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.

-----------------------------------------------------------------------------------------------------------------------------------------------
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)
 

Christmas Reflections

Christmas, for many reasons, is a time of year when I always feel particularly contemplative. I'm not a religious person - I was raised in a "respecting all religions but following none of them" kind of household and seem to have continued along that path into adulthood - but there's still something about Christmas that seems special. There's no denying that, as a little girl, at least part of the excitement was about presents, but I think it's always been about more than that. My Daddy used to finish work at lunch time on Christmas Eve, we would probably see friends and cousins who we didn't see often, there would be lots of people visiting and, of course, no school for us or work for our parents, so we spent lots of time together as a family. Overwhelmingly, though, what sticks out in my memories of my childhood Christmases is that everyone was happy. It was simply a time of seeing the people you loved and enjoying being together.

During my teenage years, as many of you will know, I had a rather difficult time with my mood. A time when everyone was so cheerful, and the general attitude appeared to be "you should be happy, it's Christmas!" suddenly became difficult to cope with. The general tolerance for misery seems to drop at this time of year, and anyone who isn't feeling full of the festive spirit not only has to contend with their own difficulties, but also with accusations of bringing everyone else down and spoiling Christmas.

Now, as an adult, I enjoy Christmas again, but a combination of my teenage difficulties and work and family circumstances mean I'm all too aware of how difficult this time of year can be. I'm working again this year, but come Monday when I have some time off, I'll be heading up to see my parents and sisters before spending New Year with my boyfriend. I'm lucky to have not only a job that I genuinely enjoy and that pays me enough to be able to spoil the people I love, but (more importantly) people I love close by, happy and healthy.

Working over Christmas in a hospital is an odd experience which brings with it a strange combination of emotions. I still smile when I remember the sweet nonagenarian who burst into tears of happiness when Santa came around the ward and gave gifts to all the inpatients. The same day, I had to tell a lady that the symptoms her son had brought her to A&E with were likely due to metastatic cancer. Another year, I got a Christmas kiss on the cheek from a very mischievous older gentleman patient before discussing end of life care for someone else. Last year, I saw babies and children spending their Christmas in hospital - for some it was their first Christmas, for others it would be their last; for a few it was both.

Whatever you're doing this Christmas, spare a thought for those who aren't enjoying the festivities in the usual way. My colleagues in the health service, from the domestic staff keeping the wards clean to the consultant surgeons performing life-saving operations, will be there to ensure you and your family are well looked after. Those in the fire service and police force are making sure our streets and homes are kept safe. Thousands of hospitality workers are spending today serving up countless turkey dinners and glasses of prosecco to help other people have a merry day. To everyone working this Christmas - thank you.

If Christmas is a challenge for you, know that you aren't forgotten. Those struggling to get through the day without a loved one - be it for the first or the fiftieth time - I feel for you. If you're spending the day in the hospital, either as a patient or visiting a loved one, I hope Christmas is comfortable and that the New Year will be brighter. If you simply feel overwhelmed and are struggling, there are people who care and who will listen.

Merry Christmas, everyone, stay safe and I hope 2016 brings health and happiness to all xxx

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 over Christmas.

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.
For those who need help with domestic abuse, contact Refuge on 0808 2000 247.
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.

The Drugs Don't Work, They Just Make You Worse

From time to time, I find myself "borrowing" song lyrics to title my posts. This is in part because I'm not hugely creative and partly because I'm usually listening to music of some sort whilst I'm writing, but mostly because if someone else has said it well before, then there's little chance of me saying it better.

Trying to describe how depression feels is almost impossible. Years and years ago, when I'd never met anyone else who had depression in "real life" and my support network was almost entirely a (sadly long-gone) forum, we used to tell each other "for those who understand,  no explanation is necessary; for those who don't, none will suffice". It's cliched and horribly over-used, but there was an element of comfort in realising that you'd probably never fully make other people understand how you felt, so you were as well saving your energy and not bothering. One particular thread, however, which I recall over a decade later, was entitled "The Sounds of Depression". I don't recall exactly how it started, but we started to share song lyrics (as well as other literary sources) which summed up our feelings. We were unable to express exactly how we felt, but many of our musical heroes did a fine job of it. Years after I first heard them, I find some songs are still better able to describe my feelings than any words I could write. Tonight, I'm thinking of The Verve.

"All this talk of getting old
It's getting me down, my love
Like a cat in a bag, waiting to drown
This time I'm coming down"

Some days, this is exactly what it's like. You fumble through your existence, not ever being entirely sure what the point is. The inevitable drowning that you feel sure awaits means that attempting anything seems like a waste of effort. You won't be able to get out of the bag that encloses you, so maybe it'd just be easier to succumb. Settle down, drift off to sleep and let yourself gradually suffocate. The eventual result will be the same, only with less pain in the meantime.

It's no coincidence that, as well as summing up how I sometimes feel, these lyrics are from a song called "The Drugs Don't Work". Yesterday, I read a very well-written piece by the lovely @katiehodgie about cognitive behaviour therapy and how it doesn't always work, which got me thinking about my experiences of treatment.

I've mentioned this sort of thing in the past, but in different contexts. I described my first contact with mental health services in my post on adolescent mental health. If you happened to read (or hear) the grand round I gave on the same topic, you may recognise it. That's because it was copied and pasted directly from that blog. "Suzie" was, of course, me. I don't mind if people who heard the talk guessed, but I didn't want to just stand and talk about myself openly because it felt somewhat indulgent, and may have detracted from the fact that I wanted to emphasise the importance of understanding mental health for all of our current and future patients, not just myself.

You can see that my first experiences of the psychiatric team were less than ideal. Over the many years which have passed since that appointment, I have had numerous other attempts at treatment. The list of medications I've tried resembles the formulary of a major psychiatric unit. I went for CBT and tried seeing a psychologist. I've met several psychiatrists. Despite all of this, and despite being a qualified doctor, it sometimes takes me by surprise when I remember that depression is a chronic problem. I have to remind myself, and other people, that I might dip again. It's a bit of an apology and a bit of a warning, summed up by John Mayer.

"Suppose I said
I am on my best behaviour
And there are times
I lose my worried mind
Would you want me when I'm not myself?
Wait it out while I am someone else?"

I'm never sure when the best time is to explain that I may be "not myself" for a while. Does it put people off getting to know me? Possibly. Are some people none-the-less shocked by it and unable to cope with it? Absolutely. I think this experience of negativity is one of the reasons I find myself wanting depression to be a transient phenomenon. The idea that friends won't have to "wait it out" again is appealing. Sometimes, I even believe it will happen.

When I am in a "good" phase, I convince myself it was something that happened once before, but something I am now over; a dreadful nightmare from which I have thankfully awoken. When I'm at my lowest, I am like the aforementioned cat, trapped and suffocating in a bin liner wondering when the water will finally wash over and take it all away. But there is a middle ground. The days when I first suspect it might be back. The mornings I wake inexplicably early, feeling anxious about nothing in particular. The evenings I cannot focus on whatever book I try to read. The afternoons where I suddenly feel like going out with my friends later is an insurmountable task. These are the times when I start thinking there might be an answer. Maybe another pill. Perhaps a different kind of talking therapy. Eating better, exercising more, filling my time with positive things. Maybe, this time, it will stop. Sarah McLachlan explained it pretty well.

"Spend all your time waiting
For that second chance
For a break that would make it OK"

I wonder, during these days, what it will be that makes it OK. I live in a kind of limbo, hoping that eventually I'll find and answer. Someone, somewhere will snap their fingers and it will all be OK.

In my case, the drugs do work, at least a little. The appropriate dose does mean that my eating is under better control. I have fewer binges and feel less compelled to consume everything in sight. Although I have dips, it's a long time since I put myself in any real danger or tried to do myself any sort of major harm. So, they help a bit. The psychological therapies I've tried have given me a better understanding of myself and some of my quirks, but haven't really enabled me to deal with things in a different way or had much impact on how I live my life. I have no doubt that for some people, one or a combination of treatments will actually completely cure them. For most, though, I suspect things help a little, but never make it completely go away.

I sometimes feel like it would be easier if I never experienced the better days. There are times when I start to think happiness is a myth, that I will forever experience the world through a sort of grey fuzz. During these times, I start to accept the lowness. I forgive myself for having no energy and allow myself to wallow. I stop looking longingly at "normal" people and decide that's not how I'm supposed to be. I accept that a sort of ambivalence about whether I life or die isn't too bad.

And then there are the better days. I wake up as my alarm goes off, feeling like I've had enough rest. I genuinely enjoy the simple things - my morning cuppa, a sunny drive to work, chatting to an old friend. The fog seems to have lifted. I put the bad days behind me and get on with living. And then, out of nowhere, the black dog comes again. Happening at times when I can so vividly recall normality makes it all the worse; the sheer contrast with the way things have been is brutal. I'm stealing more lyrics now, this time from James.

"Now I've swung back down again
It's worse than it was before
If I hadn't seen such riches
I could live with being poor"

This is sometimes the worst thing of all. Those good days are reminders of what I'm missing. Without them, I could almost settle into the grey and accept things. It's those good days that make me wish for a magic wand, some kind of switch to make it all go away. Of course I don't wish I didn't have good days, but sometimes I think it would all be much easier not to be reminded that there's an alternative existence out there.

If you happen to meet me on a grey day, you may not notice. But if you do, if I seem distant or like I'm not listening, or if I make excuses not to meet you, please don't take it personally. Bear with me. I'll have another good day eventually. Matchbox 20 explain it better than I do.

"I'm not crazy, I'm just a little unwell
I know right now you can't tell
But stay awhile and maybe then you'll see
A different side of me"

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