Two units under

According to my other half, I am one of those people who are permanently short of two units of alcohol. I’m undoubtedly better company when slightly I’m under the influence- I’m more sociable and relaxed. I can engage in conversation without feeling self-conscious when I’m with people I don’t know well, or haven’t seen for a while. Life just flows more easily. Two units a day, you say, that isn’t very much, its 14 a week, that’s just on the ‘safe limit’ for women. So why have I been trying to reduce the amount that I drink?

Since my early 20s I’ve been aware that I have an ambivalent relationship with alcohol. Most of the time we remain on reasonably good terms, but when my mood is low, or I’m under stress the booze likes to get one up on me. Like many people, when I was working full-time, I began to rely a little too much on my liquid friend. Days began to be measured on a new scale of severity- the number of bottles of Stella Artois I needed to feel relaxed after a weekday in the real world. One bottle (330ml 2 units) was a normal dosage, two bottles (4 units) for a tough day and 3 bottles (6 units- thankfully not very often) for a bloody awful day, plus a very strong Martini on Friday night to decompress and sometimes again on a Saturday, and wine (3-4 glasses) over the weekend. Mostly I drank just about up to the limit. Sometimes, and increasingly so as time went by, I exceeded it.

Okay, I can hear you saying, ‘what are you worried about, I know loads of people who drink a lot more than that!’ You may even do so yourself. I’m not asking you to consider it that is of course your choice. But it’s not only the amount you consume (although most diseases related to alcohol haven’t been informed there are ‘safe’ limits, the risk just gets greater the more you drink) it’s the nature of the relationship you have with booze. It’s addressing why you sometimes feel the need to rely on a friend whose apparent affability, social and legal acceptability masks the risk it poses for those of us who have the potential to depend on it, not just emotionally but physically too if we drink long and hard enough. Earlier this year, when I was experiencing, for a while, the most severe physical symptoms of anxiety I have ever known, when my chest was permanently tight and my hands shaking, there was only one substance easily accessible that took those symptoms away, and it usually took one of my husband’s martinis which is a fairly lethal combination of gin and vodka (plus Lillet Blanc and a twist of lemon if you are interested) to help me feel anything like calm. Mindfulness exercises didn’t touch it. Exercise was difficult as I felt exhausted most of the time and too anxious to venture out much. I’m quite sure diazepam would have worked too, but I’ve spent so many years trying to help people withdraw from it I wouldn’t wish to take it. I remember one of my patients who was depressed and couldn’t sleep said to me. ‘I didn’t want to take any pills, so I just decided to try alcohol, it’s a natural remedy isn’t it? Well no, it’s about as natural as anything that’s been processed by a brewery or distillery can be I suppose. And the Distiller’s Company also gave us thalidomide too. Not that I am any way comparing alcohol with that particular drug, but we know it also can cause terrible damage to the unborn. Alcohol is acceptable, available and costs comparatively less than it used to when you buy it in bulk at the supermarket or in Happy Hour.

When I worked as a consultant in a substance misuse service I saw so many young men whose problems with alcohol had begun in their teens, when they drank to self-medicate for social anxiety, unable to approach a member of the opposite sex when completely sober. The problem is alcohol doesn’t only relax you, it lowers your inhibitions in other ways. You are more likely to put yourself at risk, for example by having unsafe sex or walking home in the snow with insufficient clothing after a night out risking hypothermia, when you are drunk. Alcohol has a curious relationship with mood disorders that mental health services in the UK (but not in Australia) still don’t pay enough attention to. People with bipolar disorder can drink excessively when they are high and when they are low. Those of us with depression use alcohol to numb the pain of being alive, but the side effect is that we then feel much less inhibited about trying to harm ourselves or end our lives. When I was a student I discovered the advantages and disadvantages of drinking to oblivion. I was in danger of becoming the person we all remember who seemed to go that little bit further than everyone else, and we much later heard was not only emotionally but physically dependent on booze and on their way to destroying their career. Medicine is noted for its relationship with alcohol. There even used to be a bar in the doctors residence in Manchester when I was a junior doctor. I’ve glibly asked students at interview what they do to relax, because ‘medicine is an emotionally taxing profession’, and heard them list all their sporting and musical activities knowing full well how many of us fall back on the nightly Stella because it’s the easy, instant option.

So, of late, I’ve been considering this relationship much more honestly than I have in the past. I’m aware I have within me the potential to spend far too much time with this erstwhile friend and be lead seriously astray, but I’m still ambivalent. l so love the feeling of being intoxicated, at least until I wake in the early hours next morning. But I rarely allow things to go that far now. I’ve been staying alcohol free for longer and longer, particularly when I’m in Scotland. I don’t drink alone in the house, and I can no longer have anything at all when I’m out due to the new drink driving laws. I hope they are having an effect on the overall amount people consume, but we still need legislation on minimum pricing. I learned as a medical student that national consumption was governed by cost and availability. Why is more research required?

I still enjoy the occasional drink but I’m beginning to know, and like, my persona who is always two units under a little better and helping her find other ways to manage her anxiety. It’s a healthier option for me, in the longer term, giving alcohol the brush off.

(Still) taking the tablets

Not so long ago, I asked my current doctor how he thought I would have been over the last 20 years if I hadn’t stayed on antidepressants continually. He said he thought I would have had at the least a period of in-patient care. When I asked my other half, who has known me for nearly 30 years, and remembers life before and after I had medication his response was simple.

‘You would be dead.’

Since I last somewhat reluctantly shared my views on antidepressant medication a year ago, (before that I’d kept my head below the parapet) there has been a continuing debate about them both on twitter, where I’m quite active, and in the media. My blog was paired with an article written by a fellow psychiatrist who has very different views from my own, who told the Daily Mail she wouldn’t take antidepressants even if she were suicidal. I was pleased our contrasting views went out together. Others have questioned me directly with comments such as ‘I can understand why you take them if they’ve helped you, but why do psychiatrists still prescribe them when they don’t work?’ and a little more personally: ‘well you would say they help because you’re a psychiatrist.

When I joined twitter, I expected there would be primarily a view that medication was unhelpful and shouldn’t be prescribed. I guess that’s because that’s the message that the media often seems to prefer. There are several eminent mental health professionals who share this view and write about it frequently. Many of them are involved in the Council for Evidence Based Psychiatry and are active on social media. In fact, what I found, as well as people who share their views, was a substantial section of people who were willingly to talk of how medication has helped them. Some of them, like me, have also had psychological therapies, but many others have unfortunately not been able to access them.

NICE (the National Institute for Health and Clinical Excellence) is about to start a new review of the evidence, but its current advice is that antidepressants should not be used in milder depression, should be offered as option in moderate depression, and should be used in addition to psychological therapy in severe depression. That’s why I prescribed them when I was still practicing and most other psychiatrists and GPs, still do. But unfortunately the difficulty in accessing psychological therapy makes it hard in practice to follow the NICE guidance as we should. Many people do not get offered evidence-based treatment. If this happened in cancer it would be a national scandal, yet untreated depression, as we know too well, not only causes great suffering but can also be lethal. There are people who wouldn’t benefit from antidepressants who end up on them unnecessarily and only experience the side effects. There are others who feel there is no other choice open to them without a long wait. In severe depression, treatment which doesn’t also include psychological therapy is incomplete. Medication alone is never the solution.

I’ve stayed on tablets because, as my doctor and husband agree, I don’t think I could have managed to live the life that I’ve been fortunate to have, if at all. It’s been a productive one, but it hasn’t been easy. I’ve still had relapses: I was unwell earlier this year again and am now recovering. I didn’t cope with work stress well at all, although latterly Cognitive Behaviour Therapy helped me to find new ways to manage that; and I know that I still react badly to loss events. I have a family history of mental illness, and one first degree relative was hospitalized. My early life almost certainly contributed to my susceptibility. I’ve written at much greater length about this in my memoir, which will be published this autumn. However I haven’t been as low or completely unable to function as I was prior to taking medication. Psychotherapy helped me earlier in my life, but couldn’t prevent me having more severe episodes in my mid-thirties. Each time I’ve relapsed, my medication has been changed. Sometimes things have been added in. I’m on a combination now once more. I know there will be people who will say my recoveries are due to the placebo effect, which can be very powerful, but last time, as previously, I’ve begun to recover in the time scale predicted by the evidence. This time it was around 3 to 4 weeks. It certainly was not immediate, in fact as sometimes happens, my mood continued to deteriorate after I started the new treatment.

Medication has some truly vile side effects; I’ve experienced many of them and still do. I’ve had withdrawal symptoms too. Some people cannot tolerate them, and others feel much worse. Fluoxetine made me so agitated I had to stop it. In young people that effect can lead to increased self-harm. Medicines can help, but they can also be dangerous too. Its always about balancing the risks and potential benefits.

To suggest I would only say medication was helpful because I’m a psychiatrist devalues my experience as a service user. Perhaps it’s not easy to be seen as both at the same time. But I know others have found medication helpful too so I’m not alone. When writers suggest antidepressants shouldn’t be used, those of us who have benefited find that very scary. We know we are not weak because we need to take them, but sometimes it can feel like others honestly think this of us. All I am asking is that those who don’t want to take them respect the choice of those who do and continue to allow people who may possibly benefit (and have potential problems on them too) to make a fully informed choice. As I said previously I have never forced anyone to take them.

I have been suicidal, and I chose to start taking an antidepressant. At that point I was still sufficiently ambivalent about death to try anything that might help.

I’m still here.

Relapse and rewind

It’s fortunate that my other half and I share the same acerbic sense of humour.

‘When you aren’t well you start to talk all the time, and about 80% of it is rubbish, ’ he told me, ‘and you’re doing that now.’

It was at this point that I was finally able to admit that my mood, up and down since last autumn, had taken a major nosedive since New Year. The problem is that when I’m going down, I don’t generally recognise it until quite late, and I’m not always willing to listen to advice to ‘slow down’. This time, along with the usual symptoms of depression I’m so familiar with, I experienced the worst constant physical symptoms of anxiety I have ever felt; resulting in panic when I lost my bearing in Manchester’s Arndale Centre and I couldn’t immediately find the way out. This time, nothing would relieve the anxiety apart from alcohol. What my other half was referring to was the emotional and verbal expression of my anxiety. The constant seeking of reassurance and ruminating out loud about life problems, in a way that probably drives those around me crazy too.

However given my history of recurrent depression, it’s no surprise really that I’ve had another relapse. I had hoped that since retirement I somehow wouldn’t experience the same stresses I used to. And I’d been pretty well for a couple of years at least. But I was wrong. Losing my animal companion and several major family and health stresses I won’t go into here were enough to tip the balance again. It was back.

It’s the beginning of March now. For a while I panicked when I simply switched on the desktop computer. Now I can write again. I burst into tears in the middle of my last blog but I forced myself to get it finished. I have this feeling that if I can’t write then somehow I couldn’t live. Maybe it isn’t right, but I kind of believe that. For the last couple of weeks I’ve gradually been feeling better and the constant anxiety is subsiding to its usual level. I don’t feel like something awful is going to happen imminently and I’ve stopped thinking about death (I was having passive thoughts that life wasn’t worth living again). I heard birdsong the other day as I walked up the garden path and I realised I hadn’t taken any notice of the birds in the garden or their choruses or the bulbs shooting up for…well I’m not sure; because depression creeps up insidiously.

Why is my mood lifting?

Perhaps it just would do anyway. Spring is on the way. I’m bound to feel better…except for me it doesn’t happen that way. Even after the events that precipitate it are all past, my downturn goes on and on, thought not as low or for as long as when I was off medication altogether.

I can only make sense of it as a combination of the following and as you might expect from me, it’s a biopsychsocial combination of remedies:

  • I found a way to talk about my worries and fears about the future with my partner. It wasn’t easy but we managed to resolve some practical things I was concerned about.
  • I was able to utilise some of the practical coping skills for managing my rumination I learned from cognitive therapy and I started to use the guided mindfulness CD I had always been ‘too busy’ to listen to. I tried to stop myself from fighting against my mood, and simply accept that I was feeling terrible: bleak sad and empty. Paradoxically once I do that, I’ve learned, it is always a little easier to move forwards.
  • I forced myself to keep going out even though I wanted to shut myself in the house and never come out again. I’ve met many people in my career who have done just that. I had to ‘feel the fear and do it anyway.’
  • I was able, too with support, to put aside some of the impossible self-imposed deadlines I place on myself. I have to remember that my ‘Rules for Living’ are nigh impossible to live up to. Instead I set myself somewhat simpler goals like going out for a walk, and doing some washing. Small achievements which then helped me to move forwards.
  • I agreed to a change of medication. I wasn’t happy about it. I’m now on multiple tablets for my various conditions, but at the point I was at, it was worth a try. I cannot bear the thought of being sedated by medication and fully understood all my patients who refused to take medication that numbed their thinking. My mind has to be clear but when I’m very low I can’t frame the words and sentences either. I try to get to somewhere in the middle. I just cannot do it without pharmaceutical aid.
  • I sought and accepted the support of friends, real life and on line.

My other half did his part by being there for me, as he always is, even if I am talking rubbish, and arriving home one evening with a present of Lindt chocolate bunnies. Chocolate has antidepressant properties too, I tell myself as I bite the head off one of them. He tells me he knows I am getting better because I’ve started to talk about it all in the past again now. I think I’m getting better too, but I wont really know until I can look back and recognise how much I’ve improved.

That’s the nature of the beast.

‘Misery’, moods and madness

I find I learn what I think about something as I write about it. Composing words on a screen (I stopped writing by hand when I gave up clinical work- I have a writing corn from years of scribbling in notes) helps me to formulate what exactly it is that is troubling me. But for a few weeks I’ve had difficulty writing anything very creative other than a single blog. I’m well aware I’ve been grieving for my beloved cat; I was feeling very sad but I began to feel a little better again. Then I had a visit from a family member, which stirred up unwanted thoughts (and dreams) about the past.  I began to ruminate again about all sorts of other ‘stresses’ in my life although I’m still not sure how really threatening they actually are, and, for a couple of weeks, my mood plummeted downwards.

 

It’s become fashionable in some circles not to use the word ‘depression’ but to refer to ‘misery’ instead. ‘Depression’ is a contested concept and there is a powerful view that it is primarily a state that is socially determined, a natural response to life events that will respond to social and/or psychological intervention without the need for anything more. Particularly medication.

 

While I wholeheartedly agree that the DSM concept of a unitary ‘depression’ is simplistic and that there are, as the founder of the Black Dog Institute in Australia, Gordon Parker, has suggested, many different ‘depressions’, I really must draw the line at the increasing use of the word ‘misery’. To be described as ‘miserable’ not only means being constantly unhappy but also has connotations of wretchedness and being an awful burden to others. ‘Misery’ as an idea I can just about tolerate, but to be described as miserable because you feel down feels like yet another form of stigmatization of the ‘undeserving poor’ who are unable, or cannot be bothered, to help themselves.

 

And the question is should all experiences of depression now be lumped together as a result of social causes? This is as simplistic to me as suggesting its all down to incorrect or ‘faulty’ thinking or something wrong with the level of monoamines in the synapse. All of these are, for me, similarly discredited ideas. Surely our brains (and our experiences) are worthy of more complex theories than these?

 

What I’ve learned is that there are times when something really seems to shift in my mood, as though some unseen worker in my brain pulls a lever.  Usually this happens in response to a build up of life events (yes, social factors play a key part), and when these events are of a particular kind that holds an inherent threat to my sense of who I am (the psychological part), then my mood is much more likely to shift, and quite rapidly too. When I was working full time I could move from feeling anxious, but keeping my head above water, to quite a different state of mind, within a day. When I am there I feel quite different. I don’t only feel sad, I feel physically ‘changed’; heavy of limb, tired, unable to sleep yet also very agitated. I ruminate about things that at other times I would be able to cope with easily and I am full of ‘fear’. When I look in the mirror I am quite sure I can see it in my eyes. There are times when my fear can shift into frankly paranoid thoughts and feelings of wanting to end my life. It’s terrifying and yet oddly familiar at the same time. I’ve been there many times, and I’ve just been there, albeit fairly briefly this time, again.

 

I’m fortunate that I haven’t had depression severe enough to warrant admission to hospital but I’ve had several episodes in my life. Why does this happen to me, but not to so many others who seem to be much more resilient? If I’m just ‘miserable’ perhaps it’s because I’m just inherently weak? For me, this is the obvious conclusion I must draw.

 

What I do believe is that ‘depression’ is a complex, multidimensional experience incorporating everything from profound and painful unhappiness to suicidal thoughts and psychotic degrees of despair. As I’ve said before, ‘depression’ and ‘anxiety’ are also very closely linked to the degree that I don’t find the idea of diagnostic co-morbidity useful at all.

 

The only way I can explain why only some of us seem to become depressed in response to life events is by drawing on the concept of vulnerability. A combination of genetic factors, early life experiences and unremitting life stresses such as lack of support and long-term physical illness add to our vulnerability. Such that, when a torrent of life events come along, those of us who have the greatest vulnerability and lowest threshold for becoming depressed, will get washed away by the waves while those who are fortunately more resilient seem to remain standing.

 

I don’t find it difficult to identify all of those factors in my own life. I’ve used biological (medication), psychological (therapy) and social (retirement from a stressful job) strategies to overcome them. Most of the time now, it works for me.  But there are still likely to be times when my mood just seems to switch gear again and I begin to see an image of the world distorted through a glass, darkly. I’ve never been clinically high, but when I begin to feel better I do sometimes feel an odd surge of well-being to be back in tune with life again.

Just please don’t call me ‘miserable’.

Grief

With so many people experiencing loss and hardship at the moment its not easy to admit the depth of grief I have been experiencing over the last month.  I’m sure I’ve glibly told many people over the years how ‘grief is a normal human experience,’ but that doesn’t make it any easier to bear. It may simply be an everyday kind of emotional pain, but it washes over me in waves of acute sadness and despair. One moment I’m fine, the next I’m in tears; and it hurts physically too. There is a pain my chest right above my heart. But this grief is not for a human being, but for an animal companion, my cat Sophie.

 

I’ve seen that wry smile on a colleague’s face when I tell them how it feels to lose a pet . Not that Soph was a ‘pet’, she was a fiercely beautiful but barely tamed Maine Coon cat who viewed the human race if not quite the enemy, certainly as all potential vivisectionists. But those who don’t understand how attached you can become to an animal are simply embarrassed by our tears; they don’t know what to say. Statements like ‘well you can always get another one can’t you?’ are unhelpful. Yes, I have another cat, but he isn’t her. He is different. I will probably have a few more in my life (or rather they will have me) but each one I have lost has left a unique shaped space behind in my heart that another will eventually fill- but not in quite the same way. Some colleagues of mine have written about the important part that animals play in providing support for people with long-term conditions. But we live in a society where older (and younger) people with mental health problems are regularly separated from their companions when they have to move into new rented accommodation due to the desperate state of our housing policy. I cannot imagine the pain of having to give up my companion animal. Perhaps I will have to one day.

 

Grief is something I know about. I treated many people in my career who were failing to grieve for someone, or something they had lost. It doesn’t have to be a person, it can be a career, a person, your health, or even your hopes for the future. The list is endless. The process IS normal but it can be frightening if you have never felt it before. It isn’t the same as depression although if a person fails to grieve properly depression may follow, and in the vulnerable, loss may trigger it. But it should not be medicalised as it has been in DSM-5 where two weeks of depressed mood following loss is taken to indicate depression. Two weeks? That’s crazy. Grief can take years, a lifetime to resolve. The key thing is the trajectory of the process and the severity of the symptoms. Is it gradually getting easier over time or unchanged in intensity? How low are you feeling? Have you had thoughts of suicide or wanting to join the dead person?  I failed to grieve successfully once when I lost someone very important.  I didn’t talk about it. I tried to work my way out of it at the hospital rather than go through it.  You cannot shut it out. You have to talk, remember …and weep.

 

Sophie was killed by a fox one night in August. She loved going out at night to hunt. She began her life as a pedigree puss and then heard the call of the wild. She escaped when she got very frightened as were taking her to a cattery and wriggled out of her harness. She would never travel in a cage. I missed her terribly but I always hoped she come back to us, and she did. She spent two years living rough before she finally trusted a lady enough to accept help, and was returned to us (due to her microchip) by the RSPCA. She would sit next to me on the sofa and purr loudly, demanding her share of my love. Her coat was soft and silky before she disappeared, but woolly and thick when she returned after two winters outside in Yorkshire. But she knew she was home and she embraced it with enthusiasm. She was a happy, healthy cat and she was only seven years old. It’s really hard to accept she could have survived so long on her own and then die now. But I couldn’t have kept her inside. That would have been unbelievably cruel.  Yet I still feel I should have been there to protect her. Grief isn’t just about sadness, but guilt and anger. And remembering.

I have some of her fur, and a library of pictures to remember her by. I can look at them now. It was very painful at first.

It’s getting a little easier each day.  That I’ve been able to write this is a sign I’m coming through it.

But I’ll always miss her.

 

Strategies for Living

In the last few weeks, while I’ve been largely alone in Orkney, I’ve been aware of having to cope with my mood and thoughts from day to day and reading about how people with mental health problems cope on Twitter and support each other.

I’ve also been reminded of something I read many years ago.

At the turn of the millennium, the Mental Health Foundation carried out some service user research and produced a report called ‘Strategies for Living.’ Over 400 people had completed Knowing our own Minds – a user-led survey of alternative and complementary treatments and therapies in mental health and Strategies for Living reported the findings from interviewing 71 people with experience of mental health problems in depth. This was a really positive piece of work, which highlighted the particular activities and experiences which people with mental health problems found helpful in coping with their everyday lives: from on-going survival strategies, such as the need for financial security to crisis strategies such as making contact with friends or professionals, ways of controlling symptoms such as taking medication, having therapy, taking exercise or using a Walkman (yes it is a few years old) to distract from hearing voices, to ‘healing strategies’ through religion and spiritual beliefs to complementary therapies.

Relationships with others were key. Several common themes could be identified:

• Acceptance
• Shared experience… shared identity
• Emotional support… ‘being there’
• A reason for living
• Finding meaning… and purpose
• Peace of mind… and relaxation
• Taking control… having choices
• Security… and safety
• Pleasure

Mental health services were largely absent from the accounts that people offered although some individual professionals clearly offered a great deal of valued support

Why am I reminded of this now?

How we cope from day to day is a very personal phenomenon. There are of course some common strategies that people find helpful and these were the ones reported in Strategies for Living.

However there are also some other ways of coping that were not reported in here. The strategies that people do not always want to admit to. I know some of these intimately. Despite growing up in a household of heavy smokers, I’ve never tried a cigarette, but I watched my father consume 40 a day as his own personal way of keeping life at bay. Excessive drinking is something I’ve always suspected I could sink into and I’ve consciously tried to cut down in recent months. It isn’t always easy. I spent some of my career working in alcohol services and I know how hard it can be to withdraw from alcohol and other substances. But there are other ways too that we cope with how we feel: eating, or not, over exercising, self-harm and self-injury , spending every night out on the town or shutting ourselves away completely from the world to the point that we feel completely isolated and ultimately brooding about strategies for dying rather than living. Suicidal thoughts are themselves a coping strategy. Knowing there is a way out when it all gets just too much.

My concern with much of the self-help literature, some of which sits on my own bookshelf unopened, is that it makes various assumptions:

  • We actually want to change, and stop using the sometimes self-destructive ways of coping we find helpful in day to day survival.
  • We can find the resources to be able to do that.
  • We have the material resources and social capital to be able to adopt some of the positive strategies people suggest to us, such as time, money and a place to live to start off with.

Its difficult to adopt new ways of coping until you have acknowledged what you will lose in giving up the other strategies, the ones health professionals would prefer you to unquestionably ditch. Such positive ways of coping cannot be prescribed (such as in the advice to ‘go home and have a warm bath and a cup of tea’ that currently seems beloved of some crisis support teams- actually I didn’t  see these even mentioned in Strategies for Living either). Health professionals need to start from where we are at now. What have we found helpful in the past? What do we do now to cope? What is difficult about changing ? And avoid being judgmental if they want us to be honest.

The problem with feeling depressed is that it involves rumination. Indeed in some cultures it is considered to be a problem of ‘thinking too much’. We become aware of our thoughts, and struggle to cope with them minute by minute. I certainly have some obsessional features to my thinking, and I’m aware that if the day doesn’t go ‘right’ in some often hard to clarify way, I can feel as though everything has gone ‘very wrong’. I have to mentally restart the day in some way. These thoughts can be painful and repetitive and I seek ways to avoid them. Distraction is probably the most effective way I’ve found and I deeply resent that some psychologists I’ve met seek to denigrate such an effective coping strategy as a ‘safety behaviour’ in CBT speak. Hell- give me a break- it’s what I find helpful!

There are many different strategies for living and quite a few for dying.
Help me to find the ones that fit me best to help me survive.
Don’t advise, lecture or proselytize.

Solitude

Winter sunshine, Orkney

I’m back in Orkney after six weeks away. I’ve been busy, teaching and working, as far afield as Bangladesh. I’ve also found it impossible to sit down and write even when I’ve not been occupied.

One of the things I’ve had to learn as an adult is how ‘be’ with myself. When I was a child, I was often very solitary. I enjoyed reading and spending time alone. I’m one of those introverted people who needs to recover from a stressful day, with people who never seem to stop talking, by being on my own; rather than, as some people relax, by heading out to a noisy party. Extended time interacting with others without a break is for me a peculiar form of torture, although I strangely never experienced this much in the company of my patients and closest colleagues.

Unfortunately the world is full of extroverts who cannot understand the needs of someone like me. As Anneli Rufus commented in her book Party of One: The Loner’s Manifesto, its not easy to be a loner in a world obsessed with ‘team-building’; in a society where the very word ‘loner’ has connotations of being odd, crazy, secretive and strange.
However, being alone brings it’s own challenges. Living inside your own head is all very well if it’s fairly pleasant in there. But if it’s rather a mess and full of the rubbish left over from past relationships and conflicts, it’s not a peaceful place to be. Its tempting to spend more time in the company of others, not necessarily because you want to be with them, but in order to drown out your troublesome inner dialogue.

It is true that spending time on your own can be a way of escaping from dealing with things you have to tackle in the ‘real world’, but its really important not to assume that is always the case. I’ve seen too many people forced out of their protective shell by extroverts who think they should ‘socialise’ more. It happens in mental health because of the belief that those who are on their own mustn’t feel lonely. Some people need time alone to feel safe.

Looking back over my adult life, I’ve spent hours, days and weeks in the company of others trying to avoid feelings of loneliness and unworthiness, while at the same time resenting the time I’ve wasted not doing all the things I wanted to be able to spend time on. Something changed for me in adolescence. I started to hear the self-critical voices in my head (and my mother too- a born extrovert) telling me to ‘get out and mix more’. Its also hard to meet a partner too if you never leave the house, though social media is changing the way we view dating and our other interactions with the world to a degree that mental health workers haven’t quite caught up with yet. The on-line world can seem more real to you than the jungle out there…and can be just as threatening.

I find it difficult to be creative in the company of others, or when there is too much ‘going on’ in my life. Virginia Wolff was so right about needing a Room of Your Own. I’m on an island. As Anthony Storr wrote in his now classic text Solitude we need time and space to discover what we are capable of achieving. Being alone is a necessary step to learning about your self. The difficulty of course is that you may not like what you find. There may be a great deal of ‘stuff’ reverberating around your head. Being alone forces you to begin to sort out the packed store cupboards of your mind and throw out the junk. When I am on my own with my thoughts I have to find ways of dealing with them, e.g.by going out for a walk or having a sleep. Not by seeking out others who will then make more demands on ‘me’. It sounds a little selfish as I write about it. But its self-care.

An increasing number of people live alone, including many who are depressed. Loneliness is viewed as a growing problem in our society, yet there remains a real stigma to being on your own, which I suspect prevents some people from embracing their solitude and learning to live with it as they fear becoming even more lonely. I can see now that I felt lonelier in a failing marriage, making meaningless conversation at corporate parties, than I did when I really began to come to terms with being on my own on a prolonged stay in a remote Scottish cottage.

I am not completely alone now. I have a husband to whom I speak to every day, but from whom I spend quite long periods away. He is a person who needs his own space too. Each of us needs to find, what is for us, the right balance of intimacy of aloneness to be able to function.

There now….I’ve started writing this blog again.

Taking the tablets

I’ve been putting off writing about this topic. Even though I know it is something I really should talk about. I’ve used the excuse of the failure of British Telecom to sort out my intermittent broadband connection, which can be real a problem living alone on an island. But I cannot avoid it any more. So I am going to say what I think about antidepressants.

In the spirit of presenters at the American Psychiatric Association currently taking place in New York, let me begin my presentation with a few disclosures, so that you are fully aware where I am coming from:

I am a psychiatrist.

I don’t practice now, I’ve retired, but throughout my entire professional life I prescribed antidepressants regularly.

 

I have spoken at meetings funded by pharmaceutical companies and they have funded a couple of small research projects for me over the last two decades.

Neither my talks, nor my research have been promotional. I’ve never been involved in any research trial of a medication. At meetings I’ve generally been the acceptable psychosocial meat in the biological sandwich- squashed between presenters talking about the latest research into the biology of depression, much of which I’ve had a great deal of difficulty really understanding, even as an academic.

Last, but not least, I’ve taken antidepressants for most of the last 25 years. I’ve been continuously on them for 20.

My treatment record reads a bit like a history of the pharmacology of depression- and the promotion of antidepressants. Tricyclics (dosulepin), SSRIs (paroxetine and fluoxetine), SNRIs (venlafaxine and duloxetine) and adjunctive therapy (Lithium) with some antipsychotics thrown in.

So those are my disclosures.

What can I say about the rights and wrongs of taking medication?

First of all, just that: It is neither right nor wrong. I number among my friends people who will not take medication, and others who do. I don’t try and impose my view on them. Neither do they try and do that to me. It’s a matter of personal choice. But I hope it’s a fully informed choice when you make it.

Secondly: I dislike a great deal of what is written in the press about medication, because it often diminishes my experience of both having personally benefited from it and of seeing many of my most severely depressed patients do so too. Suggestions I would be harmed by it (which I haven’t been, though I’ve certainly experienced a great many side effects and had to withdraw from Seroxat- so I know about withdrawal symptoms) have proved incorrect. Some of the items in the media of late diminish the whole experience of severe depression by telling me everything can be solved by my going out for a run (radio 4 today) or taking up gardening.

Thirdly: Just because I’ve taken medication it doesn’t mean I haven’t had episodes of depression, but they haven’t been as severe as they were before I went on it. They are certainly not ‘happy pills’. I wear black most of the time and my friends will tell you I am not known to be pathologically over-cheerful. My mood dips, usually in response to how I cope with life events, and when I’m on medication it rights itself a little faster, but at least it bounces back. It used to take a lot longer, and I would get much lower, when I wasn’t.

Fourthly: Even Skeptics will acknowledge there is some evidence for antidepressant medication in severe depression. My approach clinically was always to work through the advantages and disadvantages of particular treatments and add my own opinion. As an expert, my patients expected me to have one. But the choice was theirs. If they were severely depressed, I’d ask that they not completely dismiss medication as an option, but to hold it in reserve for a while. I would do all I could to help them with their preferred option first. But if that didn’t work could we re-evaluate the decision at a later date?

Fifthly: Medication has its risks as well as its benefits. There are no easy options when your mood is very low. Side effects can be awful, and there are situations in which antidepressants should be used with extreme caution. Especially in younger and older people. A combination of venlafaxine and lithium gave me a prolonged Q-T interval in my ECG, which in lay terms means I had a greater than average chance of dropping down dead. I recovered on it, but it had to be stopped.

Sixthly: there is no place for the use of medication alone. Most people get depressed because they have problems, and if they don’t have them before they get down, persistent depression will cause them. It’s difficult living with a person with chronically low mood. Our physical health suffers too. We cannot work.

Talking of one form or another is an essential accompaniment to medication; anything on the broad spectrum from an honest and open conversation with a GP who listens to you and provides continuity of care to a longer term psychological therapy to help deal with some of the issues which increased your vulnerability to depression in the first place. Whatever is most appropriate and needed at the time.

Lastly: If the life events and problems which originally contributed to your depression have not resolved, you may benefit from staying on medication. Not everyone is able to make the changes in their lives that are needed to stay well. I’ve spent my life working in places where people lead very tough lives. There is nothing to be ashamed of in staying on medication, and I’ve argued the point with GPs who wanted to ‘wean’ patients off tablets prematurely. (Weaning is such a demeaning and unwarranted term anyway- it suggests a degree of infantilism).

I don’t know what would have happened if I hadn’t taken medication, but I can tell you things were not looking very positive. There are times when engaging in talking therapy is very difficult. When you feel as though there is a weight pressing down on your chest, making it very hard for you to breathe or carry on. The idea of going out for a run….well….need I say more? It feels impossible to be sure of your next breath. Antidepressants helped me to get to a point where I could use psychotherapy effectively. I’ve been able to keep going, write, research and hopefully help others. So I cannot put off honestly saying what I think and hope you will listen.

That’s all I can ask for.

A diagnosis of anxiety

On one of those occasions when I peep around the screen at what my GP is typing I see a diagnosis of ‘anxiety with depression’ at the top of the screen. I’m not sure how I feel about that. I suppose I’ve always thought about my problems as being more to do with depression than anxiety. But regardless of the idiosyncrasies of the recording system that GPs use (for the uninitiated, the Reed codes used in British General Practice don’t much conform to DSM or ICD), I think it’s probably right. In my life, low mood comes and goes, while anxiety has been pretty pervasive at the times when it hasn’t progressed to frank agitation.

This all comes to mind recently because the National Institute for Health and Care Excellence (NICE) just published its quality standard for anxiety disorders. It has information on all the different disorders neatly laid out- with specific pathways for Generalised Anxiety disorder, Panic disorder, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder etc. At the same time there has been the usual and continuing debate about the validity of diagnosis in psychiatry in the twitter sphere, in which I occasionally participate.

My problem with NICE guidance is that there are so many different pathways for the different diagnostic categories of what are called Common Mental Health Disorders– which consist of all the anxiety disorders plus depression. Some mental health professionals disparaging call these ‘minor’ mental health problems and the people who suffer with them the ‘worried well’. I’ve unfortunately heard psychiatric trainees use those terms.

Warning: don’t ever use these terms in my presence, I can’t be responsible for the consequences.

If you add in the other common mental health problems in the community, use of drugs and alcohol which many use to self-medicate for these ‘minor’ problems, you have a complex bundle of guidelines for a large section of the community (around 15%) who mostly get their mental health care from primary care. In common with the main classification systems, NICE treat all these as distinct diagnoses. If only life were so simple.

The problem is that in the real world they all overlap, co-occur and change around over time much in the way that my own symptoms have done since adolescence. ‘Anxiety and depression’ is the commonest mental health problem that GPs see. Mixed in with that may be some phobic symptoms, panic attacks, obsessional symptoms along with other features which suggest post-traumatic stress such as hypervigilance. Add to this the common ‘co-morbidity’ with drugs and alcohol, and the difficulty some people with these problems additionally have in social relationships which equates to some degree of personality difficulty, we have the potential to label a person with multiple diagnoses. At the other extreme we could say, these ‘disorders’ are all part of the same problem. You are suffering from something called ‘life’.

My view is somewhere in the middle, but I struggle with it. I’m a supporter of the need for psychiatric diagnosis and anyone who doubts the need for it should first read Robert Kendell’s classic book The Role of Diagnosis in Psychiatry. But to say that doesn’t mean we’ve got it right, or that the same system is appropriate in all settings. In my work with WHO, I’ve helped towards developing the ICD-11 system for primary care, which is a good deal simpler than anything DSM can ever think up. However what is key for me is that a diagnosis is only a construct,

as Kendell puts it:

‘thoughtful clinicians are aware that diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organising and explaining the complexity of clinical experience in order to provide predictions about outcome and to guide decisions about treatment.’

Clinically I have found the NICE stepped care model useful: severity of symptoms is the key to what intervention is likely to be helpful. But my approach to helping people has been to start with their life, their problems and hopes and concerns and help them to work out goals for how they would like it to be different. To work towards this by both finding out exactly what they are experiencing, and have been through, and then use a range of therapeutic tools from medication, psychological and social interventions in an essentially transdiagnostic way according to what is likely to help, both from the evidence base and their own past experience and preferences. This has been how I’ve supervised step 2 workers in Improving Access to Psychological Therapy (IAPT) in Salford where I worked for several years, to deliver care for people who might have ‘anxiety and depression’ in some kind of admixture, but had complex life problems. I’ve utilised a very simple set of ‘working’ diagnoses which can easily change over time.

I think we do underestimate the importance of anxiety, but it’s not just that we fail to recognise anxiety disorders. Anxiety pervades all of the common mental health problems except for in those people who experience depression without it. There is a significant genetic component which I can easily identify in my own family. Anxious symptoms in the presence of both bipolar and unipolar depression tend to make the outlook worse and suicide more likely.

Recently, since I gave up the day job, I’ve been feeling much less anxious. This was (unhelpfully) commented on by a colleague whom I hadn’t seen for a while who decided to mime how agitated I used to be at times. I have to admit that I was (strangely) usually worse when in his company. However this coming week I have to have more investigations for my physical health and the familiar churning stomach, sweating and tension have returned once more. Hopefully, after tomorrow, I will be able to return to the combination of exercise and mindfulness which I have recently found helpful in managing my ‘anxiety’.

Fingers crossed.

The healing power of the sea

I’m on the coast of North Yorkshire this week weathering a storm. I can hear the waves lashing the sea wall below my window. It’s different from the storm I would be facing if I were still at work, having to face the reality of providing care for people with mental health problems when services are being so constrained. While I listen to the windows rattling and watch the water rising up the slipway at high tide I find myself dipping into twitter every now and then. I can sense my blood pressure rising as I follow the debate about whether it is actually possible to achieve parity of esteem with physical care for people with mental health problems when everything is being cut. In some ways I miss work, particularly for the sense of being able to make a difference and for the contact with my patients. In other ways, for the constant anxiety it evoked in me for so many years, I don’t miss it at all. I’m still writing, and involved in research and teaching but I have control over what I do each day. That sense of having control over your life is important when you experience depression.

The sea can be both a source of fear, and of great comfort. I grew up next to it, and it evokes powerful memories of my childhood. My father was an excellent swimmer, but however hard he tried he never succeeded in teaching me. I was simply too anxious to take my feet off the bottom. I didn’t entirely trust he would not let go of me, yet now those times when I sat on the beach and watched him powerfully crawling through the waves off the Lincolnshire coast are some of the fondest memories I have of him.  I was born a couple of years after the great flood, which devastated the East of England. Since then I’ve travelled all over the world but have always felt the need to dip my toes in the water of whatever ocean I find myself beside. It’s like touching base with the past.

I cannot begin to imagine what it is like to be swept away in a tsunami, have your home battered by tidal waves or lose your husband when a fishing boat goes down with all hands. I’ve stood in the waves on Copacabana beach in Rio, and felt the warm tropical current try and drag me down into the depths. I’ve been unable to go into the shallows in Queensland for fear of being attacked by box jellyfish and sharks. The ocean is immense, merciless and can be so destructive, and yet it connects us all together. It has a power over which we can have no control; we have to accept it.

When times are bad the sea has a way of helping me to get my problems into perspective. I came here once, to the place I am now in Yorkshire, when an intense relationship that meant everything to me had broken down. Listening to the sound of the waves pounding the walls below as I lay in bed, with only the moonlight shining through the curtains illuminating the room, both resonated with my mood and helped me to understand how life goes on whatever happens.

Some years ago when I was on a beach in the Pacific Rim Park on Vancouver Island in Canada, I saw a woman meditating whilst sitting on a driftwood log next to the ocean. Since then, I’ve always taken the opportunity to use the sound of the waves to help me to clear my mind and relax whenever I am in earshot of the sea.  Next time you are there, whatever the weather happens to be, find somewhere to stand or sit awhile that is sheltered from the wind (or rain). Focus on your breathing as you would in any kind of meditative practice, but listen intently, with your eyes closed, to the sound of the waves ebbing and flowing and crashing to the shore. Try and carry on for at least ten minutes or longer if you can. When I make time to do this, it gives me a wonderful sense of wellbeing. For me it’s a kind of meditation in which I connect directly with nature. I suspect it’s a similar feeling to that achieved by mindfulness practice, but I am only just making time now to learn more about that. I will write more on that topic soon. In the meantime I am returning home with the sound of the sea, not in a shell in my pocket as I did as a child, but in my soul instead.