Phil says 'I have to admit that I am not well read on personal accounts of depression. This is, in part, due to an inherent disability with, and a secondary dislike of, reading. The notion of trawling through others' experiences of misery is also an uninspiring thought and one that fills me with inertia.  Despite this I have decided to inflict this upon you with no obligation or expectation that you read any further.'

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I believe the term "Black Dog" is attributed to Winston Churchill.  I have been in a quandary as to whether this is an accurate title for my personal observations as most contact I have had with dogs has left me with the distinct impression that they are happy souls. Whilst I have nothing against carapaced quadrupeds, I feel a closer analogy is with a “grey tortoise”.  The lower case initial letters are deliberate. This, for me, better illustrates the global psychomotor dysfunction that is my depression.  The “Springer Spaniel” is the reader who has never experienced a depressive illness.  I started this account when I was just emerging, touch wood, from a 7 month period of this mental plague.  In some respects words are the problem and any account is restricted by the sufferer's vocabulary.  There are, I think, also limitations to the human language in this respect.  The process of perception to description is a complex one and as thought processes are affected by this condition, possibly a flawed one. That said, this is what it felt like to me at the time.

Perception is as good a place as any to start. The effect I observe is one of a multi-sensory damping. This could be described as a blunting of the senses or of the filtering of input.  All of the senses are affected.  I hear things as if underwater, I see things in greyscale, I smell things through charcoal and touch is as though wearing gloves.  This is not unpleasant and I postulate a sort of involuntary sensory inattention brought about as a result of a diversion of brain resources elsewhere.  Periodically, input will be totally overwhelmed by thought, such that I cease to exist in my physical environment.  This could be described as a feeling of detachment, depersonalisation, being half alive and half dead or being a passive observer of what's going on around.  All these descriptions are inadequate linguistic approximations. Indeed there exists a paradox as there is much activity in the head but little interaction with the outside, as if somehow the balance between these two is disturbed.  Thinking about thinking itself can ensue and it is this phenomenon, also known as metacognition, which resulted in my jottings.  I did attempt to use mind mapping, as processing the thoughts into words was difficult.  Unfortunately my ability to concentrate made learning a new thing impossible.

This rather conveniently leads me to remember one of the classic diagnostic criteria used by doctors. We are asked if we have loss of concentration but that is the observed effect. I would suggest, however that what I experience is a diversion of concentration into an internal place. It is as if the full cognitive functions of the mighty organ in the head are diverted into resolving the turmoil or malfunction. In doing so, the outside world has to go on hold. This could be regarded as an exaggerated normal trait of the male sex, the tendency to internalise problems, whereas the female sex is widely described as preferring to talk things out in search of an answer. So the man shuts down, goes quiet and turns his exhaust on himself whilst the woman wails vociferously and makes a dramatic overdose in an attempt to communicate their distress. Sorry for the simplistic and sexist characterisation, but I had a flight of idea! So there is a limitation here, whereby I can only account as a man. My feeling is that it is possible that the apparent lack of concentration ability is only an external observation, secondary to the preponderance of compulsive, obligatory, irresistible and unstoppable thinking, which diverts finite mental capacity to the detriment of external functioning. 

Presently, I believe the primary dysfunction of this disorder is of thinking. Thought becomes pervasive and continuous but is disorganised, and this may be the root issue, that because thought itself is dysfunctional, the ability to explain one's predicament, look for answers, is impaired. This inability to provide an answer invokes an internal struggle to resolve a problem for which one temporarily has no answer. It is exhausting and frustrating. Once again male / female differences could lead to separate manifestations of this disorder, as we are told that the male strives to solve problems internally for the good of his mate. A deficiency in this innate function could easily emasculate a man and cause feelings of inadequacy. 

For me, the hyper cognition is, on occasion, stimulating.  The circular un-resolving thought process however, I could easily describe as a state of misery.  Perhaps this dichotomy goes some way to elucidating the term bipolarity.  There lies a key difference between sadness and depression in my view.  The "misery" of depressive illness is as a result of the disordered internal thoughts whereas sadness is an emotional reaction to an external event.

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I have been aware of a quite incredible ability to hide the severity of my condition from others.  Even my wife is spared from the worse extremes of my feelings although she will often say in retrospect that she saw it coming.  This may stem from my reluctance to give in to emotion, particularly to crying.  It is not to say that my wife does not suffer, indeed I am periodically aware of being a burden and causing distress, although this tends to come to the foreground as my thought processes clear.  Even at my worst I am able to have seemingly quite normal interactions for short periods of time with friends, relatives and acquaintances.  I am an honest man and matter of fact about mental illness.  I have no difficulty discussing it or admitting to having it and do not feel the stigma but am aware of its effects.  However, I somehow and for some reason strive to hide the symptoms from others.  The feeling is one of not wanting to bother others with it and so burden them or cause awkwardness.  There may also be a contribution to these efforts made by my belief that no one else can understand my situation or can help.  This mask is almost impenetrable except to my wife and after some fighting, my psychiatrist.  This is undoubtedly a cause of delays in my diagnosis and treatment.

Negative thoughts abound within this inner melee and a further battle is present to suppress these.  Approximately fifteen years ago, I underwent hypnosis as an adjunct to antidepressants.  I appeared to be susceptible and my experience was very satisfactory.  My abiding memory of this is that I was "implanted" with a suggestion during hypnosis that I would recognise negative thinking and not allow it to continue.  I believe that this really does provide me with an almost automatic "booting away" of negative thoughts.  This facility however, appears to be overcome during my depression, possibly as a result of the impaired resource of thinking.  Negative thinking festers when I am at my worst to the observer; this is when emotion can appear and in my own experience has resulted in the agonising symptom of morbid jealousy.  I know, absolutely that this is my disordered thinking, as when well; I eulogise about how important trust is in a relationship and genuinely feel immovable in my trust of my wife.  Another strongly held belief of mine is that there is nothing after death and my simple scientific foundations allow me to accept that memory ceases at death so it holds no fear.  However, again, at my worst and to a point even now, I am apprehensive that death will occur and I am not "ready".  I have been able to assuage this negative thought up to now but it initiates itself several times a day.  It could be postulated that the fear of death, in my case, is what protects against suicidal intent.  It does not stop suicidal ideation, which at times seems a logical solution to my predicament.  Possibly, it is when the fear of death goes that suicide attempts are considered more actively.  My feelings were that I would like the pain to stop and if that meant death then so be it: effectively passive suicidal ideation.  I am thankful that I have only felt suicidal for fleeting moments.

This physical manifestation of anxiety troubled me enough to attract the label "agitated depression".  Most notable was the churning stomach.  I have not thought a lot on this subject but felt it significant enough to mention.  I tend to think of it as secondary to the "misery".  It could simply be that anxiety is a reaction to the panic associated with not being able to resolve thoughts or that panic is a direct complication of circular thought.  Certainly, it is a real feeling that the problem is not going away and fear of what the future holds is reasonable.

I am by my very nature cynicism personified.  I say this merely to add dimension.  Immediately prior to my current exacerbation I can recall factors that could have combined to precipitate a metaphorical overload of my thought mechanism.  I have always felt "out of place" in medicine.  I am from a modest upbringing but have always shown above average intelligence and achieved exam success without effort.  I am extremely shy and to this day still have difficulty overcoming this in my everyday interactions with everyone, but specifically patients.  Being a doctor has been helpful in learning to manage this, but it involves significant effort to keep it up.  I feel somehow exposed to others and doubt my abilities.  Being a doctor however is so rewarding and interesting that it is easily possible to build up a belief in one's ability.  I continually get positive feedback and am sure that patients appreciate me.  I am compassionate and considerate.  I think that I can suffer fatigue from the demands of the job particularly because some patients take advantage of my willingness to listen.  Further insight into my vulnerability here is that I feel bad that I have just said that about my patients.  In retrospect, my depression had resulted in me, quite inappropriately, feeling under acknowledged by my colleagues.  There have been specific disagreements between myself and a younger but more senior consultant colleague which have frustrated me and I have decided will necessitate me dropping an area of my practice.  This makes me sad and I have railed against it internally for some time.  However, this area of my practice, chronic pain management, does involve contact with patients who I will describe, uncharitably, partly as a result of their predicament, as demanding.  It’s probably wise to restrict my contact with these patients.  I have started a period of my practice where younger doctors are less experienced than me, but more qualified - my facility with exams stopped after undergraduate level.  I have no difficulty accepting my lower position of authority when I am well.  I am completely disillusioned with the state of the NHS and of hospital management locally and nationally.  I therefore, feel an element of walking up the down escalator.  I am bitterly opposed to the encroachment of people’s civil liberty in the name of public health, specifically smoking bans, but inclusive of all dictates demanding life style changes.  The smoking ban has seriously affected my daily life and caused social separation for my wife and me.  The effects are everyday and every way invasive and diabolical.  I am financial wreckage as a result of an inequitable divorce and no education into money management.  I suspect these factors are enough to cause a derangement in thought.

As a discrete observation I will describe my experience with crossword completion.  I enjoy a simple crossword and tend to attempt those that I know I have a fair chance of completing.  These are the Sun, Times2 and short Daily Mail non-cryptic crosswords.  Occasionally I will start the Daily Mail cryptic and get half the solutions.  However, during this last depressive episode I felt more attracted to the Mail cryptic and doggedly pursued the answers despite cloudy concentration abilities.  I would come back to it, after a rest, repeatedly and despite completing it only once, I kept going back for punishment!

I am almost convinced that, in my case, and by inference many others, the primary fault is with the handling in the body of serotonin and its precursors.  I have read and read and will continue to look for the best scientific understanding of “Depression”.  Essentially, the key factor is serotonin supply.  Its existence is evanescent and so a continual supply or turnover is occurring.  The situation is therefore dependant upon a supply of the substrate for its production, the essential amino acid tryptophan.  Much is written about non-pharmacological methods of managing depression, but the key to these alternatives has to be producing or maintaining serotonin levels.  Serotonin exists as an almost humeral neurotransmitter all over the brain and certainly has a place in maintaining motor activity, mood, thought and sensory information processing.  Depression is a decline in performance in all these areas as witnessed by the global “depression” of all these functions.  Depression is a wholly inadequate handle for this condition and belies the pervasive effects it has on the sufferer and the undeniable fact that it is a physical illness, a derangement of brain physiology.  The non-pharmacological methods of managing depression no doubt can play a part.  Mood enhancement, happiness training, the avoidance of negative thinking (Cognitive Behavioural Therapy), counselling to help resolve problems and exposure to light, in my opinion are almost certainly helpful.  Exercise, I reserve judgement about, as the balance of opinion is still equivocal, and my experience is negative in this respect. Tryptophan availability however, I suspect, could be key and very significant.

Tryptophan competes with other large amino acids for transport from the gut and across the blood brain barrier.  Dietary manipulation using tryptophan rich foods is therefore of doubtful benefit as the tryptophan is available in the protein content of these foods.  This means that it has to compete with the other amino acids also present in high levels.  To increase absorption, therefore, the tryptophan content has to be increased differentially, as L-Tryptophan.  Furthermore fructose malabsorption syndrome, which exists in at least thirty per cent of the population, can cause malabsorption of dietary amino acids, probably due to increased intestinal motility.  High glucose/fructose content ratio foods are recommended in this condition.  In addition irritable bowel syndrome (IBS) will cause a reduction in efficiency of amino acid absorption.  The incidence of IBS in depressed patients may be higher than the rest of the population.  Serotonin has a neuro-axial regulating effect and a direct effect on gut function and selective serotonin reuptake inhibitors (SSRI’s) have been used specifically where bloating, pain and flatulence are predominant.  Tryptophan may therefore be important to regulate bowel function in depressed patients in order to maximise serotonin availability for bowel function and therefore tryptophan availability itself.