Tag: depression

Antidepressants are a feminist issue

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It’s 35 years now since I first took antidepressants, and I’ve been on them continuously for 31, the last 25 years or so on an SNRI (Serotonin and Noradrenaline Reuptake Inhibitor). So, it can be more than a little disturbing to reflect that just like my mother (who took Ativan and Valium long-term) I’ve ended up on psychotropic medication for much of my life. Particularly when I read an article Are antidepressants a feminist issue? published 3 years ago by Halima Jibril in Dazed Magazine, which cites NHS data from 2021/2 that 5.5 million women in England and Wales were prescribed antidepressants compared to 2.8 million men. That’s twice as many. Its woman who are much more likely to be taking them. 

Women are more likely to get diagnosed with depression than men, but there are several reasons for this, many of which I’ve discussed in a previous blog. Jibril also mentions the issue of over-medicalisation of distress, which has been a key theme in feminist critiques of psychiatry over the decades. It’s been suggested that not only are women’s emotions pathologized, but also that medication is used as a tool of control. Both have been true in the past, and in some places they still are. My profession has yet to acknowledge the full extent of its past and continuing poor treatment of women. However, if you are a person who believes there is no such thing as ‘depression’, as many do, it seems logical you are unlikely to believe there is a place in the world for antidepressants. 

I recognise depression to be real and very disabling in its severe forms. I’ve suffered from it much of my life and I’ve met and tried to help many other women, patients and friends, who have too. So, I’ve no doubt we have been the key market for antidepressants, just as we were in the past with benzodiazepines: 

Jan, ‘single and psychoneurotic’ because ‘she had never found a man to match up to her father,’ as the ideal candidate for Valium. [from an advert Archives of General Psychiatry 1970]

My mother didn’t fit this description, but she suffered with chronic anxiety. Something I inherited.

Many of us have benefited from antidepressants. I wouldn’t have been able to engage with some of the psychotherapy I received unless I had recovered sufficiently first by taking the pills. Nice recommends a combination of therapy and medication for severe depression. However, we do know much more now about antidepressants than when I began to use them in the early 90s. We’ve learned about the problems they can cause – particularly difficulties in withdrawing which can be severe for some people and also sexual dysfunction – including PSSD (Post SSRI sexual dysfunction). 

Women respond better to SSRIs than they did to the older Tricyclic Antidepressants (which I took at first), and younger women respond better than postmenopausal women. Hormonal fluctuations affect how our bodies metabolise them.  However, women have also been found to experience more severe sexual side effects from some antidepressants than men do. I’d like to know much more about sex/gender differences in both how we respond to and experience withdrawal from antidepressants, given that they are taken much more commonly by women. 

We still don’t know enough either about the impact on younger women of beginning and continuing on medication for long periods in their lives. Having started pills at 35 after the failure of therapy to prevent a severe relapse, I know how difficult it is for me to answer the question, ‘Who am I really?’ The person I was before I took the medication, whose mood fluctuated sometimes to extremes, or the person I am now, calmer, more level, able to focus (I’ve never experienced emotional blunting although I know some people do) but also not quite the person I was. Is this me or is it the medication? I’ve managed to cut my duloxetine dose in half without too many problems (I am well familiar with brain zaps) but what would happen if I tried to cut further given the length of time that I’ve taken them? I share Awais Aftab’s measured opinion on what we know, and don’t yet know, about withdrawal. We cannot be complacent. 

However neither can we be complacent about how many women are being prescribed antidepressants. It isn’t a decision women take lightly but I know from my own time in practice how antidepressants are prescribed when therapy, if it were available, would be effective. I also know that some, like me, would benefit from medication when therapy and other options, just don’t work. They were far from my first choice in my early life. However, alternative treatments – including any kind of therapy without waiting for months – but particularly, longer-term psychodynamic therapy for women who have experienced early trauma and therapy for depression associated with PTSD related to domestic violence, are all difficult to access quickly if at all in the UK unless you pay. The specific issues facing women who experience depression, either in terms of better access to care other than pills, or politically in the multiple problems in our misogynistic society that make women more likely to get depressed, are not being adequately addressed.

                  Depression is real. As women we need to campaign not only for changes in society to help prevent it, but demand access to more effective and a wider range of treatments for it, when it happens, than simply a prescription. 

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is available now.

What is happening to the mental health of young women?

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Society seems to have great difficulty in talking about the mental health of women just now. That’s problematic when the latest figures show the gender gap between men and women remains and is especially stark for young girls and women. The proportion of all those aged 16-24 with a common mental health condition rose from 17.5% in 2007 to 25.8% in 2023-4. However, the proportion of young women reporting a mental health condition is now the highest on record, at 36.1% in comparison with 16.3% of men. This news went almost unregistered by the media in Britain at the end of June.

It’s just girls isn’t it?

The authors of the latest iteration of the Adult Psychiatric Morbidity Survey (2023-4) say in their Conversation article, ‘Mental health in England really is getting worse. One in five adults are struggling.’ They also challenge the claim of overdiagnosis. “The APMS has been conducted with consistent methods over decades, using the same robust mental health assessments with large, random samples of the population. This means the results are largely not affected by changes in levels of mental health awareness or stigma, and changes in levels of diagnosis or service contact.”  These data are epidemiological estimates based on official criteria. (Helpfully the survey also shows self – diagnosis rates too for comparison, and these are higher).

So what is happening for young women? And why do we seem to find it so hard to discuss it? 

We know this is a worldwide phenomenon and in many countries suicide rates are increasing more rapidly in young women than in men. A recent Australian study reported an annual prevalence of nearly 50% for mental disorder in young women. Socioeconomic factors play a significant part in why both men and women develop mental health conditions – debt, unemployment, chronic ill-health, homelessness – but women are more likely than men to be in precarious work, to be reliant on benefits to survive, be single-parents and unpaid carers. Poverty matters, and if you add in intersectional factors such as being from an ethnic minority and/or LGBTQA+ risks to mental health multiply. Women are also more likely to have faced early traumas such as sexual abuse and then must deal with sexual harassment and gender-based violence in their everyday lives.  If in doubt, look at the pages of Everyone’s Invited which spells out the experiences of many young women very clearly. We have rising levels of misogyny, which is rightly leading us to question what is happening to young men and what needs to change for them. But this fails to take into account what happens to those who experience and survive the damage caused by the behaviour of boys and men, and the harm this is causing to the psychosocial development of young women. Gender based violence and abuse alongside being in poverty creates a web of adversity and mental ill-health in women’s lives.

Growing up now as a girl is very different from how it was for me in the 1960s and 70s. The pressures in terms of getting an education, feeling good about your body image, navigating sex and relationships and discovering and developing an identity are considerable and amplified by social media, which I’m so relieved I never had to contend with. 

Women are more often seeking help for anxiety, depression, eating disorders and self-harm but their mental health issues are not being considered through a gender specific lens. The menstrual cycle plays an important part in the mental health and well-being of young women but has been largely disregarded in the past in mental health care. We still need to know, for example, much more about the interactions between ovarian hormones and early life trauma in women. The APMS reveals that more men are getting access to care than they previously did. However, waiting times for psychological therapy remain long, the majority on those lists are women and the therapy provided will most likely not be tailored to the specific needs of women who have experienced trauma and violence. It is all too easy, as a young woman, to receive a diagnosis of Borderline Personality Disorder when you have been subject to repeated abuse and trauma.

 Is it surprising that new claimants for disability benefits in the UK are more likely to be younger, for mental health related problems and to be women? Limiting access to those benefits will increase poverty and continue the cycle of despair and adversity. Instead, we must rethink the way we support women and girls. Many will need access to a tailored, person-centred, biopsychosocial assessment, designed around their needs and preferences but its most definitely not a problem to be solved with more medication. To stem the increasing problems young women are facing demands that society recognises it, talks about it and has the political will to address the serious challenges young women currently face such as gender-based violence and misogyny. As women we are expected to not complain too much, ‘put up and shut up’ and if we do need help, ask for it ‘appropriately’ which doesn’t include harming ourselves, even though our needs often go unnoticed anyway. We often are accused of exaggerating or faking it. There is a continuing pattern of raising concerns about women’s mental health and society failing to act.

Isn’t it time we listened to young women, believed what they are telling us about their lives and talked about it rather than just let each new report drift by and disappear into the ether?

Then let’s get together and do something about it. 

My latest book: Out of Her Mind: how we are failing women’s mental health and what must change, is on sale now.

Reflections on reading Unshrunk by Laura Delano

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Forty years ago, Carol Gilligan, the veteran feminist psychologist wrote about how young women may lose their ‘voice’ during adolescence as they navigate the pressures of society. We women resist these pressures to disengage from our honest voices but are told that we must repress our anger and questioning selves and conform to societal norms if we are going to succeed in the world. We are told that it is wrong to resist.

Laura Delano’s world was a privileged one, but it was a life which nevertheless came with quite firm expectations. At the age of 13 she looked in the mirror and began to question what was happening to her in this somewhat gilded existence. ‘I had no idea who that girl was anymore. All I knew was that she was someone else.’  

The tragedy of the next couple of decades is that, instead of having an opportunity to try and voice these thoughts, feelings and fears through conversations over time with a therapist skilled enough to both engage and work with her (she is sadly declared too serious a case for the one she does see), Delano is diagnosed with bipolar disorder by a psychiatrist at the age of 14 and given the bleak prognosis that she will need to take medication for the rest of her life. She is started on both Depakote (a mood stabiliser) and Prozac. This leaves her feeling betrayed, alone and ‘in a battle to protect myself’. 

Reading about what happened left me feeling both full of compassion for her  and anger that a fellow shrink could ever consider this to be good psychiatric practice. But that is only the beginning of this shocking story of multiple diagnoses and dangerous polypharmacy.

Oddly, I wasn’t surprised by the experiences Delano describes with each subsequent psychiatrist because I’ve read some similar accounts in recent years, notably Rachel Pruchno’s moving account of trying to help her daughter obtain good mental health care for bipolar disorder. I’m not going to pass any judgement on the diagnosis of bipolar that Delano received other than in my opinion coming to any such conclusion in one so young should take much more time and caution. Its also stunning how it sounds as though the diagnosis first provided is then taken as read – something that I was taught never to assume. Diagnoses are only working hypotheses which change over time, and as Allen Frances says, should be written in pencil. However, further additional diagnoses and medication are added to the list over the following years. 

The period that Delano spends at McLean Hospital in the unit for Borderline Personality Disorder is however, for me, the most disturbing. It’s hard not to see this as some sort of place where it feels like attempts were made to overcome her resistance and get her to ‘behave’, in order perhaps to restore the ‘promise’ for society that she once showed as a New England debutante. I know many therapists will disagree but it’s a diagnosis some of us intensely dislike – rooted in a misogynist perception of how women and girls behave when extremely distressed, and here there are so many of them, collected together and regularly judged as to their ‘progress’. 

The polypharmacy is chaotic and dangerous. I have some skin in the game here, both as a (now retired) psychiatrist and as a patient. I’ve prescribed many of those drugs but also taken quite a few of them too. I know about the side effects – the weight gain caused by Seroquel, the terrible thirst and tremor of lithium (I was never able to discontinue the thyroxine after lithium damaged my thyroid gland), the constant gut problems and the difficulties of coming off SSRIs and SNRIs. I’ve had episodic depression throughout my adult life, which at times has proved difficult to shift but I benefited from excellent care from colleagues in whom I trusted, and medication did help me to survive and thrive, even lithium. 

One reviewer of this book has criticised it as a study in ‘black and white’ thinking. But I’m old enough to remember the change from ‘black’ to ‘white’ that came about in American Psychiatry, when it shifted from reliance on psychoanalytic interpretation to declaring the dawn of ‘decade of the brain’ accompanied by a hefty dose of psychopharmacology. Psychiatrists treating Delano seem to keep these modalities quite separate too. Never wanting to ‘see’ the whole person in the round – a young woman getting minimal benefit from treatment and experiencing what is desperate and suicidal anguish – to find out what she really needs.

However, Laura Delano did ultimately resist the ‘psychiatricization’ of her life and triumphantly survived to found the non-profit Inner Compass Initiative which helps people withdraw from medication. It probably goes without saying that I don’t share her view that psychiatry is the main problem though I’ve met people over my career, and some of my personal friends, for whom it certainly has been a significant part of it and who have only thrived when away from it completely. I believe it can do great harm but can also do much good too. In my professional and personal experience mental illness not only exists but can benefit from medication and psychotherapy. Some will say, of course I would say that, but I do also acknowledge the importance of the existence of the ‘other’, outside of psychiatry and mental health care, to whom people can turn if they need to, for advice, support and advocacy. 

I have known people who have been diagnosed with severe mental illness who have been able to come off all medication and live a drug free life, and others for whom this was quite impossible. I still take duloxetine to stay well and often wonder what I would be like if I didn’t. The medication free me is a person I’ve not known for many, many years. But having reduced the pills considerably I know that last few milligrams will be hard to withdraw from given the decades for which I’ve taken it. Support is vital, and, even if we disagree, ‘inside’ and ‘outside’ psychiatry might benefit from working together for the very sake of those we are trying to help. 

Laura Delano fought to rediscover her voice. 

Even if you disagree with what she has to say, it is indeed a powerful one.

*Laura Delano Unshrunk : How the mental health industry took over my life and my fight to get it back. Monoray 2025.

My latest book Out of Her Mind: How we are failing women’s mental health and what must change is published by Cambridge University Press and is a PROSE award winner (American Association of Publishers) in the USA.

Why aren’t we talking about what’s happening to women in mental health care?

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It was utterly shocking to read Scout Tzofiya Bolton’s description in the Guardian a week ago of how she was re-diagnosed from having bipolar disorder to having a diagnosis of emotionally unstable personality disorder (EUPD), and, excluded from care then ended up in prison.

                  And yet, sadly, wasn’t. 

Because many women and girls have told me similar stories during my research for Out of Her Mind. 

We know it’s remarkably easy to be given this diagnosis. Women are three times more likely to be given it, and some are very clear about how easy it is to receive it. Challenging a doctor’s views, as Scout did, is one way. 

When I was training in psychiatry ‘borderline’ or ‘EUPD’ wasn’t a recognised diagnosis but difficult women were usually labelled as having ‘hysterical personality disorder’ until they received sufficient time and care to be able to tell their story to someone who would really listen. It can take years to get a diagnosis of bipolar disorder, especially if you are a woman perceived as behaving ‘outrageously,’ and you can be rediagnosed easily too, as Scout’s story demonstrates.

 However, we don’t seem to be any better now than we were 40 years ago at listening to women with complex problems and finding out what is needed to help them. Now we have the diagnosis of borderline personality disorder and undoubtedly, as clinical psychologist Jay Watts says, some with this diagnosis are suffering from missed bipolar disorder, are autistic or have premenstrual dysphoric disorder. The vast majority have experienced trauma, if not before they came into mental health care, certainly afterwards. I’ll discuss the issue of complex post traumatic stress disorder cPTSD versus BPD in another blog, but I’ve made no secret of my desire to put ‘borderline’ in the bin – and that is a change of opinion from my experiences of listening to women.

What we do know is that a  majority of those with this diagnosis who take their lives when under mental health care are women.  Not only are they unlikely to get an adequate assessment but they have great difficulty accessing appropriate psychological therapy. We hear about them quite frequently now at inquests and/or there are investigations into the quality of their care, after which we are told that ‘lessons will be learned.’  

Surely, in mental health care, and society too, we should be paying more attention to this? Yet when I recently shared my views in a psychiatry teaching session, several (male) colleagues told me I was mistaken. It was a helpful diagnosis – for them. And I felt like I was once more being a ‘difficult’ woman. That’s familiar.

We also know that women are regularly victims of  sexual violence in mental health care, though without the fact that the majority of victims are women being mentioned. 

Many women who end up in in-patient care have already experienced trauma of one form of another.  In mental health care, be it from the lack of respect, kindness and compassion from staff that women described to me (and was clearly visible in the BBC Panorama report) or the risk of sexual violence, women are being retraumatised every day.

                  All-in-all its not so very different now for women in hospital from what I described in The Other Side of Silence of my experience as a new consultant in an old asylum in 1990. I didn’t name the hospital, but everyone who knows me can guess where it was. We closed those places, but the culture sadly hasn’t changed.

In the focus on men’s mental health in the last decade, we have failed to pay attention to what’s been happening to women in the mental health system. I know that many of these problems happen for men too, but being ‘gender neutral’ is not helping to address the very specific problems that women are facing.

We need a women’s mental health policy. 

And if that’s at the risk of offending men, well so be it. Something has to change.

My book: Out of Her Mind: How we are failing women’s mental health care and what must change, is out now.

Making sense of psychiatry

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A review of ‘Conversations in Critical Psychiatry by Awais Aftab. Oxford University Press 2024.

Reading Awais Aftab’s masterful interviews with prominent commentators on psychiatry is rather like returning to when I was first trying to make sense of what psychiatry is all about. Moving from one placement to another as a young trainee I was confused by the different models of mental illness applied, biological, psychological, social and, yes, even existential and sometimes (I thought) too ferociously adhered to, by the consultants with whom I worked. They all broadly worked to the ‘biopsychosocial model’ but each clearly had his (and they were all men just then) favourite lens through which to try and make sense of what a patient was experiencing, and how best to help them. 

                  I’m critical of much psychiatric practice but I’ve never identified with the British version of ‘critical psychiatry’, finding it rather like having to adopt a complete ideology that will only consider hypotheses that are self-confirmatory. But it was refreshing to find a much wider range of thinkers who inhabit the borderlands of psychiatry, psychology and philosophy.

I was reminded of everything that really fascinated me in my own training. The knowledge about descriptive psychopathology conferred by the older consultants who looked beyond the restrictions of modern ideas and introduced me to the classical descriptions from old german texts that sometimes fitted so much better with what the patient was conveying to me (usually involving long German words such as my own favourite ‘Sensitiver Beziehungswahn’). And the weekly case conferences where biological, psychological and social perspectives on formulation were fiercely debated and questioned. Together these demonstrated for me the need for both nosological (referring to how we classify mental experiences) andexplanatory pluralism (how we understand them).  Additionally. a strong grounding in social psychiatry resulted in my interest in working with primary care where there really are no absolute certainties when a person first presents to a health professional and a pragmatic approach is essential. 

This acquired knowledge didn’t ‘fit together’ into a coherent logical whole of checklists like DSM-5. We now seem to have lost the awareness that psychiatry is an ‘imperfect community’. Aftab’s conversation with psychologist and philosopher Peter Zachar about the conversations around the ‘bereavement exclusion’ in version 5, which caused controversy at the time because of fears about medicalisation of grief clearly demonstrates this. It reminded me of those students who would simply list the DSM symptoms when asked, ‘What do you think it feels like to experience depression?’ 

The need for pluralism and pragmatism reverberates through most of Aftab’s interviews which were initially published in Psychiatric Times and have been brought together in a book by Oxford University Press. They explore current controversies in psychiatric theory and care and in particular the history and philosophical underpinnings of psychiatry . Awais employs a ‘critical’ lens, but he doesn’t define it, instead ‘approaching the notion as a tool to explore the rich multifaceted space of psychiatric critique’. There are 27 interviews with many leaders of the field, some of whom I knew of already such as the British Critical Psychiatry group (Duncan Double, Joanna Moncrieff and Sami Timini). Some whose work has informed my own thinking such as Allen Francis (‘diagnoses should be written in pencil’) and Paul McHugh whose book with Slavney, The Perspectives of Psychiatry, has been helpful in making sense of how a particular person’s distress or mental illness develops.

There are others to whom I was delighted to be introduced to in this way such as Sanneke De Haan talking about Enactive Psychiatry. De Haan sees psychiatric disorders as disorders of sense-making, of the way that we make sense of ourselves and the world around us. Her interview provides a different way of making sense of how body, mind and world interact.  ‘All living beings engage in some basic sort of sense-making… it remains an embodied and embedded capacity.’  

That really resonated for me.

I have yet to read Robert Chapman’s book The Empire of Normality but their critique of Szaszian views (‘it undermines and gaslights those who do find a medicalized approach helpful’) has encouraged me to do so! 

The views of Dainas Puras, the psychiatrist and human rights advocate whom I briefly met many years ago on a journey to Lithuania, have not been well-received by many psychiatrists. However, the interview with him helped me to understand much more about how and why he has arrived at his conclusions about ‘liberating global mental health care from coercive practices.’ Aftab writes how he has struggled too with the United Nation’s Convention on the Right’s of Person’s with Disabilities but 

‘…simply invoking the necessity of involuntary care in our present circumstances doesn’t render our current practices just or ethical, especially if we are not also trying to improve them.’(p20)

Particularly notable for me was the conversation with Nev Jones (who has herself experienced psychosis) where she movingly describes how: 

‘…at multiple points I felt heartbroken hearing other individual’s stories and the extent to which they felt they could not open up, had never even tried to describe so much of their experience to clinicians, or had long ago given up trying. Many of these were folks who had been in the public mental health system for decades; who had worked with dozens and dozens of different clinicians and social workers. The areas of misunderstanding or silencing or invisibilization took different forms, and I listened to this and really this is what informed my initial research.’ (p63)

I should like to have heard more from others who have used services themselves, particularly those created from a critical standpoint – but I suspect that would have required another volume.

                  Ultimately, Aftab himself, in an interview with Richard Gipps and Nev Jones, shares his own views and I agree with him that much of the ‘diagnostic reification, eclecticism, reductionism and over-reliance on psychopharmacology and neglect of iatrogenic harm’ we see is related to a failure to address the underlying concepts of psychiatry in our training. What do we really mean by a diagnosis? By ‘normal’ and ‘disordered’? What does it all mean? 

                  We need to encourage those training to be psychiatrists to not only be more thoughtful but listen to as many patients’ stories as they can and read widely, even the work of those they are convinced they will disagree with. 

That’s only how we will begin to make sense of psychiatry.

On writing a book about women’s mental health

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For the last 5 years I’ve been working on a new book about women, mental health and feminism, addressing two big questions – how are we failing women’s mental health? and what needs to change?

                  Over the last decade, we’ve been rightly concerned about men’s mental health. Men continue to take their own lives at 3 times the rate of women. However, women are suffering too, and the size and nature of the mental health problems and illness they experience seems to get lost beyond that desperate headline. Just as women’s physical health is much more than about our reproductive system, the mental health crisis we currently face is much more than about perinatal mental illness. Girls and women are twice as likely to experience depression and anxiety, ‘common’ mental health problems and intersectional factors such as race, LGBTQ+ and disability, along with poverty, simply magnify this difference further. Girls and women are much more likely to self-harm than boys and men, experience 2 to 3 times more post-traumatic stress disorder, more commonly have eating disorders and are 3 times more likely to be given the diagnosis of borderline personality disorder, a diagnosis that I argue (controversially still for some) should be finally consigned to the bin. Young women are presenting with more anxiety and depression than ever before and since the pandemic there has been a considerable increase in their distress and requests for help from services than have been unable to cope. Some of those who have been failed by ‘mental health care’ in our hospitals and community services are tragically dying too.

                  Why is this happening to women?

                  Has feminism failed?

I have no doubt that what happens to women in our society plays a huge part. Women not only experience more sexual abuse in childhood, but they are also subject to greater intimate partner violence as adults than are men. There is an epidemic of male violence towards women in our society and it is happening too within our mental health services. Misogyny and sexual harassment are rife. Women are more likely to be single parents, working in low paid, precarious jobs, and be forced to live on benefits.  And it is clear that when women who experience trauma cannot get the understanding and help they need, they alone can become the problem, rather than helping to address the circumstances that contributed.

Women who discovered during the pandemic that their jobs were considered of less value than those of men, so they could return to full-time childcare, certainly felt failed by feminism. The silenced women in the street of Afghanistan must surely feel the same too.

In the 1980s when I started training in psychiatry there was a real resurgence in feminist interest in mental health. In ‘Out of Her Mind’ I’ve explored what has changed since then. Most recently some feminist writers have denied the reality of ‘depression’ and accused psychiatrists of simply labelling the impact that trauma has on women as mental illness. In my view that denies the reality of what many women are experiencing and can be perceived as another form of gaslighting. Instead of repeating the mantras of the past about the evils of psychiatry, even though I can and do acknowledge horrendous things have happened and still do, to women in mental health care, we must also focus down on the experiences of individual women, here and now. What needs to change?

Listening to this woman’s story has always been my starting point. What has happened to her? What is she experiencing? What does she need now to help her move forwards? 

As a psychiatrist I work from a biopsychosocial perspective, and looking through biological, social and psychological lenses, identify what increased her vulnerability to mental illness, and what has stresses in her life have caused it to occur right now. However, we must add a fourth lens to these three, the political. What part does her status as a woman in this society, particularly if she is also subject to intersectional inequalities, play in her experience of emotional distress and mental illness? 

What can all this tell us both about what might help her? 

                  I began to write this book while not only researching but most of all listening to many stories from women not only in the UK but elsewhere too, as well as interviewing expert commentators. Those stories add to the many I have collected in my own mental filling cabinet during the years when I was working as a psychiatrist. The book is framed as a narrative of how I returned to my own feminist roots as a doctor who spent so much of working life both working with and trying to help women. Everyone whose story and/or opinion is included in the book gave permission and had the opportunity to comment on/make changes to text that was finally included – over 120 people. I’m immensely grateful to those who gave me their time. 

You can purchase the book here its called ‘Out of Her mind’

A final note I’ve donated a large proportion of the advance I received from the publisher, Cambridge, to three charities: WISH, Self-Injury Support and Southall Black Sisters. They continue to help, daily, those who are facing sometimes incredibly challenging problems.

Therapy

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I know many people have enormous difficulty accessing therapy for depression- but as someone who has benefited for it, provided it, and supervised others, I realize how fortunate I’ve been, and how important it has been personally for me. Antidepressants have helped me with many of the symptoms of depression, but I still needed to sort out the conflicts and problems in my life that had contributed to the emotional mess in which I found myself. We keep hearing how there will be medication tailored to suit each individual some day, but I don’t think there will ever be a tablet labeled ‘take two a day to come to terms with how you feel about your mother.’

Over a period of about 12 years, during my twenties and thirties I underwent psychodynamic therapy, something in which I had also had some training – with 3 different therapists. Two of them helped me but there was one with whom I simply could not ‘gel’. Finding a therapist with whom you can make some kind of emotional connection is essential. I was able to learn how the problems in my childhood and the dysfunctional relationships I had with both of my parents were still affecting my adult life. I’m quite sure that, at the time, that was the best type of therapy for me. There were some major unresolved issues from my childhood and adolescence that  interfered with my ability to make stable, trusting relationships. I had also spectacularly failed to grieve for my father, who died when I had just qualified as a doctor. There was a period of a few years in my late twenties when my emotional life can only be described as chaotic. With therapy I was able to access the parts of my personality that I had been desperately trying to keep under control, but sometimes the new and more assertive me who emerged from the chrysalis of therapy was more of  an abrupt and outspoken moth still seeking the light of day, than a perfectly finished social butterfly. Nevertheless talking therapy helped me to address some of the difficulties that I had in the major relationships in my life and embark on what has been a successful second marriage.

Later, when undertaking a course of cognitive behaviour therapy (CBT), I found ways to begin to manage the way I ruminate about being me in this world and to cope more effectively with people in day-to-day life. Therapy was anchored in the present, not the past and I began to learn much more about how my mind actually worked. I could identify my previously unspoken, but very difficult to live up to,‘Rules for Living’ from David Burn’s book the ‘Feeling Good Handbook’, and I began to understand how attempting to live up to my internal very high but often conflicting standards, led to experiencing anxiety in everyday life. It is six years now since I completed that last course of therapy and I am beginning to realize just how long it can take for it to work. I still continue to have new insights into why I am the way I am, and what triggers and sustains those periods of anxiety and low mood, as life goes by. Life is a ‘work in progress’, or at least that is how it has seemed for me.

What most people get offered now in the first instance now is brief therapy, mostly based on CBT principles. For many people that will be very helpful- and when I was supervising a primary care based team of therapists, I saw how effective it could be- particularly if the behavioural aspect of CBT – behavioural activation- was employed first. CBT is very much about ‘doing’ things to feel better. Like setting goals for activities that you may have stopped doing. Or actively trying to address the depressive automatic thoughts that can both trigger and maintain depressed mood- both with the aim of getting you out of the shadow of depression to which you retreated when you lost the energy to fight anymore. In some ways the conceptual basis of brief CBT based therapy isn’t all that different from medication- in that both seek to ‘activate’ either your mind or your body. You get going and take up your life again. You are ‘fixed’ at least for the present as your deficit, of either serotonin or self-esteem ,has been addressed, as Alain Ehrenberg in his book on the sociology of depression, ‘The Weariness of the Self’, clearly describes. And in today’s climate you must of course take responsibility for helping yourself to get fixed- through self-help or presenting yourself at the doctor’s office.

CBT helped me when I was struggling with  my depressive ruminations and it was the right therapy at the right time. But when I was younger, and I couldn’t make sense of who I was or wanted to be, I needed time to build up trust in a therapist, and work on the complex problems from my past that actually interfered with me engaging in therapy in the first place. As I wrote recently, the simple ‘fix’ doesn’t work for a significant number of people who are depressed- particularly those dealing with painful conflicts and the impact of trauma- and we realistically should not expect it to. They need what I was fortunate enough to receive, but it is less available than ever- not only because of cuts, but the prevailing view that depression in primary care is something that can be ‘fixed’. Some people need time to engage, to trust and to work out how to discover who they are and learn how to forgive themselves for even being alive. Some who don’t respond to the simple fix are labeled as having borderline personality disorder- and their anguish is downgraded to ‘distress’ but they too are experiencing something that is only one aspect of the many faceted but hard to define experience that we call ‘depression’. I can assure you that it is real and those who suffer from it kill themselves.

Those who need more than the quick fix are  just as deserving of our attention- and our help.

 

Going North- the problems of trying to lead a disciplined life.

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It is high Summer in Orkney, and I am back again in Scotland once more.

When things are difficult in my life I’ve always headed North. I don’t mean the North of England. That’s pretty much where I come from now. I’ve lived and worked there long enough to be a real ‘Northerner’. When I go South to London I like to broaden my accent a bit for the hell of it. But for most of my life the real North has only existed somewhere in my imagination- a magical place that never seems entirely real until I arrive there- and when I do it isn’t because I’ve reached some point on the map. Its more than that, it’s the sense of peace that infuses first my limbs and then seeps through my body. My heart rate slows down. I can feel the blood pressure in my arteries falling as the valves that constantly drip adrenaline into my system and contribute to my persistent feeling of anxiety are closed down one by one. Not by medication, but by nature. I can stop moving. My skin begins to tingle and itch as the wounds beneath, the invisible ones I’ve carried around most of my life, begin to heal.

Recovery isn’t just about absence of symptoms. Researchers who deal in the currency of symptoms talk about how in depression we pass from ‘normalcy’ (whatever that is) to the experience of ‘disorder’ followed hopefully by ‘response’ to the treatment, ‘remission’ of symptoms (in which they lessen or disappear) and then ‘recovery’, but many of us have ‘residual’ symptoms which wax and wane over time. Similarly psychological therapies are not designed to achieve a ‘cure’ in medical terms. We have to find ways of living with from day to day with our symptoms, problems and unresolved psychological conflicts. Health professionals rarely ask ‘How do you get through the day?’ yet that is such an important question. Every morning when you finally get out of bed, you have to face several hours of being, doing, feeling and interacting before you can get back under the duvet. For me, how to survive this daily experience is central to the process of recovery.

But I’ve never been very disciplined and in many ways I am still a rebellious child. I dislike going to bed. Without my husband to get me up to bed I can sit lost in my thoughts, reading, surfing the net or watching the TV for hours. I can lie in bed half the morning like a teenager.

I have this intention every time I come up here that this time I am going to get myself into some kind of healthy daily regime. There is so much information about the kind of lifestyle I should lead if I am going to learn how to manage my recurrent downswings in mood and loss of energy, which are the first signs that I might be becoming more severely depressed again. I know there are some things I can do to stay well. The list is endless and I know there is some evidence for all of these things: taking regular exercise, getting sufficient sleep for my age, avoiding alcohol and other ‘substances’ and eating a “Mediterranean diet” (not always easy in Scotland- never mind if you are on a low income). I also know that, given my propensity for relapses I should stay on the medication I have taken, in one form or another for more than 20 years, as well as the other tablets I have for my physical health problems. Keeping my mind on track is essential here as I am alone most of the time. It’s a great place to practice the skill of allowing the boxes containing ‘difficult thoughts’ to pass across on the horizon of my mind without having to unpack them. I know there is a lot of rubbish in them that really needs to be thrown out. If I allow a worry to take over my mind here its quite difficult to elude it. My mood soon begins to spiral downwards. These are the skills, based on Mindfulness I began to learn in the Cognitive Therapy I underwent a few years ago, to help manage ruminative thoughts.

I must get to bed before midnight and up before 8. Eat healthy meals that I have cooked myself. Take some exercise every day. There is a voice inside me saying ‘if you do these things you will not only be well, but you will be good’. But why do I have to be good? I find it impossible to be good all the time. Can anyone truthfully manage that?

So I cannot tell you a satisfying tale of how I did all of these things that I know should help me and they did. I can only say that when I am able to do them, they do.

I am gradually learning to forgive myself for failing to always live up to the targets I set myself for each day. I made them, so I can break them. I don’t have to spend every hour doing something useful- where does that idea come from? I have a choice. It doesn’t really matter if I don’t get any cleaning done until just before I return to Yorkshire. The North is a place where I find it easier to be me because it reflects something about what is inside me- I can see myself reflected in the lochs, the moorland and hills- a little chilly at times and not to everybody’s taste, but perhaps worth discovering. We all have to find a place where we feel we can be ourselves. I need to learn how to carry the essence of it back South with me. The longer I am here, with each visit, the easier it is becoming.

My latest book’The Other Sides of Silence- A psychiatrist’s memoir of depression is out now and also just published in  USA

The diagnosis

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It is only 6 words.

‘I think you have polycystic kidneys.’

But there is nothing simple about being given a diagnosis. It means interaction with a new world of people and initiation into a different way of life – the doctors, nurses, therapists, surgeons, technicians, and the places you will find them in- the new hospital clinic you haven’t been to before, the x ray department, the laboratory, each with their own particular perspective on your illness and what is going to be best for you- body and/or mind. It is about learning how to speak in a different language. It is also about your own memories, ideas, worries and expectations of what that diagnosis means to you, and all the other things you will have to do in your life, or have done to you, that you have never experienced before and hoped that you never would have to. And all those things that you hoped to be able to do, but now perhaps never will.

I don’t have much memory now of how kidneys should work. Blood flows in and urine flows out- and the kidney works some kind of magic in between. The first patient whom I cared for long enough in my first job as a doctor to get to know as a person, and who I then saw die, had kidney disease. It was very different from my own. He had diabetes and came into hospital when a viral illness sent his damaged kidneys into failure. I listened in the ward office to the renal team as they decided against taking him on for dialysis, which unlike now was very unusual for patients with diabetes as they ‘did badly’. I watched from the door of the single room where he spent his last few days as he said goodbye to his wife and children. He was a young man- no more than 40. And I felt even more helpless as his wife screamed out in agony at the sheer unfairness of his sudden, and so unexpected passing. A phrase, ‘The Renal People’ uttered by the surgeon, a very kind and well-meaning man, evoked a particular and unwelcome memory for me.

Despite feeling fitter than I had for years, it felt as though my body had let me down. Something was happening inside me over which I had no right of determination. For the first few days after the surgeon delivered his verdict I felt numb. Then, like many people, but especially doctors, I spent hours on-line researching the subject until the rational part of my brain was exhausted. I collapsed onto the easy chair in my study and burst into tears. I sobbed until my throat was hoarse, my chest was tight and my shirt was wet with tears. John put his arms around me and held me. I knew I was beginning to grieve for the loss of my health, and the hopes I had for the future. And it all seemed so terribly unfair. Just `at the point that I had given up the work that was gradually killing me, and was prepared to restart that life I had postposed for so long, I had to find out that something else was going to do that anyway. The sociologist Mike Bury talks about the biographical disruption of chronic illness- how it necessitates a fundamental re-thinking of one’s biography and self-concept. The timeline of my life has been fractured and it is still physically painful.

Now I know that I have a genetic disorder of the kidneys that I’ve had for many years, but didn’t know about before, and which is going to get worse as I get older, at a rate as yet undetermined. There is a possibility I will eventually need to have dialysis. My kidneys and liver contain within them cysts, which have been slowly growing in size, squashing the healthy tissue into destruction since my childhood, or that is what the Professor of Nephrology had told me.

‘It is something you have always had. It isn’t new. Its autosomal dominant so you have a 50% chance of developing it if one of your parents carries the gene, but in about 10% of cases it’s a new mutation.’ He couldn’t understand why investigations carried out in my early thirties hadn’t revealed the problem then. As the years passed the timer on my kidneys had been ticking away silently inside me and I had been completely unaware. It had been programmed into me at birth and was probably running quite slowly otherwise it would have been noticed much sooner. But I suspected that the other problems that my family genes had contributed to- a constant sense of anxiety and periods of severe depression, would have been even harder to bear if I had known. Neither of my parents had been diagnosed with kidney disease as far as I knew before they died, but my maternal grandmother had collapsed in the street and died suddenly in her thirties. I’ve always believed that must have been due a brain hemorrhage, and brain aneurysms are a possible complication of this disease.

It may be impossible to ‘recover’, in terms of restitution to my former state of ‘health’, in mind or body and I have no idea what will happen in the future- other than I hope I can manage my mood more effectively than in the past, and that it is possible I may need renal dialysis at some point. I can no longer make the excuse that I am still waiting for the future to arrive before I have to reclaim the life I always wanted to live if I just had the time. The ‘future’ is now and I will have to discover how I can make the most of it.

My latest book, a memoir of psychiatry and depression, The Other Side if Silence is available now

 

 

 

Moods

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Not everyone who gets depressed recognizes the experience of simply ‘feeling low’. The pain of emotional suffering comes in many different forms. The agony of heartache; the exhausted feeling of weariness with the world; the anguish and torment of ruminative thoughts of guilt and despair; the perception, which can develop into a terrible sensation of being beyond any feeling at all, that all of the joy has simply gone out of being alive. A sense that the world has gone from being a place where there is still a potential for happiness, to one which seems empty, hopeless or even dead.

But each day I am aware of something I call my mood. I have more time now to reflect on my life from moment to moment than when I was working. Rushing around all day meant that I was probably less acutely aware of it and yet my mood is a key part, for me, of my experience of ‘being in the world’. It’s the lens through which I see what is happening around me- and its qualities on any particular day colour, clarify or even completely distort the different ways I am able to think about myself, the world around me and what will happen in the future- just as when I was a child, the Hall of Mirrors in the fairground warped my reflection: sometimes I was amused by the altered image that was reflected back to me. Other times it horrified me.

Mood is more than simply ‘feelings’ or ‘emotions’- it’s a longer lasting state of mind and it encompasses everything you are thinking about- it can transform how you view events around you and change something which yesterday you thought was a great opportunity into tomorrow’s disaster in the making. We aren’t always aware of our mood but the people around us often are. My mood is not only the spectacles I wear but the overcoat I show to the outside world.

My mood is both me and yet not me, simultaneously. I cannot manage without my glasses. I know, rationally, when I feel down that if I could will myself in some way to change them to a different pair, the world wouldn’t look as bad as it does to me at that moment, but those are the only ones I possess. Tomorrow, or even tonight things may appear differently though them, brighter, sparkling and full of hope. My mood has never been ‘high’ –However I do have periods of irritation and agitation when I can get very angry with people around me when I don’t think they are doing what I think is the ‘right’ thing. But what I perceive as ‘right’ can also change with my mood. When I’m feeling positive even the things I find most boring can seem worth doing. At times my mood seems to be balanced on a knife edge- it can change within the space of a few hours. But then it can remain stable for months.

When something really seems to shift in my mood, it is as though some unseen being 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. I am full of fear as the negative thoughts I have about myself the world and the future come flooding back.

If I am going to manage my moods more effectively I know that I need to work harder at challenging my familiar, but hard to live up to, rules about how to live in this world that I identified in therapy. But I mustn’t beat myself about the head if I am not able to do it every time. Making another rule for living that I cannot keep is not the answer. I fantasize about being the kind of disciplined person that meditates every morning, exercises every afternoon and eats a healthy supper in the evening, doing everything that I know is ‘good’ for mental health.

I want to be able to keep the awful low periods and those hopeless suicidal thoughts at bay if I can, but if I don’t succeed I have to remind myself that, with time and care, the way I see the world usually changes once more.

The first rule we often have to challenge in life is that it is unacceptable to fail.

My memoir: The Other Side of Silence: A psychiatrists’s memoir of depression is available now.