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216 pp Price £7.99 ISBN 0-571-20727-8 (p/b)
London: Faber & Faber, 2001 .
A pastime of doctors is to rate the diseases they would wish not to have. Depression invariably comes high on the list. A colleague of mine, prone to recurrent episodes, remarked on the special bitterness of being a doctor-victim; and, in Malignant Sadness, Professor Wolpert (a research biologist) acknowledges that the burden on physicians is particularly high. The book, originally published in 1999 and now reissued with a new introduction, is derived from his own experience of depression. Responses to his personal revelations, in newspapers and in a television series, indicated that many people still hesitate to seek treatment because of the stigma attached to this condition. Wolpert himself, before his severest breakdown, subscribed to the ‘sock’ school of psychiatry—pull them up.
Malignant Sadness is written for lay people and for the support organizations to which many now turn. Patients with depression will find it helpful, particularly when they are recovering, and it will be an invaluable read for their relatives. Wolpert's inclination is towards a biological cause and remedy but his discussion of psychological explanations and psychotherapy is fair and balanced. But with his enthusiasm for evidence-based medicine he barely touches upon the group of patients that causes doctors most concern—those off the evidence-based map. Most medical conditions lend themselves to an algorithmic treatment which could be provided by almost anybody. What distinguishes a competent medical practitioner from those ‘anybodies’ is an ability to help that minority. Indeed for an open-minded scientist Wolpert is remarkably dismissive of the principle of taking into account the individuality of each patient when prescribing: he condemns it as a misguided stance typical of alternative medicine today. By contrast, he commends the patient groups for their work with depressed people and their families. Children become depressed. Wolpert points out deficiencies in our knowledge of causes, symptomatology and management. Probably depression is underdiagnosed in children, not least because the presentation differs from that in adults; unexplained symptoms, both physical and behavioural, may have a depressive origin.
The relationship between depression and uncharacterized polysymptomatic conditions such as chronic fatigue syndrome (CFS) is explored. Depression is part of the differential diagnosis of CFS and a complication of it; but many who suffer from CFS, and those who care for them, resist the notion that it is a primary psychiatric illness. It shares with depression an inadequate vocabulary. Victims point to the feeble descriptive name and Wolpert makes the same point concerning depression: ‘we certainly could do with a better word for this illness than one with a mere common connotation of being “down” ’. His title Malignant Sadness reflects his view that depression is a pathological and destructive maldevelopment formed from the everyday experience of sadness. The widely distributed (and sometimes perhaps beneficent) ‘sadness cell’ undergoes malevolent differentiation, resulting in the malignant condition of depression. One wonders what is the corresponding clinical condition for malignant anxiety and whether it is recognized as such.
Finally and most welcome Wolpert tackles international and intercultural psychiatry head on. From his discussions with clinicians and sufferers in Asia and South America he concludes that depression is as heavy a burden in these places as in the UK. Many depressed individuals in developing countries lack access to the kind of services that helped Wolpert so effectively. There is a hint in the book that, though a non-believer, he does not reject totally some Eastern beliefs such as taoism. Writing this review in Sri Lanka I am surprised to read that here ‘hopelessness is positively valued as it fits with the Buddhist's view of the nature of the world’. I am not surprised that, in this wartorn country, the incidence of depression in civilians has hugely increased and that ‘Sri Lanka has recently acquired one of the world's highest suicide rates—47 per 100,000 in 1991—with most victims under 30 years old’.
In this review I have not otherwise touched upon suicide—the cruelest outcome of malignant sadness and one which does not always attract sympathy. Its rising incidence, especially among young men, takes its own emotional toll. How disappointing, considering the range and effectiveness of pharmacological and physical treatments, and how regrettable it would be if this became an acceptable way out of depression; might the dead hand of euthanasia not be far behind? Malignant Sadness is an absorbing book which I read with great profit; enjoyable, no—but thankfully I did not feel gloomier at the end than at the beginning.