Razer's Class Warfare

Mar 1, 2018

Razer: “awareness” is going to solve very little when it comes to depression

Johann Hari's new blockbuster book is doing good work debunking the power of "awareness", but we're still not given the full story.

Helen Razer — Writer and broadcaster

Helen Razer

Writer and broadcaster

Johann Hari

If you ask me, the dominant discussion around mental ill health is a guarantee of more mental ill health. Of course, you didn’t, but I have been wont in any case to provide an answer: popular journalism, political speech and public campaigns on mental health are faulty. Both conversation and policy are led by a faith that “awareness” is a primary defence against illness -- nowhere has this placebo been more adamantly served than in the ABC’s “Mental As” programming, which delivers us the message that “stigma” is the cruellest cut of all.

Stigma is a problem, but to declare this with such centrality is to imply that stigma’s absence is a cure. Yes, it is unhelpful when the common disorder of depression is perceived by some as indolent self-pity. No, if we remove the “stigma” from the social body and swap it with “awareness”, the best medicine has not been prescribed.

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26 thoughts on “Razer: “awareness” is going to solve very little when it comes to depression

  1. David Barrow

    My Personal Story Off and then On Bipolar Meds: 1989 to 2018

    1989: age 19 onset of bipolar symptoms: disruption to relationships, career and finances due to manic and depressive moods. This raged for the next 18 years.

    2005: age 36 first bipolar medical diagnosis after attending psychiatric sessions for 6 months. Diagnosis confirmed through second opinion of world leading psychiatrist Prof Isaac Schweitzer.

    29 March 2007: after 2 years of resistance I finally started taking Lithium. Very positive results stabilising moods which enabled me to work the regular hours of a job again. Since then have taken Lithium daily for 10 years and added Lamotrigine in Dec 2007 to give more protection against depression. It should be noted that these bipolar medications can have serious harmful side-effects; although I have not suffered any that I am aware of or have shown up in regular blood tests.

    Summary: 19 years with no symptoms; then 18 years bipolar raged without medication; then 10 years on bipolar meds and have achieved really good mood stability with access to energy and creativity that I feared were at risk of becoming impaired if I started taking meds.

    I would recommend people with disruptive moods seek out an opinion (or a couple of them) from a healthcare professional, and also consider medication. For me it has been a miracle and perhaps it will work wonders for you as well.

    David Barrow

    1. Helen Razer

      Thanks, David. Let’s also recommend adequate spending on research and treatment for all. As I understand it in conversation with psychiatrists and advocates, bipolar disorder with its relatively low prevalence (compared to depression/anxiety) is one of the conditions that “slips through the cracks”. Which is to say, people who can really benefit from the most help receive it the least.
      I am so very happy to learn that you have achieved an acceptable balance with your health. This is the thing, right? People can. Largely, though, it’s a matter of luck when it comes to mental health. We want for everyone what you have achieved.

      1. David Barrow

        Hi Helen, thanks for engaging in posts in the comment section. Some trickle down medical stats say that bipolar is actually quite prevalent at about 1% to 2% in the human population. From what I’ve read over a decade ago, a persistent difficulty is the delay in initial diagnosis, with a 10 year delay not uncommon. In my individual case, I had a sense that something was awry with my moods around the time leading ‘manic-depressive’ researcher Kay Jamison visited Melbourne University to present a public lecture in 2000. It was still another 5 years before I sought a medical evaluation after I gained more insight observing a friend who was getting more and more out of control with a bipolar condition. With recent celebrity disclosures of the bipolar condition (Catherine Zeta-Jones; Russell Brand etc) perhaps there is a risk of some initial overdiagnosis now where the assessment relies on recounting personal history. Although I expect presentation with symptoms of the spectrum of depression or mania would be alternative compelling tells, as well as the consequences of episodes that involve risk-taking and/or even self-harming.
        It seems to me that underdiagnosis is a much greater problem than perhaps fashionable overdiagnosis. Again from my reading of over a decade ago, substance abuse is a vast problem for people with a bipolar condition as a ‘self-treatment’, many of whom may not have had an accurate diagnosis. I have also read that there is a suicide lifetime ‘success’ rate as high as 20% for an untreated or poorly treated bipolar condition.
        In this serious context, raising awareness of the bipolar condition through personal stories can be helpful for people to obtain medical assessment(s) and consider taking effective medication.
        For all the insight and empathy-awareness that came from the 18 years between 1989 and 2007 of whiteknuckled, untreated rapid-cycling bipolar chaos, I would have preferred that someone encouraged me to explore medical help earlier. In my case, it would have saved me much needless suffering. Helen, if I’ve understood your position correctly, your attack on raising awareness through people like me telling our personal stories is not helpful for others finding help.

        1. Helen Razer

          I do not dispute this at all, D. Yes. A clear (and not exploitative or romanticised) account of bipolar is helpful. However, this article is about the highest prevalence disorders and the ones so often discussed: depression and anxiety.
          While I agree with some of Hari’s impulses (he wants to show depression as a symptom of society) I do not agree with all (he wants to get people “off drugs”. Seriously. I do not know why he feels so able to conclude that drugs are ineffective. I get that depression may be in many cases caused by life. My own, for example. To go on to find doctors who lump all antidepressants in together, and all depressives, and say “they just don’t work, and are dangerous” is not a great place to arrive at, in my view. Hari is good and bad).
          The “depression can be social” is a good argument in both an MH and broader policy context. But, not how he does it.
          Similarly, awareness raising can be good, but not how it is usually done. Friends with bipolar tell me, for example, they find something like Silver Linings Playbook offensive for its “oh, you sexy genius” ways, or see the elevation of “successful” people, like the late Carrie Fisher or Fry, as a bit of a deception. Those guys can get help. A load of people can’t. A bipolar friend was so upset a few years back with Mental As on ABC, I started to watch the thing and got just as angry as him. He was all, “When I am on a downswing, ‘stigma’ is the least of my problems.” That stigma was discussed as being a big problem for people with bipolar (I know it is in many cases) to the point of overemphasis has the effect of making people like they are truly helping just by understanding etc. This really diminishes the political will desperately needed to make the life lived with bipolar less uneven.
          Anyhoo. I know bipolar folks often have periods of “depression”. Just to be clear, this depression is not the sort I am discussing here or the sort Hari describes in his book. It’s the medical category.
          And, seriously, you really have done bloody well and you get a Mental Health gold star from me.

          1. David Barrow

            Well, I think bipolar sufferers get a Mental Health gold star when we consider getting more information from a healthcare professional about the turbulent mood waves. And if a diagnosis is confirmed, I found keeping a mood diary helpful and eventually trialing the gold-standard medication of Lithium even more helpful. These treatments don’t work for everyone but it sure helped me.
            I can’t recall any high-profile bipolar sufferers when I was in the first decade grip of the illness. I went to my local GP in about 1990 and said I felt really down. He asked ‘why are you really here? Come on, there are sick people waiting to see me’. Reluctantly he ran some blood tests and of course nothing showed up, as the bipolar condition is not determined in that way. After that I felt doctors were not going to be so helpful. An extraordinary anecdote. Times have changed.
            I feel I would have benefited in the earlier stages of my condition if I had seen a celebrity-stacked Stephen Fry type doco on bipolar. Or even a Silver Linings Playbook (which director David O. Russell said he made as a gift for his 18 y.o. bipolar son). And the discussion around these. If the present me sat down with the me in my 20s and raised insight / awareness through my personal story then (1) there would likely be a tear in the time-space continuum that could destroy our part of the universe (sorry) and (2) I could have helped me to find treatment earlier.
            Helen, in 2016 you wrote: “I feel for Guy Pearce. But, as a person who once had a diagnosis of PTSD that led, as such things overwhelmingly do, to complete professional meltdown, I know that seeing a handsome dude who makes about five feature films a year talk about his struggles with anxiety would just have made me feel more unproductive and worse.”
            Me, I prefer to hear stories like Guy Pearce. That raising of awareness can help to reduce stigma and encourage those who could benefit to seek out treatment. Perhaps Guy Pearce became more productive making movies because he is receiving effective treatment? Or just suffered less in not dragging himself through the process with a needless burden. In the case of bipolar, I get enough pills to last me 3 months for about $7. But first you need to know that these pills can help you.
            Helen, if you want to frame ‘awareness’ as some ineffectual exercise on Beyond Blue brochures then I’d encourage you to think more broadly.
            You also say your article is about the “highest prevalence disorders and the ones so often discussed: depression and anxiety”. Um, if a spectrum of bipolar occurs in 1 to 2% of the human population, that’s over 70 million people (200,000 Aussies). A lot of people who could benefit from awareness, even if it breaks through to them with the dazzle of ‘celebrity’ lives: Stephen Fry, Catherine Zeta-Jones, Richard Dreyfuss, Carrie Fisher, Linda Hamilton, Jean-Claude Van Damme, Adam Ant, Sinead O’Connor and Russell Brand… and perhaps Robin Williams.

          2. Helen Razer

            Take your points, D. But, am not striving to say that depression is more “important” than bipolar. Just that it is much more widely felt. An estimated 25% of the population is more than 2%.
            I understand that you and others have felt great gratitude where stigma is reduced. My only point is that this helpful thing is often posited as a solution.
            My other point is that real focus on everyday people would tend to be more helpful not only to everyday people but to policymakers, who have largely begun to believe in inspirational accounts themselves as solution.
            I really mean that you are admirable in the way you have dealt with your diagnosis. I think your story is one better to be told than others.
            Also, I am really not disagreeing with you. Just saying that in the context of the close media and parliamentary relationship. other things need to be said.
            Again, thanks so much for your comments, which are great. We only have different views on effectiveness. And, again, I am talking here about depression, the topic of Hari’s book. The same does not go for all diagnoses.

          3. David Barrow

            To be fair, perhaps I was not so receptive to insights in my 20s. A flatmate diagnosed me as “bipolar” in 1993, as flatmates are wont to do. This came after a kitchen dispute. And then she did not speak to me or acknowledge my presence for the next few weeks until I moved out. Again not unknown in flatmate wars… except she was a 30 y.o. psychiatrist at the time. And I just Googled to find she has gone on to a steller career since then. Perhaps her empathy has improved as well (or awareness could help with that). Alas her diagnosis was completely dismissed by me in the non-clinical context of the share-house… and her couch-side manner.

          4. David Barrow

            Helen, sorry I’m just not understanding your comments:
            “Anyhoo. I know bipolar folks often have periods of “depression”. Just to be clear, this depression is not the sort I am discussing here or the sort Hari describes in his book. It’s the medical category.”
            You do realise that a bipolar condition is marked as significant variability between moods described at the extremes as Mania/Hypomania and Depression. And as far as I understand medication that is used to treat unipolar depression can also be used to treat bipolar symptoms, although generally only for the acute phase as after the ‘kick-start’ depression medication can itself trigger mania/hypomania? Further, the conventional view is that the depression aspect of the bipolar condition is ‘medical’ — which can also be triggered by societal events of trauma, particularly after a build up of traumas (the poetic ‘kindling’ effect) —
            according to the sort of awareness literature available through Beyond Blue which you seemed opposed to. And also an understanding in my lived experience, as one individual case.
            Helen, you seem to be getting out a utilitarianism slide rule out when you say: “Just that it is much more widely felt. An estimated 25% of the population is more than 2%.” It is true that 2 billion humans is more than 76 million (10 million Aussies is more than 200,000). But both are heaps, mate.
            When liberal politician Andrew Robb disclosed in 2011 his long-running problems with depression and its effective treatment, the media and parliamentary personalities intersected. I believe Robb’s high-profile disclosure helped reduced stigma and encourage depression sufferers to seek a mental health assessment… Notwithstanding the facet of Robb’s book that the disappointing Mark Latham chose to focus on for attention.

  2. Desmond Graham

    The psychologist’s mental health diagnostic book

    With the names writ under

    does it make me well I wonder?

    Or more intelligently mad.

    if you want to talk about mental health issues to make has been politicians
    happy few free to contact beyond blue appointments restricted to ousted politicians – helps them get over their problems

  3. Alex

    I don’t think this very often about Helen’s work but, that is a good article. I have spent many hours discussing such things with my Professor of Psychology neighbour. Every person/patient is different and to even begin to understand the causes of, particularly, chronic depression, one must spend a lot of time getting to know the subject as there are as many causes as sufferers. Nothing pisses me off more than when a person who is in the public eye, and who suffers a few months of being depressed, suddenly becomes a spokesperson for the condition. It is almost like a good career move. I know that it can help the public develop an understanding of the complaint but if the celebrity was a life-long sufferer of chronic depression and or anxiety it would have more meaning.

    1. Helen Razer

      “I don’t normally like Helen, but” continues to be my favourite response after some years of reading it. Many thanks!

  4. Mr Smith

    Very useful article Raze, thanks.

    1. Helen Razer

      No wuckers, Smithy.

  5. Desmond Graham

    Helen – part social cause of mental illness ,someone has been there before you – see Hogarth’s – Gin Lane

  6. Kathryn

    Good article, thankyou for that.
    Something that bugged me recently was the whole “Do it for Dolly” movement that arose in the wake of the suicide of a young girl from the Katherine region who went to boarding school in the Darling Downs. It was focused so, so heavily on stopping bullying but barely a word about improving the mental health services in the regions where she lived and studied. I have lived in Katherine for some time while working in the region and while I applaud the work of the mental health professionals who work there, they are fighting a losing battle and are so under-equipped to face the momentous task of providing adequate services to people covering land the size of Victoria. I really, really wish that more of the awareness building could focus on the dearth of services available. I understand why they don’t, they want to keep up the image that when you need help it will be available. But it is not always the case.

    1. Helen Razer

      Thanks for this, Kathryn. V insightful. Goodness, yes. What a stark illustration.

  7. awnelson

    This is really a book review, right? But who is Hari, and what are his qualifications to write on mental illness? I’m none the wiser at the end of the article. What are Razer’s qualifications on mental illness? Surely that is worth a sentence or two. It appears Hari recommends alternatives to medication for mental illness, but what are they? Doesn’t seem to be clearly stated. Is this really a book about the triggers and types of mental illness, or remedies or both? And why spend so much time criticising the ABC and Beyond Blue, while really seeming to circle around the central themes of the book. As a matter of fact it was after hearing Gary McDonald speak on the ABC many years ago that I was prompted to be more proactive about my depression. I reckon the best preventative for me was plenty of strenuous exercise on my bike. No, I am not prompted to go out and buy the book, even with (or maybe because of) Hilary Clinton’s endorsement.

    1. Mr Smith

      I think Raze is pointing out what she thinks are the strengths and weaknesses of the book. Without trying to provide an answer to Life, the Universe and Everything.

    2. Helen Razer

      Hi, Awn. Yes. It’s a book review. I do them every so often as Crikey readers are generally readers of books and/or eager for a precis of any public intellectual blockbuster. I will suggest to eds that book reviews be marked as such. It’s a good idea.
      The thing about non-fiction book reviews (which you could *say* I am nearly qualified to write as I *nearly* finished my English hons!?) is that the best ones draw from other material. I learned this from reading, but also from Stephen Romei when he was literary editor of the Australian Literary Review, for which I wrote before that good publication lost its funding.
      You ask “What is the social and broad communications context in which this idea is being proposed?” as a non-fiction reviewer.
      So, if Hari, in a popular book, is saying such-and-such, what are most saying about such-and-such? Hari says “depression is socially created” to counter the narrative “depression comes from inside the individual”. What are examples that everyone reading would likely know of the case that Hari is countering? Beyondblue and ABC TV are the two most prominent and widely recognised examples.
      My qualification as a reporter is only that I have a special interest in reporting on these mental health narratives, I guess. For the last decade, I have read popular books and reviewed popular narratives around the thing and I guess I have “expertise” in that sense. I also both privately enjoy and publicly report on conversations I have with true experts and advocates about communications around mental health. I am sure Professor McGorry won’t mind if I tell you I have learned a very great deal from him.
      I guess because I have written often here about mental health, I was assuming a certain trust with readers. A bit silly of me, of course. But, there you go. My “qualifications” to talk about communications around mental health.
      As for Hari’s expertise. That’s actually there in the article. It’s a popular book. And, that’s not a bad thing. I explain why it is okay for a reporter to write a personal and popular book on mental health. I explain the shortcomings of this approach in this case.
      I hope this addresses your concerns.

      1. awnelson

        Thanks for the clarifications and additional information. I generally enjoy book reviews, but this one left me a bit puzzled, I admit. After rereading several times I can see more of the points you mention. And the old story regarding Hari is coming back to me. I would quibble with your point that if a book is poular that’s not a bad thing. Unfortunately a lot of the best books are not widely read, and the most widely read can, in hindsight, turn out to have been a fleeting phenomenom. Anyway, what your article has demonstraed is that people with mental healt issues want to talk about them!

  8. Reverend Owen

    Even when it is perfectly rational and realistic to be deeply, deeply depressed about… well, everything, it doesn’t mean the depression isn’t pathological.
    Best to eat, drink and be merry, for tomorrow…

  9. Mark out West

    Mine was the social and not the biological, I was a cop talking against other cops and eventually fell prey to the sort of corruption that comes from being ostracized and working without support.
    One day I woke with depression and all those negative thoughts running through my brain.
    After medication, which didn’t help, but what has helped me was to take the fear away by calling it the emotional flu and saying that these symptoms will pass just like the flu.
    One other observation from the small amount of psycho babble that I’m aware of is the locus of responsible both external and internal. Most of the population have an external one and easily blame everybody else for their problems and internalize nothing, seems that these people have that thing called resilience in abundance.

    1. Helen Razer

      Oh, “resilience”. That is a super fun term, isn’t it? “Your ability to take a load of knocks.”
      I mean, sure. Don’t be a “snowflake” etc. Explain to kids that life is full of disappointment. But when we have popular language to describe and valorise the ability to withstand trauma. Well. You can see why Hari wrote the book.
      But like you, and like medical practice and research, I also see that intertwining things must be seen as intertwining.
      Good post though, Mark.

  10. Bozwell

    A very good overview of models of depression Helen, one that I am in general agreement with.
    As a retired Psych Nurse, I have seen both the effectiveness of pharmacotherapy, and it’s lack when used in isolation from adjunctive therapy.
    As for the Biopsychosocial model, my observations from working in drug and alcohol services and in the forensic setting, confirms the lack
    of treatment success when social factors are not given adequate recognition.
    After all, it’s too costly, time-consuming, and difficult to address the very real human factors such as poverty, trauma and social disadvantage.
    Most of the poor buggers I dealt with never had a chance in the first place.

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