Ever since the beginning of its recorded history, and almost certainly previously, the human race has used drugs, a term which can perhaps be best defined as the taking into the body, by any route whatsoever, of any substance that is not literally water or a food that will effect the way the body work, and it is important in this context to remember that our mind is basically a reflection of the workings of our brain, which in turn is an organ of our body. What is often not appreciated however is that there are two fundamentally different ways in which the human race has endeavoured to gain benefit by the use of drugs, and that one of these is properly regarded by sensible human beings, who understand the process behind it, as being highly undesirable, while the other must be seen, again by any sensible human being, as being equally desirable.

The undesirable use of drugs involves their use to suppress normal emotions of a painful and unpleasant kind which for many reasons carries with a high risk of eventual personal disaster, or alternatively to enhance pleasurable emotions, a process which is perhaps not quite so dangerous, but still contains many inherent risks. Essentially in responding to normal psychological pain by using drugs, human beings find the normality of their existence either too boring or too painful, and turn to a drug to remove those painful feelings, usually with a very high level of initial success, but only at the cost of disastrous long term consequences. Drugs used in this manner have certain characteristics, they may be legal, illegal, prescribed by doctors, or available off prescription, frequently as a result of differing cultures and legal systems rather than on any logical basis.

Also they tend to be drugs to which the body habituates, that it gets used to the effects of, and as a consequence of this a steadily increasing amount of the drug is required to obtain the same effect, a phenomenon which interacts with the effects of the person's failure to deal with the fundamental causes of their painful mood state to produce a steadily escalating consumption of the drug until problems of withdrawal effects, that is symptoms which did not exist before the drug was taken, and frank poisoning of the bodily system begin to emerge. This form of drug usage is perhaps best described as social or recreational drug usage, and has been a powerful and effective feature of human behaviour, probably for as long as we have been human, but unfortunately has not been productive of particularly desirable consequences.

In contrast the second method of drug usage, the legitimate medical and therapeutic usage, has probably existed for as long as the social and recreation use of drugs, but until recently has been manifestly and profoundly less powerful and effective, it being only with the emergence of modem medicine, essentially in the second half of the twentieth century, that this form of drug usage has become truly effective. In the medical model of drug usage the individual, now a patient, is aware of a loss of their usual normality, either in physical or psychological terms, a loss that is associated with illness and the symptoms of that illness. As a consequence they consult a doctor, essentially seeking not an escape from their normality, but an escape from their illness and symptoms, and a consequent return to their normal health. Both in physical medicine and psychiatry, it is unfortunately true that we still in general lack drugs which can literally cure the illnesses from which human beings suffer, one exception being the. manner in which antibiotics will actually cure many acute bacterial infections, although a purist might say that even in this case the drug merely assists the body's own immune systems to effect the permanent and lasting cure.

.In general however the proper use of modern medical drugs involves not actual cure, this being beyond our current knowledge and ability, but the control of the symptoms of disease processes that we cannot actually cure, and of which the causation is often still largely unknown, a fact that is in general as true with respect to many physical illnesses as it is with respect to a range of psychiatric conditions. Nevertheless in spite of the absence of a true cure, the patient's quality of life, and frequently duration of life, is greatly enhanced by the control which is achieved over the symptoms of the illness. Such an outcome is seen in the use of insulin to control the symptoms of diabetes, in the use of a range of medications to control the symptoms of asthma, in the use of drugs to treat heart disease, and in the use of anti-inflammatory and pain killing drugs to treat arthritis. In all these physical diseases there is control of the symptoms, with great benefit to the patient, but not an actual cure of the disease process. The result, unlike that of the social use of drugs, is an improvement in the patient's functioning, and therefore their quality of life.

In general drugs tend to fall into two large groups, one group being used for a social and recreational purpose, and the other in a legitimate medical fashion. Widespread and common recreational drugs are of course alcohol, tobacco, these two being the major drug problems in Australia today, marijuana, heroin, LSD, and a whole range of modem artificially created hallucinogenic drugs. Amongst the legitimately used drugs are the whole range of medications used in physical medicine today, and essentially three groups of drugs used in psychiatry, the major tranquillisers, used to treat severe psychiatric illnesses such as schizophrenia, the minor tranquillisers, used to treat excessive anxiety that is interfering with the patient's effective functioning, in contrast to normal levels of anxiety that can enable us to respond effectively in the face of challenges of many different kinds, and the antidepressant drugs, which are used specifically to treat depression.

A small number of drugs, principally the minor tranquillisers, that is drugs of the Valium type, and the amphetamines, may be used either appropriately or inappropriately, in which case it is often useful to speak of them being used, that is in the legitimate medical sense, or abused, that is for the undesirable purpose of avoiding painful feelings rather than dealing with issues. The use of legitimate medical drugs to control the symptoms of chronic physical illness now has a widespread acceptance in the community, but unfortunately this acceptance is far from being extended in the same manner to the equally legitimate use of medical drugs to control the symptoms of chronic psychiatric illness.

It is probable that this difference of attitude arises in the fact that we perceive the use of a drug to control a physical illness as being relevant only to our bodies, whereas a drug that controls a psychiatric illness appears in some way to be controlling our very selves, and thus easily leads to confusion with the abuse of drugs as outlined above. It cannot be emphasized too strongly however that this confusion is not appropriate, and that the use of antidepressant drugs in the treatment of depressive illness is as legitimate and necessary a medical exercise as the use of any drug to control the symptoms of a physical disorder, indeed it can be said in a very literal sense that in the final analysis true depression, as opposed to unhappiness, is in its origins an abnormal physical condition, that produces psychiatric symptoms merely because it exists in that region of the brain where our emotions are determined and controlled.

The brain is in effect an extremely complicated computer, which, unlike electronic computers works only partially on electricity, the remainder of its mechanisms being chemical in nature. It is in essence an infinitely complex network of nerve cells, each of which has a body, from which long fine fibres extend to make contact with other nerve cells. However the contact between the nerve fibre and the next nerve cell is not complete, there is a small space between the two called a synapse. With the arrival of an electrical current down the nerve fibre a chemical is released, called a neuro-transmitter, which crosses the synapse, and, on arriving on the cell on the other side, generates a further electrical impulse which carries the message onwards. Whilst there are many different forms of neuro-transmitters the physical basis of true depression lies in the existence of a relatively low level of a particular group of these chemicals, known as amines.

Our knowledge of the chemical abnormalities in depression however is not based on the ability to measure these chemicals in a living human brain, but on research carried out in the brains of people who have committed suicide, and in experimental work on dogs, which has been possible as a consequence of an old fashioned anti-blood pressure drug, Reserpin, being found to produce severe depression in approximately one third of the patients who used the drug, this being of course in the setting of general medicine an overwhelmingly inconvenient side effect, but nevertheless providing a useful research tool for scientists investigating the nature of depression, as it could be used to produce similar chemical conditions in the brains of dogs as were known to exist in the brains of suicided human beings. It was further possible to show that modern antidepressant drugs prevent the development of those chemical changes in the brains of dogs exposed to Reserpin, thus completing a reasonable body of evidence pointing not only to the mechanisms of depression, but also the manner in which modem drugs control the symptoms of that condition.

Once a neuro-transmitter has been released into the synapse, and achieved its purpose by generating an electrical current on the other side of that synapse, it is normally taken back into the fibre which has released it for re-use. The majority of modern antidepressant drugs work by preventing the re-uptake of the neuro-transmitter, with a secondary consequence that an increased demand for further neuro-transmitter production is placed on the manufacturing part of the nerve cell, which results in an overall rise of the levels of neuro-transmitters. In the case of one smaller, but long established and frequently useful, group of drugs however the increased level of neuro-transmitters is achieved by a different mechanism, in this case by the blocking of the action of a further chemical that normally breaks down the neuro-transmitters at the end of their useful life. Unfortunately however the blocking action of this chemical also prevents the breakdown of the various substances which can be present in a small number of foods, substances which if not effectively broken down can cause a dangerous rise in blood pressure. As a result there is a minor inconvenience to patients using these drugs, in that they are unable to eat a small number of foods, and, for similar reasons, unable to use a small number of common drugs, principally cough medicines and anti-asthma drugs. However these disadvantages are small compared to the benefits for those relatively small number of patients in which these drugs are fully effective, whereas the alternative medications prove ineffective in controlling their particular illnesses. Subject to the proper observation of the simple precautions associated with the use of these drugs they are as safe as any other modern drug, and can confer literally life saving benefits on the patient.

The relationship between true depression, as defined and described above, and the kind of ordinary life events that produce normal unhappiness or sadness is somewhat complicated and not yet fully understood. However certain things can be said with reasonable certainty, the first of these being that there is no necessary connection whatsoever. It is common to see a patient who has had a psychologically completely healthy childhood, has grown into a stable, effective, and happy adult, effected a good marriage, worked effectively in the community and who quite clearly does not have, and never has had, any psychological or social problems of any significance. Nevertheless such a person may develop a severe depressive illness, either abruptly or slowly, and commonsense suggests that the mechanisms in these cases must be purely physical. Some of these mechanisms are now well recognised, particularly the existence of a post viral depression which occurs after a viral illness, and post natal depression, which is generally held now to be an immediate physical consequence in the form of an abnormal reaction to the normal hormonal changes of pregnancy rather than having any particular psychological significance with reference to the woman's attitudes towards her sexuality or reproductive processes.

However at the other extreme it is also a well recognised clinical experience to see a patient of similarly sound previous constitution and experience who, following the loss of a loved one, does not undergo what would be expected of them, that is a normal and healthy, if painful, grief reaction, but is plunged immediately into a severe depressive illness. It is of interest that one of the consequences of recovery from such an illness, either following treatment with drugs or, particularly in the past, if it occurs spontaneously, is that the patient thereupon recovers their capacity to grieve, and enters into a normal grieving process. Whilst many people sense intuitively that we cannot be happy if we are depressed, few realise that we cannot be normally unhappy in the face of depression, as that condition exists only when the normal mood mechanisms for the production of appropriate happiness or sadness has been gravely damaged. In such cases it seems reasonable to accept that a purely psychological event has triggered the physical illness of depression, however it must be emphasised that, in terms of diagnosis, course, and treatment, including response to modern antidepressant drugs, illnesses of this kind, triggered off by psychological stress, appear to be exactly the same condition as those triggered off by physical phenomena such as virus illnesses.

In between these two areas of relative certainty however there lies a significant amount of grey in that the question of a direct causal relationship between less clear cut psychological, social and financial pressures, both past and present, and the emergence of a specific depressive illness can be neither established nor rejected with any degree of certainty. A common mistake however, which can give rise to serious complications in the individual's life if not identified, is for the sufferer, their relatives and friends, or the doctor, to respond to the depressive illness as if it were in fact unhappiness as in these circumstances one tends to inspect the environment for possible causes for the presumed unhappiness, and frequently events, attitudes and feelings, which are in fact a secondary product of the depressive illness, are misidentified as causes of the mood state. It has been known for people to literally sell farms and other businesses, leave well established, and normally satisfying or financially rewarding jobs, or end marriages, on the basis of this kind of tragic misunderstanding of the realities of the cause and effect that exists between their internal experience of depression and the external world.

It is because of the danger of this particular kind of mistake that one of the most basic principles of all in the management of depression is that no serious, and certainly to irrevocable, changes should be made in one's lifestyle while there is any reasonable suspicion that a significant level of depression still exists. This does not however necessarily mean that the desire for such change is inappropriate, and it is not unknown for people, when they have recovered from their depression, to make just these kinds of changes in their lifestyle in which circumstances there are reasonable grounds for suspecting that it is possible that the truly unsatisfactory nature of their current life experiences may have played a role in the triggering of the depressive illness.

As a general principle, when a clear depressive illness emerges against the background of ongoing psychological and social stress it is reasonable to suppose there is at least a real possibility, if not probability, of a direct cause and effect association between the two, and such a concept currently attracts a significant level of acceptance in the Victorian legal system with respect to the consequences of both road traffic and work accidents and extreme work stress.

In terms of treatment and management these concepts give rise to another very basic principle, that is that, whatever cause and effect association may be considered to exist between the past or current external world and the depression, the depression itself must be treated first, as its continuing existence will of necessity make it far more difficult, or even impossible, for the patient to effectively address the circumstances that may have played a role in triggering the illness. Although, as has been described, there are reasonable arguments in favour of the view that depressive illness can be triggered by external events, unlike appropriate unhappiness a depressive illness triggered in this manner has a separate life of its own, and does not, like normal unhappiness, disappear if the triggering event is satisfactorily resolved, even supposing that can be achieved in the presence of an ongoing depressive illness.

Article contributed by: Dr. Chris Percival, Psychiatrist, Shepparton, Victoria, Australia.

Milton Sofoulis Sr, Dip.B.S., Dip.Min(Hon), Dip. Prof.Couns., is a professional counsellor based in Deniliquin, NSW, who specialises in relationship counselling, stress management, self esteem, and for general personal issues.

He is available for personal counselling, group counselling, interactive discussion groups, corporate presentations, and presentations for special interest groups.

Phone/Fax: (03) 5881 2581. Mobile: 0438 812 581. .