World Mental Health Day

Today, 10th October, is apparently World Mental Health Day. The World Health Organisation apparently endorse this, and I guess it's one of campaigns aiming to raise awareness of mental health and illness globally.

I always find the concept of a topic as vast as mental health being squashed together in one day a little odd, but although there are a vast number of mental health issues which are lumped together under one heading, they do have something in common and I can't criticise anything aiming to improve people's awareness of such a common and yet seldom discussed group of problems.

Any regular readers of my blog will be aware that my own mental health issues are longstanding so I can't pretend I don't have a personal stake in this. For that reason, I always feel slightly guilty pushing the mental health agenda. However, it's an important issue that will affect 1 in 4 of us (I think that's probably a conservative estimate) so I won't avoid talking about it.

My first experiences with mental health problems were back when I was a teenager. The support I received was less than ideal, my parents and school didn't really understand what was happening or how best to help me and even the professionals I encountered seemed out of their depth. A lot of my experiences were covered in this pseudo-anonymous post, which I initially wrote as a presentation to give at work. It's now nearly 15 years since that first consultation in that dreadful old building and I still remember it vividly. I can't ever change that, but I hope that when I meet young people in my professional life who are struggling, they remember their encounter with healthcare in a more positive way - someone cared, someone listened.

Unfortunately, it's not just a teenage problem. Although it's pretty common for mental health difficulties to begin in adolescence, they frequently persist into adulthood. Mine certainly have. Despite my struggles, though, I'm doing ok. I'm in a stable relationship. I'm holding down a (fairly intense at times!) job. Not everyone is so lucky. Mental illness is one of the most common reasons for claiming incapacity benefit. Plenty of people struggle and suffer, and yet stigma still persists.

Once again, my blog has become a ramble with no real direction or structure. I'm not sure it says much. But, if you're reading this and you're struggling, you aren't alone. Help is out there. And remember that just because you've been unfortunate enough to get unwell, doesn't mean you aren't awesome.

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There are a number of places you can get help should you need it. The services I've listed are free to call and open 24/7. A more comprehensive list is available through the NHS choices website, but not all services are free or open at all times.

If you're struggling today, or any day, the Samaritans are there to listen for free - call 08457 90 90 90.
Children and young people can contact ChildLine on 0800 1111 whilst adults who have concerns about a child can call the NSPCC helpline on 0808 800 5000.
If you feel in danger of hurting yourself and don't have a crisis plan, please call 999 or go to your local A&E department.
If alcohol is a problem, you can call Alcoholics Anonymous on 0845 769 7555.
If you need help with drugs, you can speak to Frank on 0800 77 66 00.
Men with any difficulties can use the online chat/email service here
If you're struggling with an eating disorder, Beat can be called on 0845 634 1414 (adults) or 0345 634 7650 (for under-25s)
 

I'm Not A Lousy Doctor - But I'm A Lousy Friend

If you've read this blog before, you'll probably be aware that I'm a prolific tweeter. In fact, I'd be surprised if you were reading and had come across this post via anything other than seeing me tweet about it. One of the things I love about Twitter is that it makes the world a smaller place. One of my favourite Tweeters is the lovely @dr_ashwitt; although she is as far from me as is basically possible (Melbourne, if you were wondering), I frequently read her tweets and think "oh my God, me too!". Recently, Ash re-posted a link to a post she wrote a couple of years ago about her experiences of depression. She urged other doctors to post their own 140 character experiences of mental health issues, and #MH4Docs got a fair number of tweets which Ash has collated here. I haven't actually tweeted yet, but I've been pretty vocal about my own issues over the years and it's good to see that people feel they can open up about these things. The thing that really made me think, though, was the sentence she used to link to her blog.

"I have depression, but that doesn't mean I'm not a good doctor."

I think a big part of the reason that a lot of health care professionals (and non-health care professionals, come to think of it) are reluctant to open up about mental health issues is the fear that their abilities at work will be called into question. I know that one of my major fears when I "admitted" to having depression was that people might think I was unable to do the job I love and have worked for for a long time. 

My mental health problems don't mean I'm not a good doctor. I have a need to be busy which means that I will crack on with as much work as I can, and I'll find non-essential tasks which just "need doing at some point" to keep me occupied. Focusing on other people means I'm not thinking about myself and my own emotions, so I'm unlikely to slip into a spiral of despair. My lack of self esteem and constant impostor syndrome mean I'm keen to please and make an extra effort to be friendly and polite. Work makes me feel better and I think my own issues mean I will always work as hard as I can. Possibly I'm at risk of burnout, but it's nothing I've ever felt close to, and the other hobbies I've developed to occupy myself and prevent negative thinking mean I have outlets outside of medicine.

No, depression doesn't mean I'm not a good doctor. It does mean I'm not a good friend, though. Being nice and polite to people can be frankly exhausting. After a whole day smiling and engaging in banal conversation and generally giving the impression that I'm a functional human being, I am absolutely worn out. I very rarely agree to after-work plans because I know I'll be too tired to be good company. If I've made arrangements, there's a good chance I'll flake out at the last minute because I just can't face being around people any more. Finally living alone rather than with flatmates is a Godsend because it means I can have meltdowns in the living room and kitchen rather than being restricted to my bedroom. On nights out, I'm renowned for disappearing without telling anyone after being consumed by an overwhelming wave of misery and wanting to get away before I spoil anyone else's night. As for relationships, I am probably one of the worst girlfriends out there. I take insecurity and anxiety to ridiculous levels, any compliment is analysed repeatedly to ensure it isn't actually a heavily veiled insult and "I love you" is not infrequently followed not with "I love you, too" but "..really? Do you actually though?".

So yeah, I have depression, and that doesn't mean I'm not a good doctor. But it does mean I'm not a good friend. If you've stuck around anyway, thank you. I may not say it with nights out or long conversations, I may cancel half of our arrangements and you might feel like you're walking on eggshells when we talk, but you are loved and appreciated.

 

Skinny Minnies

I've blogged in the past about eating disorders, both my own experiences and my thoughts as a doctor. I don't claim to be an expert at all, but from a combination of personal experiences, talking to friends and acquaintances who have had similar difficulties and encountering many patients with eating disorders at work, I've built up my own ideas about eating disorders and have also tried to read around the area to expand my understanding.

I make no apology for the fact that the forthcoming post may be a bit angry and ranty. I'm cross, and it was my annoyance and crossness which lead me to write. On reading it, I also appear to have used an awful lot of brackets. For that, you can have a bit of an apology I suppose (but only a bit).

A few days ago, I was casually scrolling through my timeline on a well-known social media site, when I saw a post which an acquaintance of mine had apparently showed some kind of appreciation for. The headline was "These 12 Anorexic Girls Look Stunning After Beating Their Condition". This annoys me for several reasons. Firstly, "desperately sick people look much better when they aren't ill anymore" is stating the obvious and is yet another reflection of (modern? Or has humankind always been so inclined?) society's obsession with appearance. Secondly, and more importantly, it demonstrates and perpetuates a deep and serious misunderstanding of what eating disorders are. Pictures of terribly sick, skeletally thin young women next to pictures of them looking healthier with captions like "no woman should ever be as thin as she was in the first picture, she looks much better with some weight on her" show just how flawed a perception many people have of eating disorders. I also find the use of the term "beating" to describe recovering from an illness unhelpful, but I'll elaborate on that in a separate post.

Would people write an article entitled "This Girl Who Had Cancer Looks Great Now She's Off Chemo"? How about "Man With End-Stage Liver Disease Looks Gorgeous Post Transplant"? Or "Check Out How Fit These Ladies Are Now They're No Longer In ICU With Overwhelming Sepsis"? I like to think not, unless the people in question were celebrities, in which case no doubt the first thing we're supposed to noticed when someone's been incredibly ill is whether their weight has changed or if they've got the energy to still do their hair nicely. But I digress.

What upset me most about this articles was that it perpetuates the myth that eating disorders are solely about how people look. The premise of the article appears to be "overly skinny is not hot". Now, whilst I have no problem with promoting a range of body shapes as attractive (although frankly I do wish we could all shut up about appearance), the suggestion that people (not just girls - they affect both genders and all ages) with eating disorders are driven purely by a desire to be as thin as possible is just wrong. Eating disorders are complex. Patients with eating disorders are diverse. Trying to suggest that all eating disorders occur because a person wants to be skinny is as wrong and as damaging as suggesting that all cancers are caused by excessive alcohol intake - both illnesses occur due to a variety of factors. In some cases, one of those factors may be a desire for thinness/excessive alcohol consumption, but this is only one of a number of elements which co-exist and allow the disease to develop. In some patients, this factor will be completely absent.

Now feels like a good opportunity to link to a post my lovely friend Jo wrote about her experiences of an eating disorder. Another helpful post is this one, from the website of Mind - a mental health charity. Their website has some useful information on eating disorders which may help anyone who either has an eating disorder or is supporting a friend or family member with one. As all these links stress, eating disorders are often about control and dealing with difficult situations and not just a vain desire to look thin.

This blog is explicitly about eating disorders, but more generally it's about the lack of parity of esteem between "physical" and "mental" health conditions. I use the inverted commas because personally I believe the terms create a false dichotomy. Physical conditions may well be worsened by emotions - we all know people who get more migraines when the pressure piles up, and there's now evidence that adverse events during childhood may play a role in the development of diabetes. The way our feelings and emotions affect our health is something we are only just beginning to understand. In the meantime, if we could all aim to be a bit more understanding and not jump to conclusions about people just because they have a particular diagnosis, the world may well be a brighter place. And if you're writing a headline about a "mental" illness, think about how it would look if you replaced it with a "physical" one. If it sounds voyeuristic, shocking or offensive, chances are you're best not using it.

P.S. I googled  "These 12 Girls With Cancer Look Stunning After Beating Their Condition". Surprisingly, noone's written that article.

Mad, Sad, Bad....

I recently gave a departmental grand round (i.e. a talk open to all members of the paediatric department where I work) on adolescent mental health. Various people have been keen to hear/see what I had to say, so I've posted a slightly edited version below.

It wasn't intended to be a comprehensive discussion of mental health issues by any stretch, but I wanted to at least mention some of the more common issues we encounter as paediatricians. Obviously every topic I spoke about is worthy of a talk in its own right, but hopefully this will have made people think a little bit and generated some useful discussion.

***Trigger warning*** Discussion of self harm, suicide and eating disorders.

"When I was first asked to give this talk, I had two reservations. The first - would anyone want to hear a grand round from such a junior member of the team? That was dealt with pretty swiftly, with assurances that training level didn’t matter so long as content was good. Hopefully that’s something I can achieve. The second, however, was more of an issue. Would people actually want to listen to a talk on adolescent mental health? The answer to that was less positive. In fact, it was a resounding “no”. And I think that's part of the problem, and it's exactly why I decided I should give this talk.

 

Imagine you're in your usual clinical environment, be that A&E, clinic, the assessment unit, general practice... You're examining a patient, and you find this...
 

 

How do you feel about your patient now? Don't focus on what you think the differential is, think about your reactions and feelings towards this patient. Are they wasting your time? Are you less inclined to take their other complaints seriously? Are they an attention seeker? This may sound dramatic, but we're all guilty at times of responding negatively towards issues such as deliberate self harm.

 

There are lots of different ways in which I could represent the distress caused by mental illness, but I think one of the most effective is to share the story of a young person I've been involved with, including some of her quotes.

Suzie is 15. She presents to her GP after being encouraged to attend by her form tutor. The consultation is difficult. After some encouragement, she says that has been experiencing low mood for the past 3 years. She does not feel she has any friends. She feels that she is unattractive and is not achieving at school. Her eye contact is poor and she has a blunted affect. On examination, she appears well. Some superficial lacerations are noted over her thighs and forearms.

This encounter is one Suzie still feels uncomfortable about. “I was pretty cross that I’d been made to see a doctor. It’s hard enough for people to get appointments without me taking them up. I actually felt quite guilty about using a slot which could have been given to someone who was actually ill. I was also really worried about admitting I cut myself. It seemed like people felt that that was something done for attention, so I wanted to hide it as much as I could; I didn’t want to be seen as an attention-seeker when actually I just did it to try to feel better.”

Suzie is referred to CAMHS, who commence an SSRI and offer CBT, which she declines.

Suzie vividly recalls her CAMHS appointment. “I was 15 and it was the Christmas holidays. The department was located in an old, probably Victorian, terraced house which hadn't been particularly well renovated. The room I was seen in was freezing. There were two people seeing me; a middle aged lady who was a social worker and a younger man who introduced himself as a "trainee doctor" - I suspect that he was a psychiatry registrar but at the time I was pretty convinced he was a medical student. They sat behind a desk for the whole consultation and the seats for us (my parents were with me) were a good few metres away from them. There was also a little window at the top of the wall where someone else was apparently watching what was going on. On the wall were several posters about how to deal with your child's difficult behaviour and advising against smacking. There were toys all over the floor.

My first impression was that they thought I was a child (which of course I was, at least legally, but what 15 year old doesn't think they're incredibly grown up?). I don't recall much of the discussion we had. I remember them repeatedly asking whether I'd ever been abused, and then later taking great delight in asking my parents to leave the room so that they could ask me again. Actually I only wanted my parents out of the room because I knew they'd be upset if they knew the extent of my depression, but the doctor and social worker seemed pretty desperate to uncover some horrific trauma which must have caused my problems.

I didn't go back after that first appointment. They put me on fluoxetine. They also wanted me to have CBT but I declined. In retrospect, I probably should have gone for it, but at the time the only time I could cope with being "mental" was to tell myself and everyone else around me that it was due to "a chemical imbalance in my brain". Taking medication to correct this was fine. To have CBT would have been admitting that my thinking was fundamentally flawed and that it was therefore some weakness of character resulting in my problems and not a "proper" illness. Of course I know now that that isn't true, but the explanation I got was such that that was what I believed at the time.”

Shortly after commencing treatment, Suzie attempts suicide by taking 64 paracetamol tablets.

Even now, Suzie finds it difficult to articulate exactly why she tried to end her life. “I was fed up of everything. Nothing I did seemed to have any point. I didn’t think I’d ever achieve anything. I saw how unhappy my Mum was, knowing I felt like this, and that made me feel incredibly guilty. I was sure I was making my whole family miserable and that without me there, they’d all be better off. I could just about believe that they might be initially upset if I died, but I really felt that they’d get over that and be far happier than they could with me around. I wanted to stop feeling miserable and I wanted to stop dragging other people down with me.”

Suzie recovers from her suicide attempt with no residual physical effects. She continues to self-harm by cutting herself with razor blades. In addition, she begins to struggle with food, going through periods of severe restriction followed by binges. She often induces vomiting and abuses laxatives.

Although diagnosed with bulimia, Suzie feels that her eating behaviour was closely linked with her mood. “Food made me feel better when not a lot else did, but after I'd stuffed myself senseless I'd feel so guilty and dirty that I'd have to make myself vomit... Some days, I just didn’t feel like I’d possibly emptied my stomach, so I started taking laxatives too. I knew it was dangerous but I didn’t care. I felt that I’d rather die than put weight on. Sometimes, after a purge, I didn’t feel the need to cut myself as much. It was like the vomiting was a kind of release, in the way that cutting was.”

Although all cases are very different, this is a fairly typical case. But so what?

What does this matter? What's the impact of self harm? Well, there is evidence to suggest that in young people like Suzie, who self-harm, risk of premature death is considerably higher than in the general population. Whilst, unsurprisingly, risk of completed suicide is up to 25 times higher than those who don’t self-harm, risk of accidental death is seven times and death from natural causes twice as high as the general population. Mean years of life lost was over 25 for both males and females (Bergen et al., Lancet 2012). Self-harm is also associated with poorer educational and employment outcomes, increased risk of mental health problems and increased risk of substance misuse in later life (Mars et al., BMJ 2014). The UK has one of the highest rates of self-harm in Europe (at

400 episodes per 100 000 population) (Hawton et al, Lancet 2012)

So what can we do about it? How can it be treated? Although self-harm within itself is not a diagnosis, the majority of young people who self harm will have an affective disorder, most commonly depression, although anxiety, eating disorders and psychotic disorders such as schizophrenia may also occur. The only licensed anti-depressant for under 18s is fluoxetine. Paroxetine (Seroxat) in particular has been linked with increased risk of self-harm and suicide after initiation of therapy, but there is some risk with all anti-depressants. There are multiple theories as to why this is, but it may be to do with returning energy levels and drive once treatment is commenced. It's therefore important to ensure that any young person commenced on anti-depressant therapy have regular follow-up and support. The evidence base for any therapy is limited, although psychological therapies are being increasingly developed and investigated.The current recommendation is that moderate-severe depression is treated with a combination of an SSRI and CBT, although resources mean that this isn't always available.

There are a number of reasons why people attempt suicide. Life stressors, such as financial worries and relationship breakdowns are particularly common precipitators, as are psychiatric symptoms. However, many people who attempt suicide do not realise that their symptoms are due to an illness (Lim et al., Journal of Affective Disorders, 2014). This is important because it means that the first time people present to medical services will be with a suicide attempt. They often won't seek help for their underlying psychiatric symptoms because they don't realise they have an illness which can be treated. Over 10% of young people experience suicidal ideation and around 4% will attempt suicide at some point before the age of 25. Suicide is the third commonest cause of death in 10-24 year olds. Suicide attempts are more common in girls and those with a diagnosis of depression (Grudnikoff et al., European Journal of Child and Adolescent Psychiatry, 2014). 

Eating disorders are a huge topic and obviously worthy of a whole talk within themselves. However, I felt it was worth mentioning them because they commonly co-exist with affective disorders. One study found that 18.5% of patients referred for anxiety or depression had problematic eating, with 7.3% met the diagnostic criteria for an eating disorder, with those who were younger, female and having a history of self-harm most likely to be affected (Fursland and Watson, Eating Disorders, 2013). It's therefore important that we are know to look out for these things, because anorexia nervosa in particular has a high mortality rate.

So, what can we do about this? Well, they key is to listen. A recent report published by the Royal College of Psychiatrists, and endorsed by our royal college, the RCPCH, suggests that simply listening and taking a sensitive history has therapeutic benefit. Groups such as Cello and Young Minds, who do a lot of work with young people affected by these issues, find again and again that doctors do not feel comfortable dealing with mental health issues in young people. They do not feel they have the necessary skills to help and they don't know what they're supposed to do. However, the evidence shows that actually, something as simple as just talking about the issue in a sensitive way helps. We all have the skills to take an history and listen to someone. It isn't difficult or complicated, yet it helps to reinforce a positive image of healthcare services in a young person's mind and means they are more likely to engage with services in the future.

That's been a brief overview of adolescent mental health issues. Hopefully it's made you think about how you might deal with these issues, and reinforced that all of us have skills which will help us to deal with them.



I don't usually put references at the end of blogs, but in case anyone is interested, these are some of the papers I read whilst I was preparing this talk.

BERGEN, H., HAWTON, K., WATERS, K., NESS, J., COOPER, J., STEEG, S. and KAPUR, N., 2012. Premature death after self-harm: A multicentre cohort study. The Lancet, 380(9853), pp. 1568-1574.

CELLO, YOUNG MINDS, 2012. Talking Taboos: Talking Self Harm. Cello Group

FURSLAND, A. and WATSON, H.J., 2014. Eating disorders: A hidden phenomenon in outpatient mental health? International Journal of Eating Disorders, 47(4), pp. 422-425.

GRUDNIKOFF, E., SOTO, E.C., FREDERICKSON, A., BIRNBAUM, M.L., SAITO, E., DICKER, R., KANE, J.M. and CORRELL, C.U., 2014. Suicidality and hospitalization as cause and outcome of pediatric psychiatric emergency room visits. European Child and Adolescent Psychiatry, .

HAWTON, K., SAUNDERS, K.E.A. and O'CONNOR, R.C., 2012. Self-harm and suicide in adolescents. The Lancet, 379(9834), pp. 2373-2382.

LIM, M., KIM, S.-., NAM, Y.-., MOON, E., YU, J., LEE, S., CHANG, J.S., JHOO, J.-., CHA, B., CHOI, J.-., AHN, Y.M., HA, K., KIM, J., JEON, H.J. and PARK, J.-., 2014. Reasons for desiring death: Examining causative factors of suicide attempters treated in emergency rooms in Korea. Journal of affective disorders, 168, pp. 349-356.

MARS, B., HERON, J., CRANE, C., HAWTON, K., LEWIS, G., MACLEOD, J., TILLING, K. and GUNNELL, D., 2014. Clinical and social outcomes of adolescent self harm: Population based birth cohort study. BMJ (Online), 349.

ROYAL COLLEGE Of PSYCHIATRISTS, 2014).Managing Deliberate Self-Harm in Young People (College Report CR 194). Royal College of Psychiatrists