Tag Archives: mental health

Treating mental illness is trial and error

The Locum psychiatrist looked enraged when I pointed to the BNF and said with a heavy heart “I’ve tried everything in there.”

(The BNF is the British National Formulary for medicines used in the UK by all doctors, pharmacists etc as the medicines bible. It has all tried and tested drugs listed with their uses, dosages and side effects.)

I was experiencing another dip in my depression, my current anti-depressant was not working and I’d checked my copy of the BNF, there wasn’t really much else to try unless I was prepared for almost certain weight gain (which I most definitely was not – I was on a waiting list for treatment at an Eating Disorders Unit for my anorexia – I did not have any support at the time!)

The psychiatrist didn’t like a) that I knew what I was talking about (they like to hold the power and control and sadly some feel threatened by my medical degree) and b) I was presenting with “treatment resistant” depression. This phrase is used when it is felt that various treatment avenues have been exhausted and the depression remains. Looking back at this particular appointment, a short admission would have been useful but it seems this psychiatrist decided that would be too much hassle. Despite me having spent the entire appointment in floods of tears, I was sent home with no change in drug regime, no additional support and no further plan. The negligence of this psychiatrist aside, treatment resistance is an incredibly difficult phenomenon to tackle and the spiral of hopelessness can be disastrous!

There is, however, research currently being undertaking into the genetics of mental illnesses. For example, the Genetic Links to Anxiety and Depression* (GLAD) study is based at King’s College London. Therapygenetics is using genetics to predict treatment response in mental health conditions. While I’d heard of research into the trying to find genes “responsible” for various mental illnesses (a hunt that’s proving to be futile), this shift to looking at what our genetics can tell us about what treatment options are more likely to work is relatively new.

Recent research* showed 80% GPs admitted they treat mental health problems as a progress of trial and error. They try one approach after the other, based on what is available in their area and their own experience. This is not just frustrating but could be fatal for some who’re suffering with suicidal thoughts, they might not have time to try one drug after another until they find the right one. New research could enable doctors to finesse their prescribing so the patient can get the most effective treatment, for them, as soon as they are diagnosed.

My story did not end with being let down by a Locum psychiatrist – fortunately, on this occasions I had a good friend scrape me off the floor and supported me over the next couple of days until I could see my GP, and I eventually got to see the eating disorders team, then the psychotherapist who changed my life, and the rest, as they say, is history. To date, I’ve been on, maybe 10 anti-depressants, a few anti-psychotics and a couple of mood stabilizers; I’ve also worked with about 15-20 psychologists and therapists who all believed their approach was right for me. Fortunately, my current anti-depressant has been working for about 8 years (I did come off it, but went back on it!) and I continue to use skills gained from various therapies but it was individual systemic therapy from someone with specialist knowledge and experience in eating disorders that was right for me.

Just imagine if I’d been able to give a sample of saliva 20 years ago and from that, I’d been able to access the right drug and therapy treatment immediately!

Some research is finding genes that implicate how we respond to both negative and positive environments. It is noted that people with a particular gene variant are found to be highly sensitive to adversity, they also respond particularly well to social support and positive life events. This research, with children, looked at different outcomes of individual CBT, group CBT and parent-led CBT. Being highly sensitive to environmental influence led to a good response to individual therapy, whereas those who were less sensitive had similar outcomes to each course of therapy. This is just one example of where a generic variant could possibly predict outcomes to different therapies.

Biological, social and psychological Venn diagram with mental health a the the centre.

But let’s hold fire a minute. We’ve always known all mental illnesses have a bio-psycho-social cause; that is, there are elements of nature and nurture, our genetics and our environment that can lead to development of a mental illness, so doesn’t it follow that we need to take all of this into account when treating an individual? If we run off into the genetics trap, thinking we can pinpoint the ideal treatment with a mental illness, we’ll forget that they will bring with them a whole host of environmental and psychological factors that will influence their ability to engage and benefit from any given treatment.

Camilla Kong*, a Senior Researcher specialising in psychiatric genomics at the University of Oxford has a background in moral and political philosophy and an interest in the ethical issues raised by genetic research in mental health. She has concerns about us focusing entering on a genetic level, she says “It is quite a reductive explanation…that diverts our attention from the person as a holistic being who is impacted by relationships, life history, structural inequalities and environment and social issues.” She is also concerned with stigma and the assumption that diagnoses are life long and incurable. The biogenetic explanation lends itself to fatalism and works against the therapeutic alliance and hope. Of genetic research she says “I think researchers over-promise – they have to, to attract funding – but even if academic institutions pay for the research, and the results are more measured, public expectations are still very high and the more nuanced findings are ignored.”

Whenever we talk about genetic research, there’s the shadow of eugenics. Kong wisely warns us, as we learn more about genetics, “It’s not that we shouldn’t do it, but we need to be very critically aware of the reasons why we are doing it.”

Perhaps what we can learn from my story is that sometimes finding the right medication and therapy takes time and this time is valuable, I learnt a lot as I went along, some things can’t be rushed! It saddens me that (in the UK) there’s a such a push for everyone to travel on the conveyor belt that is IAPT (Improving Access to Psychological Therapies) – now there’s a service that only partially living up to its name. Access has been improved, no matter what your symptoms or history, if you present with mental health problems, you qualify for 6 sessions of CBT in IAPT, this will be the answer for some but there’s no room for flexibility or individualisation. I was involved in some work to train therapists to recognise when the basic IAPT programme wasn’t going to be enough and how/what treatment to refer patients onto but NHS funding for tertiary mental health services is still floundering; scarce resources mean long waiting lists, leading to people with moderate mental illness becoming people in mental health crisis.

For every cancer patient, £225 is spent on research. For every mental health patient, the equivalent figure is £9**. It’s great that some money is being spent on research but so much more is needed. It concerns me that to attract funding outcomes are being over promised and we all know that the media always sensationalise research results. What we really need is some down to earth longitudinal studies that will back-up the need for particular groups of patients to have long term therapy while others may benefit from shorter, specialised therapies. We then need the funding to train GPs and enough tertiary services to provide appropriate support.

*Information and quotes from Therapy Today Volume 29, Issue 10 – Nature and Nurture, Catherine Jenkins.

** MQ Mental Health

Multiple speech bubbles

Thinking about suicide? Are you stupid?

TW – Trigger Warning – suicide theme.

Apologies – this title is deliberately provocative. Please be reassured, this is a carefully considered blog looking at the language used when talking about suicide.

I was recently listening to a podcast where someone was talking about their experience of mental illness and they said this:

People say “did you want to commit suicide?”, well, yes, I did want to but I never, I was never at a point where I was stupid enough to think that if I go then my family and stuff is just gonna be like, “oh well, he was alright weren’t he, let’s crack on”. I always knew that, even when I was in my lowest places.”

(We’ll gloss over the fact that “commit” suicide is no longer used since that’s related to when it was a crime, there was a disclaimer at the beginning of the podcast apologising for this language!)

I know he’s not suggesting suicidal thoughts are stupid, he’s admitting he had them, but he appears to be showing a lack of understanding about what actually happens inside the mind of someone when they’re seriously contemplating suicide and it’s language like this that perpetuates the stigma surrounding suicide.

I know it was probably a flippant, off the cuff remark and I don’t want to target him but I feel when talking on a podcast, you’re in a position of influence and I want to use this example to talk about the wider subject, we all need to carefully consider the language we use.

When someone’s mental illness is so severe that suicide feels like the only option, they have got to a point where their mind is not able to think with their usual clarity and logic. From an outside perspective we can see plenty of reasons to stay alive but the chemicals in their brain have altered in such a way that their thoughts are not their own.

When in the depths of depression, your mind persuades you that your family and friends would be better off without you. You may think you’re a burden or you’ve become a person no one would want to live with. So, far from it being a stupid thought, it feels prudent to consider your impact on others and take yourself out of the picture.

The pain of depression has been described, by some, as one of the worst pains a human being can experience. Suicide is not just as easy way out but it may feel like the only option to escape the unending agony.

It’s incredibly sad to think about a person at such a low point but I’m being blunt about the reality because this is how powerful the mind is, it grinds down your self esteem and suicide feels like a legitimate (even logical) way out.

Speech bubbles with question marks in

Sometimes suicide is spoken about as selfish, as though the person is only thinking about the relief they will gain, that they are not considering the hole they will leave behind. Knowing incredibly beautiful, compassionate people who’ve died by suicide, selfish, is not a word I was use to describe them.

If you find yourself feeling anger or bitterness towards a loved one who’s died at their own hands, this is natural; it may feel logical to consider them selfish to have escaped the situation, leaving you to pick up the pieces. I’m not saying your feelings are wrong, if you’re feeling them, by nature of the fact they exist, they are acceptable. However, it may be helpful to consider whether these feelings are keeping you stuck and whether forgiveness maybe a step you need to consider in order to free yourself.

I have also heard people say they “don’t have the guts” to complete suicide. It is very unhelpful to use this language. Talking from experience, it is difficult to think about deliberately putting yourself through pain but, as previously explained, thinking clearly and logically are not possible at this point. It can feel as though it takes bravery but when I’ve got to the point of carrying out a violent act, it’s been a case of reluctantly giving up the fight for life and giving in to the voices telling me to end my life. This was not in a passive way, but in an active “I can finally take some action, do something about my situation, to make it better for everyone”.

It did not take bravery or guts, nor was it selfish, it was simply a symptom of my mental illness.

I know, we will all, on occasion, be clumsy with our language, make mistakes and say things that are less than sensitive, I know I will! But it’s important we’re open to considering how our language impacts others and how we can improve what we say to lessen stigma and improve communication.

If you, or someone you know, is feeling suicidal or expressing suicidal thoughts, please seek help from your GP or other care provider. In the UK, you can call the Samaritans on 116123.

1 piece of broccoli and 1 cherry tomato on a plate being eaten with a knife and fork bound with tape measure

Why “going on a diet” doesn’t work!

TW – Trigger Warning – I’m aware many of my readers have eating disorder either currently or in their history. Please be aware this blog talks about food frankly and openly. If this may be a trigger for you, please click onto another blog!

One of the hardest things I feel I’ve had to contend with while recovering from anorexia is full-on diet culture! It’s everywhere, from magazines in waiting rooms to everyday in the office. A day doesn’t go by where someone talks about the weight they’ve lost, or put on, or what diet they’re going to try next.

I’ve found it quite shocking, when I was ill, I was in a bubble of denial about these kind of things, I didn’t talk to people about food, nor them to me so I had no idea there was so much rubbish out there.

I think the most bizarre, to date, has to be the potato diet – you’ve guessed it – all my colleague ate for weeks was potatoes! I’m guessing the logic is that you’ll be so bored of them that eventually you’ll just stop eating and you might lose a bit of weight. But seriously…who dreamt this up?! How can just potatoes sustain a human being?!

I’m taking this back to basics. Very broadly there are 3 reasons we eat:

1. Food is available
Buffet table full of food

This may be simple, someone has brought some cakes into the office and they’re offered round. You eat one because they’re waved in front of your nose. You may feel “it’s rude not to” or you may just fancy one.

We also follow this rule when we live by strict habits. For example, lots of people eat 3 meals a day, each day fairly similar no matter how different their needs are on each day. Habitually, it’s 1pm, you prepare lunch and eat it because it’s there.

This is also the case when we live in family groups. “We eat dinner at 6.30pm because that’s when most people are likely to be hungry”.

2. We’re emotional

Females are renowned for this but it can happen to anyone. For some it’s a case of stuffing their feelings down, “If I eat, I don’t have to feel”. Or it may feel like a comfort, food just makes everything feel a bit better doesn’t it? All sorts of emotions may work in this way, living in the western world, food is available as a coping mechanism.

3. We’re hungry

Our body’s pretty clever, when it requires more food, you experience symptoms of hunger and we can use these as a signal to eat. Your stomach may physically feel empty or may be making noises, you may feel light-headed, irritable or lacking in concentration. If you’re feeling these things but you’ve only just eaten, they’re unlikely to be hunger, but if it’s been a couple of hours, they may signal hunger.

None of these reasons to eat are wrong

If you’re at a dinner party and not hungry, it’s totally fine to eat when food is available. It’s not just polite, it’s a sociable thing to do. If you’ve had a shocking day at work and you just fancy a a massive ice cream or block of chocolate, that’s ok.

However…
Square of carrot cake on a plate

It’s important to be aware of why you’re eating. When you’ve met up with your girlfriends for a coffee and chinwag, if you just fancy that slice of carrot cake because you saw it on the counter, do it – but make sure you know you’re eating it because it was there. Don’t pretend to yourself you’re hungry, or you’ll “make up for it later” or any other “excuse”. It’s ok to say “I’m having it because it was there and I want it.”

If however, you know you’re a grazer and you tend to just eat food “because it’s there”, try to become more mindful about this. Do you need snacks in the cupboard?

Emotional eating is a really important one to be aware of – eating our feelings is dangerous. The only healthy way to manage feelings is to fully experience them a talk about them. Say to yourself, “I’m having this bar of chocolate because I’m really sad” – you may then decided you don’t need the bar of chocolate and may express your emotion in a different way but as long as your acknowledge it, you can make sure that you deal with the underlying emotions as well.

As a generalisation, people are over weight because they have consumed more calories than they have expended. This is likely to be because they have done more eating for reasons numbers 1 and 2. I reiterate, these are not wrong, but we need to be mindful of them in order to keep them in check.

Being mindful of what we’re eating and why is the most important part of having a healthy relationship with food. Having a healthy relationship with food is not about say “yes” or “no” to “good” or “bad” foods, it’s not about having rules, it’s about listening to our body and being aware of what it needs and when.

(I’m not entirely sure I’m as in tune with my body as I’d like to be – I say I’m fully recovered form anorexia but I still struggle to know when I’m hungry, what it means when I’m craving food and most of the time I feel totally disconnected from my body – it’s work in progress!)

“Going on a diet” doesn’t change anything
Potato

Eating potatoes [insert latest fad] for a month may help you lose a few pounds but if you’ve not changed your relationship with food, when you come off the diet, it’s fairly predictable what’s going to happen…!

The way to a healthy body is a healthy mind

Biscuits are on the side during a tea break/cake is handed ‘round during someone birthday/chocolates are “calling you from the sweetie draw” – do you have one? Do a quick check with yourself:

  1. Are you hungry? – is this an appropriate thing to be eating at this time of day to satisfy the hunger you have?
  2. Are you feeling emotional? – is this an appropriate thing to eat to cope with how your feeling? Would you prefer to manage your emotions in another way?
  3. Do you want it just because it’s there? – that’s ok, but make sure you’re making a conscious decision and be aware that you are not eating this because you need it.
Discipline is choosing between what you want now, and what you want most. Quote attributed to Abraham Lincoln with background of mountains and trees

Because diet culture is so much the norm, language around food is really unhelpful. If you say “no” to the birthday cake, other people (who are probably feeling guilty* about eating some) will say “oh, you’re so good”. But it’s not about being “good” or “bad”. It is entirely up to you whether you say “yes” or “no” when feeling peer-pressure to join in, only you know why you’re eating it and whether you have a healthy relationship with food.

*I recently heard Raymond Blanc completely baffled by the question “what’s your guilty pleasure?” – he couldn’t comprehend why anyone would feel guilty about feeling pleasure from food. (Obviously) he’s right! We should never feel guilty about eating. If you’re eating, no matter what you’re eating, if you’re aware of why you’re eating it, no matter whether it’s reason 1, 2 or 3, and you’re ok with your reasoning, and it’s giving you pleasure – just enjoy it!

People end up feeling guilty when their relationship with food is such that they lie to themselves about why they’re eating. Tackling the reasons will in turn address the guilt. We should not feel guilty about nourishing our bodies!

Say no to fad diets text written using food to form the letters

We may need to re-educate ourselves about what a healthy diet looks like. For our bodies to function healthily and feel good we need a balance of carbohydrates, proteins, fats, fruits and veg. No foods are “off limits” but some may need to be eaten less often. A good relationship with food is about mindfully saying “yes”!