the still sad music of humanity

The whole point of crying is to stop before you corny it up.
(Richard Yates, Revolutionary Road)

The publication in 1994 of Listening to Prozac by Peter Kramer, in which he suggested anyone with too little "joy juice" might give themselves a dose of the "mood brightener" Prozac , lifted sales into the stratosphere. (Independent, 26/2/08)

Today, a major new study shows that Prozac, taken by 40 million people worldwide, does not work and nor do similar types of drugs. For a profession normally diplomatic, the words today of one of study's authors are damning. "Given these results", Professor Kirsch of Hull University says, "there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients." (Guardian, 26/2/08)

The problem with depression is that people are generally disinclined to believe that it exists. Not that people disbelieve melancholy. Chaucer believed in it, and so did Durer. But they disbelieve, instead, that depression could be a condition worthy of medical attention. Never mind that an excess of melancholy was treated by emetics and blood-letting, before they got the circulatory system was figured out. The problem is that, having stopped treating it because the grounds for treatment were found to be faulty, which is fair enough, the treatment itself resurged because the condition was still endemic. Whether it's electroshock therapy, or some kind of analysis, or cognitive behavioural therapy, or anti-depressants, the past hundred years have (I guess) a pretty consistent theme of reworking and treating the Black Knight's complaint, assuaging his unhappiness as the dream is unable to do.

What I'm getting at is this: irrespective of whether anti-depressants work, or of whether blood-letting and leeches worked; we have been turning to doctors, asking for treatment for a pain we can't place but which saps the very life out of us for as long as there have been doctors.

Maybe anti-depressants don't 'work', however that functionality is calibrated. Maybe no anti-depressant treatment has truly 'worked' - for example, exercise is just a stimulated deferral - but perhaps it's more telling that we feel compelled to be treated. So what if the pills are placebos? To all intents and purposes I find it impossible to distinguish between a psychological medicine that works because it works, and one that works because you think it works. Any takers for that one?

I don't really mind if my antidepressants are placebos. And I am as hostile to Big Pharma as anyone else. It seems to me that antidepressants are just a heavily industrialised extension of an old solution to an old, old phenomenon: that we need institutions (and the very institution in particular that is the guardian and guarantor of our health) to recognise that we have interiority. Paradoxically, maybe we need an institutional recognition that there is something about consciousness that is indivisible?

In a way, that the latest treatment for depression is unmasked as a kind of quackery isn't a victory for the scientist who've produced this report, or the anti-Pharma activists, or for the people who say that depression is a self-constructing, self-perpetuating phenomenon. This is because we don't really know what depression is, beyond an ever more minute catalogue of its symptoms. We don't really know how to cure it, either. And we certainly don't know why it is that we keep taking cures that, though they work, demonstrably don't work. (Phrenology, anyone?)

it seems that there's a blind-leading-the-blind element here. Scientists devise fake treatments that work for a non-existent condition that is described by one analyst and philosopher as 'like death-in-life'. Other scientists then expose these treatments as bogus (although they too are wrong). New treatments are designed simply to meet demand. Lather, rinse, repeat.

We don't know what our antic disposition is (or why so many accounts of depression sound a lot like Hamlet's 'seeming' rather than 'being') but soon there'll be another cure for it. People will re-engineer SSRIs, perhaps, but there'll be something else, something new. It'll be wonderfully effective, too - it'll be the new wonder treatment for depression, until we figure out that in fact, it doesn't work at all. All this makes me think of that wonderful Simon Armitage poem, To his Lost Lover;

Now they are no longer
any trouble to each other

he can turn things over, get down to that list
of things that never happened, all of the lost

unfinishable business.
For instance… for instance,

how he never clipped and kept her hair, or drew a hairbrush
through that style of hers, and never knew how not to blush

at the fall of her name in close company.
How they never slept like buried cutlery –

two spoons or forks cupped perfectly together,
or made the most of some heavy weather –

walked out into hard rain under sheet lightning,
or did the gears while the other was driving.

How he never raised his fingertips
to stop the segments of her lips

from breaking the news,
or tasted the fruit

or picked for himself the pear of her heart,
or lifted her hand to where his own heart

was a small, dark, terrified bird
in her grip. Where it hurt.

Or said the right thing,
or put it in writing.

And never fled the black mile back to his house
before midnight, or coaxed another button of her blouse,

the another,
or knew her

favourite colour,
her taste, her flavour,

and never ran a bath or held a towel for her,
or soft-soaped her, or whipped her hair

into an ice-cream cornet or a beehive
of lather, or acted out of turn, or misbehaved

when he might have, or worked a comb
where no comb had been, or walked back home

through a black mile hugging a punctured heart,
where it hurt, where it hurt, or helped her hand

to his butterfly heart
in its two blue halves.

And never almost cried,
and never once described

an attack of the heart,
or under a silk shirt

nursed in his hand her breast,
her left, like a tear of flesh

wept by the heart,
where it hurts,

or brushed with his thumb the nut of her nipple,
or drank intoxicating liquors from her navel.

Or christened the Pole Star in her name,
or shielded the mask of her face like a flame,

a pilot light,
or stayed the night,

or steered her back to that house of his,
or said “Don’t ask me how it is

I like you.
I just might do.”

How he never figured out a fireproof plan,
or unravelled her hand, as if her hand

were a solid ball
of silver foil

and discovered a lifeline hiding inside it,
and measured the trace of his own alongside it.

But said some things and never meant them –
sweet nothings anybody could have mentioned.

And left unsaid some things he should have spoken,
about the heart, where it hurt exactly, and how often.

Social care

Secondly, as I say, I’ve looked through the Wanless Social Care Review, Securing Good Care for Older People: Taking a long-term view.

Basic points are as follows: Social care is a growth industry, with funding to maintain outcomes increasing by 139% from 2002 to 2026 alone. The aging demography of the UK is well known, and the problem is compounded by the fact that a significant proportion of informal care is delivered by the elderly themselves (one in six people over 65 delivers informal social care).

Wanless’ remit is to improve outcomes as much as possible and as efficiently as possible against a benchmark which boils down to one year of substantially improved care at 20000 pounds’ worth of expenditure per head. The three models that Wanless sets out are: partnership, (two-thirds of the benchmark cost is met by the state, then individuals make contributions which are matched 1:1 up the benchmark limit, beyond which contributions are not matched. Means-tested Benefits for those unable to contribute), free personal care, (state meets whole benchmark, no personal contribution) and limited liability (hybrid, means tested provision for the first 3 or 4 years, thereafter free).

Regardless of the philosophical arguments around free provision, it seems to me that in his summary, Wanless finds evidence over and again in support of a Partnership-based funding model for social care in the future, though in his conclusion he equivocates a little and dilutes the strong case that he has built. Wanless uses a range of economic criteria to reach this conclusion (p.xxxiii or the summary).

There is a strong localist case to be made for partnership allocation of funding, based primarly upon the complexity of the means-testing, which (under partnership would not include housing value) and on the differing allocations to be made: factors include housing, domestic support, personal care, nursing care. Because means-testing would take into account other benefits administered, the case for a locally-administered partnership funding model for social care is the same as every other argument for localist solutions (ie, that the principle of subsidiarity is inarguable), only, because of the complexity of the assessments to be made, more so.

At this point, it is instructive to look at the figures involved. Under Wanless’ suggestions (and I am taking his baseline most conservative estimate that delivers zero improvements in outcomes, but which simply restructures funding models), by 2026 costs are projected to be 24bn. With improvements in service delivery, that figure jumps to 31.3bn. This is against the background of current figures of 10.1bn.

It is worth putting these numbers into some context: Alan Johnson has just conceded that Individual budgets are going to go ahead, and to do this has released 520m. For local government to have any kind of angle in future social care provision, let’s say that it would need administration over only 50% of funding: this means that central government would have needed to sign a social care concordat handing over 5.05bn to local authorities four years ago. Alan Johnson’s commitment in December is one tenth of this.

My point is that to agitate for a localist delivery of social care is not a politically realistic thing to do. We might be able to get funding from, say, XXX, were we to write a report calling for complete local control of social care, but who would take seriously a report demanding the 12bn handover necessary to meet social care costs in 2008, dwarfing by 24 times Alan Johnson’s grand gesture? On the other hand, whilst I don’t doubt that we could put together a report which strongly advocating the partnership model and its localist implementation, I don’t think that, given the practical obstacles, a report like that would get funded. After all, we know that partnership-funded care is best because it’s there in the Wanless report already.

The problems in my argument are that the King’s Fund might have had its own agenda in putting these figures together and so there might be inaccuracies, and that the report itself dates from 2006 and so might be out of date.

The point of all this is that I was wondering whether you could set down for me a brief abstract of the angle that you think that we could viably take in such a report. If you could send me one then we’d be able to build on it start putting together a position and a proposal from there.