The Secret Strength of Depression

How to write a best-seller about depression is a secret that was cracked by Flach nearly thirty years ago when the first version of this book was published. Reading this latest edition, it is easy to see why more than half a million copies have been sold. His recipe for success is simple. He views unipolar depression as a normal reaction to stress and not a form of mental illness. He mentions bipolar depression on several occasions but recognises that it is a very different kind of condition with a different aetiology and needing a different approach. This book is aimed fairly and squarely at those who think that they might be suffering from unipolar i.e. straightforward depression and those who have to live with or cope with people suffering from such depression.

Flach insists that depression is common and a normal part of most people's lives at one stage or another. This approach is extremely positive and helpful. Treatment of (unipolar) depression as a mental illness is thoroughly unhelpful for sufferers because it deters them from asking for help. Insurance companies and employers will almost always penalise them if their condition is included within the category of mental illness. If we all treated depression as a normal reaction to stress of one sort or another, everyone would benefit.

Not only does the author see depression as normal but he also sees it as potentially healthy. It is at this point that his distinction between acute depression and chronic depression becomes important. Acute depression he sees as the perfectly normal reaction to bereavement, divorce, job loss, retirement, etc. It is not being depressed under such circumstances that is the problem. The problem arises only when the sufferer fails to face up to and come to terms with the cause of the depression. When that happens the depression may, so to speak, go underground. That is when it transmutes into chronic depression which is a more difficult condition to treat.

Flach views depression in an unusually holistic way. He lays great emphasis on the links between the psychological, environmental/social and the physiological aspects. The psychological aspect is perhaps obvious but the author covers some unusual ground, touching upon, for example, the potentially positive role of guilt and the contribution that a spiritual view of life can make. He is acutely aware of the environmental/social factors which can either support a person suffering from depression or, at the opposite extreme, can actually provoke depression. His description of what he calls depressogenic environments is extremely enlightening. A family member can, by destructive behaviour, cause a whole household to become a depressogenic environment and many of us will have come across such a person and the harm that s/he can do. Perhaps even more illuminating is the author's description of the workplace where, because of the attitudes of someone near or at the top of the hierarchy, a depressogenic environment is created. People working in such an environment either have to leave to find employment in a more positive structure or bit by bit they succumb and can end up chronically depressed. The third aspect, the physiological, is an area where the author has himself been involved in considerable research. His main area of research has been in the changes to calcium metabolism in patients suffering from depression. There is evidence that depression is linked to an increase in calcium in the coronary arteries and that, as the depression is lifted, the free floating calcium is re-deposited in bone. This is a complex area and is linked to a wide variety of other physical factors such as the level of cortisol in patients suffering from stress-related depression. However, it is good to see such a holistic approach. As the author states, "… it remains essential to view the human being as a whole – mind, body, inner world, outer world, acting, reacting, interacting, creating." (p.202)

Largely because of this holistic view, Flach is particularly open to using a wide variety of methods to help patients suffering from depression. He is not sympathetic to traditional i.e. Freudian psychoanalytical approaches but he is supportive of all less narrow, more eclectic and more all-embracing forms of psychotherapy. He recommends family counselling when it seems appropriate. He is very knowledgeable, as one would expect of a practising psychiatrist, about all the drugs available and their good and bad points. He is aware of the complex interplay between physical symptoms and psychological causes and as a result he is also aware of the 'chicken and egg' question as to which one is causing the other but he is adamant that the wise use of drugs can be a helpful part of the treatment of depression. He mentions Electric Convulsive Therapy (ECT) and the newer and less drastic [rapid-rate] Transcranial Magnetic Stimulation (rTMS) only in connection with extreme cases of bipolar depression but he states that they can be very effective forms of treatment. It is up to readers whether they agree with Flach's support of ECT. Many workers in the mental health field to-day have extreme reservations about its use.

The author's distinction between acute and chronic depression is usefully applied in several areas and linked with, for example, post-traumatic stress disorder. The difficulties involved in diagnosing and then treating chronic depression are well-described. Particularly good is his analysis of how people often engage in behaviour which traps them in a self-reinforcing depressive situation.

Flach devotes several chapters to particular problem areas. The chapter on sex and the sexual demands made of people these days has a very contemporary feel to it. Equally useful is the chapter on anger and how, on the right occasions, it can be the right reaction to a situation. The chapter on work and especially the pressure to succeed at high-powered jobs is sobering and should be read by everyone putting in fourteen hour days! The author is very sensitive to the delicate balance needed between marital partners if both are to remain mentally healthy with the result that he has a very good chapter on dependency. Other excellent chapters are on childhood and adolescence. The chapter about the elderly contains some particularly sage advice concerning retirement.

Flach's insistence on depression as being a normal reaction to highly stressful occasions, his distinction between acute and chronic depression, his holistic approach to supporting people suffering from depression and his positive view of depression as an opportunity for personal growth make this a highly recommended book for anyone suffering from or interested in depression. The book will almost certainly go into yet another edition, as it surely deserves, and this should give the publishers the opportunity to correct the typos which have crept in, especially the use of 'martial' for 'marital' on p.105 although the concept of 'martial infidelity' may well be worth thinking about!

© 2004 Kevin Purday

Kevin Purday is Head of the Cambridge International High School and is currently a distance-learning student on the Philosophy & Ethics of Mental Health course in the Philosophy Dept. at the University of Warwick.