Depression: Flaws in the system

Read the first part of this feature

Peter Archer suffered from depression from the age of 15. When he was first diagnosed, he was sent to a "halfway house" for young people with mental problems, where he was "petrified" by the behaviour of the other residents - most of whom had criminal records. His mother said: "One boy tried to knife another; another set fire to the building; there was continuous glue-sniffing."

Peter (not his real name) was finally allowed home on condition that the family underwent joint therapy. Since one of his problems was that he and his stepfather were at loggerheads, this proved disastrous.

During therapy things were said (and left in the air) that would have been better left unsaid, further poisoning the atmosphere. He was later assigned a psychiatrist, who - according to Peter himself - never passed comment. Peter believed that at times the shrink dozed off.

His mother had been unhappy that the GP practice kept her at arm's length. "I wanted to talk to someone about how best I could help, what I was supposed to do as a parent." She was told that Peter was an adult, and that he, not she, was the patient. "In other words, they were saying, 'Keep off.' " At one stage, Peter was prescribed a drug, which, he said, made him feel like "beating people up".

When he was 29, Peter gassed himself. After his death, his mother visited his psychiatrist who told her: "Oh, I always wondered about Peter, but I thought he was stronger than that." Peter had requested another appointment. The letter was sent to the wrong address and he never received it - the appointment had been for two days before he died.

His mother said: "Despite everything, I didn't think it was actually possible that Peter would take his life. Afterwards, I saw the signs as if they had been written in neon lights."

In the case of Neil Firth - the 18-year-old from Bradford, whose death we reported yesterday - there was no medical intervention. Three months before he took his own life, he did see his GP but only to complain of a "headache". Normally, on those rare occasions that Neil visited the doctor, his mother Maxine - "his taxi" - drove him. This time he went alone, without telling her. In retrospect, this "headache" visit was the only clue he might have been depressed.

Like everyone, he had the occasional headache - he spent hours at his computer composing music - and usually sorted himself out with a painkiller. So what led him to make an unheralded visit to the doctor for such an apparently minor complaint? Was he in fact hoping against hope that she would draw from him the fact that he was depressed, even desperate, and wanted someone to know and intervene?

As with all illnesses, the GP is the gatekeeper, the first port of call for people suffering from depression. There are "spontaneous" suicides, spur- of- the- moment decisions (though even these are often rooted in well-disguised depression), but two-thirds to three-quarters of those who kill themselves are at the time (or found subsequently to have been) clinically depressed. Young men are notoriously loath to go to the doctor under any circumstances, and especially reluctant to discuss their emotional health.

One mother said: "Quite often GPs are a stumbling block and people can't get beyond them. They either aren't picking up or are rejecting what they are being told." Patrick Acheson-Gray, whose son Charles - as we reported yesterday - took his own life earlier this year, said: "The professionals, it seems to us, can no more than guess at their patients' real states of mind. Sadly, the nature of the illness may lead the patient to be unhelpful or positively deceptive."

If the toll of young male suicides is to be cut (they are four times more likely than young women to take their own lives), awareness of depression must be promoted among young people; among professionals like youth workers and teachers; and among GPs. Many young men, like Neil Firth, sidle into the surgery and complain of something vague and never hint at the depression that is really troubling them.

Organisations - often born out of individual tragedies - are springing up to increase awareness. A group called Calm (Campaign against living miserably), funded by the Health Department, encourages young men to seek help at the onset of depression rather than when they feel suicidal - by when it may be too late to intercept tragedy. It works through clubs, sports venues, entertainment centres - any places where young men congregate. Although it is based in Manchester (which has the highest suicide rate in Britain), it has "active zones" elsewhere and a national helpline.

Papyrus (Parents for the Prevention of Young Suicides), established by parents whose children had killed themselves, seeks to "raise awareness of this terrible loss of life". One of the founders, Anne Parry, discovered when her son died that she knew nothing about suicide although she herself was a teacher with responsibility for health education. She said: "Mental health was never part of my agenda and suicide certainly wasn't. We know that suicide is preventable because there are an awful lot of people who make very serious attempts - do not succeed - and are now walking around."

In Dorset, advice points where young people can discuss problems have been set up in town centres. David Wilkins, one of the organisers, said: "What young people need is support and friendship available 24 hours a day, offered by people who are not authority figures."

Getting depression and its consequences on to school curricula is one of the chief aims of the Charlie Waller Memorial Trust, set up by the family of an advertising executive who killed himself when his heavy workload apparently got on top of him. It has already run competitions for pupils at independent schools to make relevant videos and design websites, but it recognises that such schemes "only picked at the edges".

It is now researching what education does take place in schools and what other charities, local education authorities and the independent sector are doing in this field. Charlie's father, Sir Mark Waller, an appeal court judge, wants education on depression to be included alongside advice on sex and drugs. He said: "We plan a think-tank. Then we'll go to the Government to say, 'This is what you should do and how you should do it.' "

The Trust's medical adviser is AndrÈ Tylee, recently appointed professor of primary care mental health at the Institute of Psychiatry, who was a full-time GP for 20 years. "When I began in 1980, I was shaken by how many people were coming to my surgery with depression, anxiety and emotional problems - about 30 to 40 per cent. I had been trained to deal with heart and kidney problems, and I was not prepared for that."

He videotaped GP consultations, and discovered that people with depression often reported only physical problems. They either didn't raise their emotional anxieties at all, or left it so late that there was no time to discuss them. Professor Tylee emphasised the difficulties a GP faces: "He sees people for every reason under the sun... 30-plus in a session, among whom there is likely to be one with new major depression. One hundred of his 2,000 patients will have major depression, of whom one is likely to kill himself every three to four years."

Professor Tylee set up a national unit to train GPs and practice nurses. On the " bottomup" principle, those trained return home to train others. Their check list of indicators is of equal value to family and friends of depressives.

Professor Tylee said: "If someone has four of these symptoms every day for a couple of weeks, you can be quite sure that they have major depression and need treatment." The ultimate danger signal is practical preparation - obtaining a bottle of pills or going to a railway station and standing on the platform imagining what it would be like to jump in front of a train. Anyone who reaches that stage should have instant psychiatric assessment.

We took 25 minutes to discuss the warning signs that a GP was supposed to detect in 10. But Professor Tylee said that an alert GP can pick them up in one consultation - though it may well run over the allotted 10 minutes. Depressed people have usually got a problem that needs talking through, so the next step is often referral to a counsellor. If the patient is lucky, one may be attached to the clinic: if not, he could face an agonisingly long wait. Talking may involve "cognitive therapy" - replacing negative thoughts with positive ones - and medication.

The key is the right drug, at the right dose, for the right duration, a combination that, in practice, is highly elusive. Only five to 10 per cent, the most severe cases, will be referred for psychiatric help. Although psychiatrists drop everything for an emergency assessment, both the parents and organisations to whom I spoke complained that the specialist service is often inadequate.

In 1998, 199 of 1,368 psychiatrists' posts (14 per cent) were unfilled. The Sainsbury Centre for Mental Health found "very heavy use of locums, which is often highly unsatisfactory" and low morale among psychiatrists, who were "overworked and emotionally over-extended". There was a shortage of both clinical psychologists and mental health nurses, and many specialist social workers were " emotionally exhausted".

Marjorie Wallace, director of mental health charity Sane, said: "Services are very, very paltry. Self-harmers are often merely pumped out or stitched up and sent home."

Even people with the money or the health insurance to seek private treatment feel frustrated. One father said: "If it is decided psychiatric help is needed, it is fantastically hard to find a good shrink. If you do, he may be booked for months if not years ahead." However, the real need is for something yet more elusive than decent professionals. It is a sea change in attitudes to depression.

It is 40 years since attempted suicide ceased to be a crime, but the subject remains stained by stigma. A man whose wife took her life told Survivors of Bereavement by Suicide (Sobs) he could clear his local bar in 10 seconds by raising the subject.

Sir Mark Waller believes that Charlie might have lived if his friends and colleagues had been attuned to the danger signals. By the time a young man is actively contemplating suicide, it may well be too late. Everyone knows what to do if a friend breaks a bone - pack them off to casualty. In an ideal world, we would all be as familiar with Professor Tylee's indicators as we are with physical injuries, and know what to do.

Hull University, in conjunction with Papyrus, conducted a survey among the parents of young suicides. So many of the findings concern regrets ... failure to realise the seriousness of the problem, failure to recognise suicidal signs, failure to talk sufficiently to their children, failure to be forceful with professionals, frustration at failing to penetrate the confidentiality barrier.

But the chief barrier remains the reticence of young men themselves. Rhian Thomas, of the Samaritans, said: "They feel the need to live up to the stereotype - not talking about feelings, not needing help. The macho culture is instilled from a very early age." Pippa Sargent, Calm's national coordinator, said: "Young men must learn that it is good to open up and talk. It doesn't mean they're weak; it doesn't mean they're weird." When it comes to suicide, lack of talk costs lives.