"Time to Talk" day - February 4th 2016
I've agonised about whether to write this, and then whether to post it. It's vital for me that the effect of this is positive for others, and not draw attention to myself. As a doctor I'm torn between wanting to help educate but also ensure my needs don't overshadow those of my patients. I hope I achieve that.
It feels like the right Time to Talk for me. I'm incredibly lucky. My job as a doctor has given me a wonderful resource in terms of patients and how they have dealt with their mental health problems. I've learnt a lot, and suspect I'll continue to do so. The suffering of others closer to me still has really made me think about how we as a society treat mental health, or indeed how we don't.
I have depression and anxiety. I have since I was a teenager, not that I knew it at the time. I'm currently in the midst of my 4th major bout of symptoms. It feels odd to summarise myself like that.
Depression isn't just days of feeling a bit down or stressed (although I have these too) but the clinical diagnosis of ICD-10 F33 Recurrent Depressive Disorder.
Language is so important: it is "normal" for everyone to have periods of low mood, fleeting suicidal thoughts and heightened anxiety, and in English we use the word depression to cover the spectrum from a shit day right up to peri-suicidal. As I doctor, this differentiation is so important, because for many that I see suffering with symptoms of a clinical affective disorder, they have already tried to rationalise their symptoms based upon others' comments that "they get depressed too". When I use Depression or Anxiety as words I use them as diagnostic terms, I mean the carefully constructed diagnostic labels that describe clear symptoms over a specific timeframe. If you're so inclined, take a look at the World Health Organisation International Classification of Disease volume 10 criteria (WHO ICD-10) at http://www.who.int/classifications/icd/en/bluebook.pdf.
I don't mean to denigrate those who have bad days or occasional symptoms, but merely try to help define the differences, as confusion leads to inappropriate treatment or lack of treatment.
As an example of the former, I see many teenagers brought to me by parents during exam time, worried that they are depressed. Few are, but have expected behaviours and thus "normal" reactions to high stress. These don't need medicines (which I've found some parents are alarmingly keen for me to prescribe), but a supportive atmosphere and time; once the exam period has finished they are fine. (There are obviously a few for whom depression is the diagnosis, but this diagnosis is best made carefully, based on several observations and not on the first day of upset)
As an example of the latter, I see many men with longstanding depression, which they have started self medicating for with alcohol, cannabis or harder drugs. They have wrongly assumed that because "everyone gets depressed", that they don't have a treatable condition. Psychotherapy and/or medication often makes a big difference here.
There are usually, but not always triggers to my depression. Most recently, I've really realised the effect of winter and in particular, low exposure to light, on my mood. I would happily hibernate; and I struggle with oversleep, increased appetite and lack of positivity in wintertime. I've started taking Vitamin D supplements and used a SAD daylight lamp this year with I think good effect. I try and go somewhere sunny in January, which helps too.
Throughout the year, exercise has a positive impact on my mood. I will often walk to events when I can, as I haven't found an activity which I can regularly participate in and enjoy. I like running, but this took a hit in 2015 when my knee prevented me doing much. My anxiety makes attending a gym really hard. I feel incredibly self-conscious being surrounded by others. It's the enclosed space, my self-denigrating body-image issues and the presence of others whom I feel threatened by (I think being bullied by bigger and sportier kids at school has never really left me). Sometimes I can handle it, but when I'm at my worst mood wise, and would most benefit, it's hardest. I once had a patient in floods of tears when she injured her knee cartilage as it was running that "kept her sane" and it was only when similar happened to me that I really appreciated her reaction.
My nervous energy is helped by bursts of activity, hence my skipping or running whilst at work. At home, I'll often dance around.
I'm sensitive, and that is my personality. I'm also quite pessimistic as an attitude. This surprises many people I know, because I've learnt to recognise it and try to combat it. I set low expectations and look for the smallest of successes. I genuinely believe that the world and life itself is generally a more negative, stressful and upsetting place than it is a good place, and so it's vital to grab onto anything good that you can, to try and balance things out. I still struggle to receive compliments, again, I think a holdover from school times where doing well in anything usually led to bullying. It also means I don't tend to trust people very quickly.
I laugh at myself a lot as a protective mechanism. If I can do it before you, I remain in control and you can't hurt me. As I've aged, this has developed into a personality where I will often initiate conversation, be quite frank and inquisitive. By projecting confidence, I believe it, much like smiling makes you feel happier!
I don't think I've had a particularly hard life at all, indeed, I'm incredibly lucky and privileged, and I think that's important to say. Perhaps if I was a starving adult in the developing world, I'd have different things to worry about, but the nature of depression is that it's hard to see out, and small things can really seem to matter. It's all relative, which is why people who have nothing can be depression free, and those with seemingly everything feel totally hopeless.
There are days where I can't leave the house, or even my bed. It feels as if the world is just so terrifying that I don't know how to handle it. At my worst, I've really struggled to do things like go shopping, because I can't handle the people, and the sense that I'm being watched and judged. I go through phases of avoiding all news, because I can feel so guilty watching tragic news that I will pray that God (whom I don't even believe in) will take my life from me to give to someone more deserving.
This widely shared video really helps explain how I, and many others, feel:
I think that others reactions to my sexuality has contributed to my development of depression. As a teen, the bullying about being gay came about before I even knew I was. I've been hit in the face and knocked to the ground simply for walking out of Canal Street and had a glass bottle thrown at me for holding a boyfriend's hand. These are landmark events, but it's also little things, like assumptions people around me make, the reactions of those close to me and the media portrayal of gay men that add to a sense of unease that becomes my normal baseline. It's also the reaction I get as a non-"traditional" gay man - many typically gay venues which could be my safe space just aren't welcoming to a nerdy, average-looking person like me (and many others like me!). I'm torn about "Pride" events - why should I be proud? I just am.
I know many LGBTQ people suffer with depression, and there's an awfully long way to go before societal change removes the additional pressure we suffer, even in a forward thinking country like the UK.
When I'm getting more depressed, I start becoming more irritable, and tend to start pushing those I care about away. Some of my closer friends now recognise this, and warn me.
My sleep becomes erratic - I'll usually sleep more yet feel more tired as I think the sleep is broken, I know this as I start remembering my dreams.
My appetite goes, and I'll start going a few days at a time eating very little.
Anxiety tends to build, and I'll struggle to leave the house to see friends.
My work often improves; I'll become more efficient and people at work will think I'm happier. I think it's because I find it helpful to put on a persona when I'm working than when I'm socialising.
I might start drinking more alcohol, and in the past, would start smoking tobacco.
My thoughts become increasingly negative, and I will become very self critical. I sometimes will self-harm.
I become numb and start to care less about the world, yet simultaneously feel like everything is my fault. I'll cry a lot, and more easily; sometimes it will take just a few bars opening a particular song, or someone saying something nice.
I've never tried to kill myself, but there have been some occasions where I've gotten close. I'm lucky that I've always had someone to turn to. I once drove to Sale Water Park after one too many days working as a junior doctor completely exhausted, unsupported and out of my depth at a hospital. I wanted to die there, having already considered other possibilities and discounted them. I have always liked water, and it seemed fitting. And on the practical side, I figured that it would be easier to recover my body from an artificial lake. I had written long letters of apology to those I cared about, and one of vitriol to the hospital trust (with a copy to a newspaper). In the end, I couldn't do it, and came home to shred the letters. I resigned not long after.
I regularly have suicidal thoughts. These are different, and almost like a reflex response in my brain to overstress. They dissipate quickly, usually. Sometimes my own mind turns against me, and I mentally self criticise to the point of upset. I've not acted on these thoughts of suicide, although I've sometimes in the past I used self harm to manage them. From a physiological point of view, I suspect inflicting physical pain on yourself has a similar effect to exercise, by encouraging adrenaline and clearing of thoughts. I definitely think exercise is a much more productive way of achieving this!
I'm nervous of drugs, including alcohol. My experiences with these have rarely been positive, although I am generally able to enjoy a few drinks of alcohol from time to time. Cannabis caused me to believe I could fly and I could have tested that theory by jumping from a bridge. It's also caused me to become extremely paranoid and hurt people I cared about. I don't usually have a problem with alcohol intoxication, and am a friendly drunk, though in the past I've ended up in dangerous situations which I really regret. The difficulty I have now is that I tend to be much more anxious and sensitive in the 2-3 days after I drink, so I need to plan carefully. I find it impossible to avoid alcohol and feel pressured in many social situations to have some when perhaps I'd rather not. It's easier when I'm around people I really trust.
I currently take Escitalopram 10mg a day and have been in this for a year. It has really suited me, by working quickly with minimal side effects. I do yawn a lot more and the biggest problem I've had is with appetite and my weight... I've gained a fair bit in the past 12 months through eating poorly as I never really feel satisfied. But with some discipline I think I can learn to manage this, especially as I feel so much better now.
I've previously taken citalopram and sertraline, both of which had side effects I couldn't manage.
Ruby Wax on Depression:
What's most helped me is talking, both informally with friends and family, in a more structured way with medical friends, and also in 3 sets of counselling and CBT (cognitive behavioural therapy) I've had. I've also had the benefit of initial psychotherapy training from my jobs in psychiatry.
My brother has been phenomenal. We have very different personalities but he accepts me, listens and has always helped in my worst times. I sincerely believe I'd have had more severe episodes than I have if it weren't for his support.
I've several friends with similar problems, or experience of them, and they too have provided viewpoints, encouragement and advice. And a kick up the arse when I've needed it... I started Escitalopram after one friend recognised things had gotten out of hand. We are good at supporting each other, recognising symptoms and knowing the right things to say,and not to say!
I had CBT twice at University. It was really helpful for me as I'm quite psychologically minded and helped me recognise how to manage my naturally occurring negative thoughts, and how to manage them. I still use the techniques now, In my last bout of depression, I had counselling, which helped as the trigger was much more reactive, and so gave me an outlet to simply talk freely.
My training in psychotherapy has helped me understand others, and thus my own thought processes. Humans are not perfect, and we are products of our environment; understanding and accepting that helps me.
It frustrates me that accessing talking therapies is rarely that easy for patients because I think they are the key to long term recovery. Many doctors give up and just prescribe medicines, which I don't think are ever that useful on their own, at least in the long term (short term they can be immensely helpful in building to motivation to change).
I'm not sure what we can do about that. Supporting mental health charities, such as Mind (www.mind.org.uk) and the Time to Change campaign (http://www.time-to-change.org.uk) , are a start. For those suffering, I'd say don't forget those around you - so many of my patients have never told anyone else how they feel, and things often improve when they start to share.
As a patient, and a doctor, I want us to be in a place where we talk about depression like we do diabetes, heart attacks or cancer. There is no shame in sharing your difficulties, although the nature of the illness makes it feel so. If you suspect a friend, colleague or family might be struggling, ask, and don't accept "I'm fine" as answer. Use your GP and local mental health charities to help, I'll add some links to web resources and support available where I live and work as a start.
This video should be useful if you're not sure how to help someone you care about:
Most of all, start up a conversation with someone around you. Who knows what you'll find out, the new friend you'll make, the secret you'll share, the joke you'll giggle about, the tragedy you'll support each other through. It's Time to Talk.
Note: I deliberately don't talk about the methods I would use to self harm or commit suicide, as evidence suggests that reports of these can lead to increases in copycat efforts. My self harm or suicidal thoughts are my own, they don't represent necessarily what others might define as them, and they aren't meant to represent everyone, just as this article doesn't represent anyone but me or anything but my experiences and beliefs.
Also, and I hate that I feel the need to say this,but yes GMC, I am fit to practise medicine. I look after myself and take charge of my health.
Also, and I hate that I feel the need to say this,but yes GMC, I am fit to practise medicine. I look after myself and take charge of my health.
EDIT ( 2134 04/02/2016): I wanted to correct a few spellings, embed the videos and add the links to useful resources; see here:
Get Self Help resources
Northumberland Tyne & Wear NHS Self help workbooks
Be Mindful Mindfulness information
In Bolton and Greater Manchester:
LGF Counselling - service for LGB people in Manchester
Mhist - Mental Health Independant Support Team (Bolton)
The Sanctuary (Manchester) 0161 637 0808 (24/7)
The Sanctuary (Bolton) 0300 003 7029 (8pm-6am)
