Page 13, 4th July 2008

4th July 2008
Page 13
Page 13, 4th July 2008 — Black dog days

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Black dog days

The New Black by Dalian Leader, Harnish Hamilton £17.99 Depression in the medical sense used to indicate something physical as well as mental which was not necessarily, but might be. a reaction to events. Despair was combined with other symptoms such as loss of appetite and early-morning wakening. Drug companies invented drugs that corrected appetite and sleep disturbances and lifted mood. The illness matched the cute: "depressive illness" described, more or less, "what anti-depressants treat".

But when, about 20 years ago, a drug company came up with a new kind of antidepressant, the SSRIs (Prozac is the most famous one), which were actually no more effective than the old anti-depressants but which were much safer in overdose and lighter on side effects, the temptation was obviously great to throw them at a wider range of mental problems and to enlarge the medical definition of depression. It can't have come as a complete surprise to doctors when research showed that these drugs don't work on many of their patients, not in the way they are supposed to work, anyway. But doctors have struck an unspoken deal with "worried well" patients. The patients believe a pill will keep them happy and who is the doctor to disabuse them, so long as no one is getting hurt?

Does this process, in fact, harm patients? Darian Leader, a psychoanalyst, thinks so, and not just because it turns out that the drugs have side effects and can produce withdrawal symptoms.

Leader blames the drug companies for manipulating the evidence to favour their products, and "today's quick-fix society" for swallowing the drug industry's PR. His solution is more talking and listening. But he has no time for the costeffective Cognitive Behavioural Therapy (CBT) beloved of the present Government: "It works. But not in the sense we might wish for."

The inadequacy of CBT goes to the heart of his book. CBT fails in Leader's eyes because "as a superficial treatment, it cannot access unconscious complexes and drives". These drives are Leader's real subject; he is a devoted Freudian.

The New Black is a clever but not completely convincing study of mourning and melancholia sprinkled with literary references in addition to the histories of patients. "Let's take a clinical example," begins a typical paragraph. Despite Leader's gentle tone as he unpacks his elaborate theories, it is clear that understanding the processes matters at least as much to him as relieving the distress.

Leader says little about what happened to his patients after their analysis. In what way, if at all, did the analysis "work"? For Leader "the primary goal is not the removal of symptoms". Which is all very well for the therapist fascinated by the complex web of causation deep in the patient's unconscious, but what about the patient? Would he like to feel better? Psychic detective-work about "X" or "Anna 0" or "Madame N", however fascinating and florid their symptomatology, does not amount to evidence that 'psychoanalysis works better than medicine.

On CBT, though, Leader makes a good point about the potential creepiness in its technique of re-educating patients to see that they are not really depressed. Now our Government has decided it likes CBT and wants state-funded practitioners on every high street. Before this, it was most widely used in China: to encourage positive feelings about the Cultural Revolution.

Andrew M Brown

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