent phenomena). It is odd to lose weight whilst unwell, then not regain it despite eating enthusiastically. Of course, I could possibly have got better without treatment, as I have many good prognostic factors and am indeed fortunate to have the loving support of my wife and family, a settled home, and a secure job, in contrast to many depressed patients.
I think about why I became depressed when I did. As with most depressed patients, the combination of familial, developmental, biological and psychosocial factors seems relevant. My thwarted mother seemed unduly miserable in her last 30 years, and my meticulous father was often irritable and morose. Twice before, I had a period of low mood and suicidal thoughts (the second over 20 years ago), both ‘episodes’ being linked to disruptive life experiences. My parents died just over a year apart: I may not have grieved enough, though the subsequent death of my treasured cat helped with that process. Six weeks after the start of online abuse, I had influenza during which I was delirious and troubled by morbid concerns, sweating in bed for a week. The trolling was progressively more vituperative and eventually overcame my resilience.
I trust this experience will enhance my care of patients. I have a better understanding of suicidal urges, the difficult process of realising the need for help, and the range of early effects of antidepressant treatment. I also hope that increased awareness of the challenges faced by psychologically distressed but still working health professionals will help in the development of our new Centre for Workforce Wellbeing.
There is some uncertainty about how long I should continue escitalopram. Some would recommend that because I have experienced three depressive episodes, I should undergo prolonged treatment. However, currently I am prepared to continue escitalopram for just six more months, because my previous episodes were shorter and less severe, and both resolved without antidepressant treatment. It feels important to make changes which might also reduce the risk of relapse–to strengthen core values, to draw on the support of family and friends and on insights from literature, and to do more of what I enjoy.
I am grateful to Gordon Bates, Kim Catcheside, Zoe Flint, Keith Hopcroft and Julia Sinclair for their encouraging and perceptive comments on earlier versions of this account. Thank you to my general practitioner, fellow patients, wife, family and friends, for their strong enduring support during troubled times.
Conflicts of interest
I work within a specialist service for patients with affective disorders, have researched and prescribed antidepressant medicines, was President of Depression Alliance and am a Medical Patron of Anxiety UK. I strive to provide comprehensive patient-centred clinical care, and adhere to no particular ideology about the nature, causes or treatment of mental disorders.