Fa keys to the cage insides_layout
Depression. Panic. Anxiety. Despair. Stress. Black dog. Call it whatyou will, depressive illness in Ireland is escalating. It is estimatedthat one in four people will suffer from depression at some stagein their lives. Yet it is still largely misunderstood. As a doctor’sdaughter, a former nurse and a medical journalist, I haveencountered many people in difficulty and despair. I have seen theirhelplessness and heard their anger. People with depression are alltoo aware that misunderstanding leads to stigma.
When the genesis for this book came in March 2009, all the
talk was of downturn, of recession, redundancy and repossession.
This, we were told, was causing a pandemic of depression. Facingbankruptcy, businessmen lost all sense of self. In despair, someconsidered suicide. People rang radio stations and describedcrippling panic attacks as they faced life with a diminished income.
No wonder experts believe that by 2020 depression will be thesecond most burdensome illness on health services in Ireland, thefirst being heart disease.
When someone has depression, they retreat into a dark world.
Unable to express their bleakest thoughts, they feel terribly alone.
They cannot sleep. They worry incessantly. Every problembecomes a crisis, their thoughts spiralling in a loop of despair.
Their view of life is skewed; they believe their life has no meaning.
They are stuck in an altered world and nobody understands, noteven the people who love them.
And that is the problem. If you are close to a sufferer, you feel
scared too. You feel you’re living with a shadow of the person you
knew. There is a different look in their eyes; a change in their
All fourteen have suffered from distress or panic, sometimes
speech pattern. Their senses seem dulled. It can be terrifying.
for years on end. They were all keen to talk. Some of them felt
The sufferer may have panic attacks. They may feel unable to
frustrated that their illness has been hidden from the public gaze,
drive, unable to work, or even to function from day to day. They
frustrated too at the treatment they had received. They have told
might spend all day in bed. Being close to the sufferer, you worry.
their stories with great courage, with humour and humanity. Parts
You are scared to leave them, even for a few hours. You are scared
of their stories are distressing. But they are ultimately full of hope.
Their experiences show that there is an end in sight. There is help
You are desperate to help, but you don’t know how. You feel
trapped, frustrated, even angry. You want to scream, ‘Pull yourself
The stories are diverse. Pauline is seventy-one and bereaved,
together.’ You know that is neither wise nor fair, that it’s the worst
Keith is just twenty. Ryan suffered abuse at home, Senan at school.
thing you can do, but sometimes the words pop out anyway.
Ned and Geraldine’s panic evolved from redundancy and job
You start to share their fears, to believe in the bleak scenarios
stress, Emma’s evolved from exams. Margaret’s panic began when
they paint. It is hard to tell what is truth, what is fiction. And if you’re
she was pregnant, Valerie hit rock bottom after the birth of twins.
not careful, you will be pulled down too into the spiral of panic. It is
Luke had problems ‘coming out’. Orla, who is naturally vivacious,
like spinning, tangled up together, out of control in a washing
struggles with the stress around her multiple sclerosis. They have
machine. You start to believe that life, as you knew it, is over.
different stories, different solutions, but there are commonalities
You talk to friends. They’re full of support; they listen and
too. And the main one, running through every account, is that
console. But you need to talk to someone who knows: someone
people just don’t understand. And that, some of the sufferers
who has been depressed or has been affected by such illness. But
there’s that stigma. People are scared to talk. There is a reluctance
Keys to the Cage
was written for everyone affected by
depressive illness. It’s for those who suffer. Reading these stories,
You almost wish the illness was physical. At least then the
they will feel less alone. At the end of each chapter the lists of ‘The
treatment would be clear. The broken leg could be set, the cancer
things that helped’ and ‘The things that didn’t help’ will give
treated with chemo. Mental illness is more complex. Should the
sufferers strategies for managing their recovery.
sufferer have antidepressants? Should they have counselling? And
The book is also for those close to a sufferer. For partners,
if so, what kind should they have? Do alternative therapies help?
children, parents, friends and colleagues. It is for everyone who
Does meditation? Should they go on a special diet? Everyone you
wants to understand depression; for everyone who wants to hear
it from the ‘real experts’ – the sufferers themselves. My hope is
As I write this, the climate could be changing. Early in 2010,
Marian Keyes wrote about her current, crippling depression. Shesaid she was living in hell. Her brave words have sparked
Sue Leonard, County Wicklow, January 2010
discussion. Perhaps understanding might follow. Certainly, thepeople featured in this book hope so.
Emma* is twenty-nine. A scientist who works at
Trinity College Dublin, she embraces life. Yet six
years ago, Emma had a mental breakdown.
She had been suffering from depression for nine
never an angry drunk, but alcoholics can be incredibly manipulative.
My parents broke up when I was eleven. I didn’t appreciate at the
The year 2002 started well for Emma. A fourth-year student at
time that that was having an effect on me. But I did get used to
Trinity College Dublin, she adored her course in science and was
sacrificing myself to my father. He came first. I thought, if I behave
better, he will love me more. And I thought that, maybe, he would
‘I’d had a great four years,’ she says. ‘I’d lived at home
stop drinking. I’d confront him sometimes. I’d refuse to get into the
throughout that time. I wasn’t a party animal; I wasn’t out every
car, but I was never a rebel. My teachers thought I was fantastic, but
night of the week, but I had an active enough social life. I did well
there, but I didn’t overachieve. At school I’d always been in the
‘I called my dad after my mini breakdown because I felt I needed
top five. I won academic awards every year, but I quickly realised
the support of a parent. I needed someone to tell me that I wasn’t
at Trinity that I wasn’t that special. And I was okay with that. I just
going crazy. After what Dad had been through with his multiple
wanted to be better than average. Just before the exams, though,
attempts at getting dry, I felt that he would understand. And he was
my mum was ill in hospital. We weren’t getting on well at the time.
great. He hadn’t anything magical to say to me, but he didn’t judge
We have a close relationship; we share a birthday. We get on
me. He didn’t really have any reaction, but that was good. He just
famously, but when we row it’s ferocious.
said, “Okay. This is happening.” And he rang a family friend, a
‘I would be studying all day long, then I’d go in and see her.
psychiatrist. She then rang me, but by then I felt embarrassed. I
She’d give out to me for only being there at two in the afternoon.
suspect she thought there was a “drama queen” element to it. And
She’d say, “Why weren’t you here at eleven o’clock?” It got very
I felt awkward talking to her because she was my mum’s friend,
messy. I felt dismissed, as if my stress wasn’t valid. One day she
and therefore her sympathies lay with her. I felt guilty.’
was giving out and we had a huge row. I had the overwhelming
Knowing she would not get a second chance at those exams,
feeling that, as a daughter, I was not good enough. I was not loving
Emma picked herself up, carried on revising and did well in her
Mum the way she needed to be loved. I felt that even if I got super
finals. She then set off for Hawaii with her boyfriend, to spend
grades, my parents would not be happy. I was doing something
what promised to be an idyllic summer working in a science lab.
wrong somewhere else. No matter what I did, it would be wrong
‘We were living the dream. I loved the work. There was a pool in
in the eyes of one or both of my parents. And that was a horrible
the back garden, and we spent all our spare time scuba-diving. But
feeling. I went home and fell apart. I remember lying on the kitchen
I was waking up every other morning crying. I was homesick, but
floor all afternoon just howling. It was a short sharp breakdown.
I couldn’t understand what was going on in my mind. Why was I
It was incredibly acute, but it blew over very fast.’
Emma had been a happy child who excelled in sport and had
‘When I returned home to Ireland at the end of the summer, I
good friends. ‘I was a perfectionist, and I was quite sensitive. There
told my mother how bad I’d been feeling. And my mother
was a lot going on in my childhood. My father was an alcoholic
suggested that I see my doctor. Luckily, I trusted my GP absolutely.
from before I was born until I was fourteen. He was never violent,
I was incredibly lucky. She’d done further studies in mental health
issues, dealing with depression and related illnesses. I went in, sat
‘In October 2002, I started a PhD in Dublin City University.
That meant I had to live some distance from family and friends. I
‘Straight away she said, “Emma, you’re depressed.” She was so
was in a new environment. Everything was brand new. I felt
completely out of my comfort zone. I struggled on but found life
pretty difficult. And at Easter 2003, my grandmother died. I was
devastated. Her loss had a huge effect on me. It was the first death
‘I was so lucky that my GP
understood. I have spoken
I had known. A cousin and myself were my granny’s favourites.
to so many people since, and
She was especially proud of me. I could always rely on her to say
their doctors have been incredibly
dismissive. There is a fear,
‘Life at this time was very complicated. I wasn’t enjoying my
amongst people, about going
PhD programme. I was struggling with it. The Effexor didn’t seem
to a GP. So many people report
to be working any more. I went back to my doctor and she gave
me a higher dose, but it didn’t really help. I was still feeling bad.
One day I started crying in the lab. That was really embarrassing.
she can get through it, then so can I. I remember feeling so relieved.
People didn’t know how to cope. How could they?
I had a name for it. I was not going crazy but had something that
‘At that stage I’d officially broken up with my boyfriend from
college days, the one who’d come to Hawaii, but we were still
Emma’s euphoria was short-lived. That evening, while chatting
seeing each other. It was a destructive relationship. He was a nice
to friends after she had been scuba-diving, one mentioned that
guy, but he didn’t know how to stand up to me. I have to watch
some of his relations were depressed. ‘He said, “I wish they would
myself. I can be manipulative. I can revert to childish behaviour,
just shut up and get on with it.” That was when it hit home. I
and I need strong people around me; people who can tell me to
realised this illness is something which carries huge stigma.
cop on and to stop behaving badly. We were having a relationship,
‘I was prescribed with the antidepressant Effexor XR 75. It
but not actually calling it one. One night he stayed with me, but
took a while to work, but after two or three weeks when the drug
two days later he came over to say he had met somebody else and
kicked in, I did begin to feel better. Meanwhile, I had weekly
wanted to be with her and not me. That was the ultimate rejection.
sessions of Cognitive Behavioural Therapy.’ ‘This is a form of
I found myself in my apartment thinking, I cannot take this any
psychotherapy that helps people to find new ways of thinking and
more. It was overwhelming. I really couldn’t imagine being able to
behaving to deal with their problems like depression and anxiety.’
face the future or to get through it. I went and found all my
‘I had six sessions, but at €70 a week it was expensive. My family
medication and took the lot. I didn’t really know what I was doing.
helped out with the cost, but I didn’t feel I could continue with it
‘I didn’t feel there was anyone I could call. At that point I felt
people were getting sick and tired of me. Here I was, nine monthsafter I had been diagnosed with depression and I still wasn’t better.
People who have not had depression have a limited tolerance of it.
‘I went to my GP the next day, and she was amazingly
They think, “how long can this go on?” Logically, it makes no
supportive. She said, “We need to take a different approach.” She
sense at all. I did think about ringing the Samaritans, but I knew
changed my medication to Lexapro 10. She sat with me for ages.
they wouldn’t give me a solution. I was beyond talking. I just
She said, “The darkest hour of the night comes just before dawn.”
And she also told me, “I think this is your turning point.” She had
such belief in me. At that point, she was the only person who did.
‘It still irks me when people say
That was the beginning of the road back to recovery.’
that suicide is selfish. Because
Emma was advised to examine her life and to make positive
when you are in that situation, in
changes. She decided then to discontinue her PhD. ‘That was heart-
your head it is the most unselfish
wrenching. I felt such a failure. I’ve always been an achiever, and
thing you can do. You genuinely
though my parents weren’t really pushy, they were proud of me
believe that if you remove yourself,
when I did well. I talked to them, and they said, “We don’t care
you are doing everyone a favour.
what you do as long as it makes you happy.” Having their support
You think you are the biggest drain
in this made all the difference to me. It stopped me from feeling so
Accident and Emergency Department at the Mater Hospital in
Leaving science, Emma changed tack and started working as a
Dublin. They called my father too. He came in, but my mother
retail manager at a store in Dublin city centre. ‘It was a frivolous
was away on holiday at the time. Dad didn’t judge me. He sat with
job. It was easy, and I couldn’t fail at it. That was such a relief. I
me, wanting to make sure I was okay. When Mum heard, she
moved back to south Dublin, close to my family and close to the
wasn’t as understanding. She did tell me a couple of times that I
sea; I’d missed living on the coast. Being close to the sea is
important to me. Most importantly, perhaps, I finally walked away
‘And there was an element of that, though not in a flashy “look
from my former boyfriend. That summer I met someone new. I felt
at me” way. I suppose I was trying to tell people that I still wasn’t
so much better by then, and in the autumn I cut the dose of
well. At that stage, talking to them didn’t seem to be getting the
Lexapro by half. And by February 2004 I came off it altogether.
message across. I didn’t need my stomach pumped out. I hadn’t
‘Two weeks later, my new boyfriend dumped me. The day after
taken enough pills for that.’ She laughs. ‘I couldn’t even do that
it happened, I walked around the Botanic Gardens and something
right! They kept me there for four hours under observation, then
told me I would be okay. It took a while, but I got through it. I told
sent me on my way. Nobody came down to talk to me. They just
myself, if I can survive a break-up without medication, I can cope
told me to go to my GP. I went home by myself, feeling such a
failure. All I had done was cause huge upset to all the people I
‘Two thousand and four was a bumper year for me. I went off
cared about. And now they were more than likely angry with me.
to South America for the summer. I was teaching scuba-diving justto please myself. And when I came back, I began a Research
Masters in Science in Trinity. I got back into sport. I went to the
was too embarrassed to ask for help. I would love depression to be
gym and I started to eat well and to look after myself. The
more acceptable to people. I would love the awareness to be better.
medication had caused me to lose weight and then gain it. I have
I’d like to stamp out the continued misconceptions. Even the term
never been skinny. So working in retail alongside all the stick
“mental health issues” has connotations. That makes it tough to
insects had been difficult. There had still been an emphasis on “the
find help. There is little information available about psychiatrists
skinnier I can be and the prettier I can be, the more successful I will
and psychotherapists. Their qualifications can vary widely, and it
be.” I am over that now. My life since then has gone really well. I
have had another bad break-up, but I coped fine. I know now that
‘The very worst thing you can say
it is not all my fault. But I recognise that I choose people who are
to someone who has depression is,
a bit broken. I try to fix people. I have to be careful about that. I
“you will be grand.” That invalidates
am very happy being by myself at the moment.
what the person is feeling. It
‘I now work in Trinity. It’s a great place to be. I could never
If someone tells you they have depression, how should you
‘I manage to stop slipping back to
really dark places by accepting that
react? ‘Talk to them. Ask them about it. And don’t dismiss it.
I will get things wrong sometimes
When people come out with news like that, their friends tend to
competitively. And it’s
shy away and feel embarrassed. When I spoke about it and people
something that I do entirely for myself, to make myself happy.
actively asked about it, I felt, this is great. I can talk about it. That
‘I’m aware that I’m still susceptible to stress. If I had a massive
upset, I am prone to getting bad again. I’m a little sensitive. I still
‘And when someone says, “I know someone who suffers” or
wonder if I am good enough to do certain things. I still don’t put
even, “I have suffered myself,” that is just amazing. You know
myself in a situation where I can fail greatly. I avoid something I
they have some kind of understanding about it.’
know I will not cope with. There have been times that I have beenin danger of slipping back into bad thoughts. Being aware that
that could happen is really important for me. I check in withmyself, just saying, “this is happening,” and I need to look at what
Having her to talk to made all the difference to me.
it is in my life that is causing it. Then I make a conscious decisionto do something about it.’
The stigma of depression, Emma says, makes life much worse
That got me back to a place where I could start coping.
for a sufferer. ‘I was very careful whom I told. Doing the PhD, I
But there were side-effects. With Effexor XR, I felt sick
constantly felt that my work was just not good enough. And
every day from two p.m. onwards. I couldn’t eat.
because the people there knew that I suffered from depression, I
Lexapro suited me better. I think that’s because there
were anti-anxiety pro- perties, and anxiety is something
I went to a counsellor and she asked me about my
‘I like to be good to myself
dreams. I thought, please stop it! The scientific side of
for no other reason than
me did not like it. I walked out thinking, I feel no better.
because I want to be. I’ll walk
For me, the problem with counsellors is that I find it
down to the Farmers’ Market in
difficult to talk to someone unless they help me to find
Dun Laoghaire on a Sunday
some kind of solution. That is why I liked the Cognitive
morning for a California
Behavioural Therapy. It gave me coping skills.
Market Bakery muffin
1. Don’t be afraid to talk. Never be afraid to ask for help.
would have had more if I had been able to afford it. I had begun to explore why the depression was
2. Go to your GP. If he or she is not sympathetic, go to
happening, but I did not really have a chance to put my
coping mechanisms in place. It did help, in that it was
3. Realise that other people have been through the same
somewhere to go and bawl my eyes out without being
thing. Read about famous people with depression such
as Winston Churchill, Leonard Cohen and Emma
At my lowest point I took a huge amount of comfort
4. Trust someone when they say you will get better.
from an online forum. It was anonymous. It gave me a sense of calm to read other people’s stories. It stopped
5. Don’t be frightened to take antidepressants.They
the isolation. But as soon as you realise you are better,
should get you back to a place where you can start
it feels like an indulgence. You realise, I am wallowing
I never attended a support group, but a couple of close
friends were a great help to me. They still are. There is
Cognitive Behavioural Therapy – www.icbt.ie.
one I turn to if things are difficult and I need
e-mail submissions to email@example.comSir—Björn Dahlöf, in the LIFE study,1Lars Lindholm and colleagues “to share exciting news” and remindme of the results of the LIFE study. cardiologists received the same letter. Iporosity of liver sinusoids in relation toloss of integrity of the endothelial lining,Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and
Evolutionary Change within the UK Pharmaceutical Industry: A Cladist Approach. Graham Leask Aston Business School Aston University Draft Paper to be presented at DRUID January 2002 Abstract This paper seeks to examine the effect of a decade of rapid change within the UK Healthcare environment upon Pharmaceutical Companies. Between 1990 and 1999 the UK Pharmaceutical