I have wanted to write a post specifically about mental illness for a while now and Mental Health Awareness Week has pushed me to put pen to paper (or hand to keyboard). I have started this post so many times, struggling with how to appear sincere and not clichéd but relevant. It’s ironic how anxious I have been to get this right! I want to do justice to Mental Health Awareness Week and my many patients who have inspired me. This is a small snapshot and I hope to do more blog posts on specific conditions/presentations in the future.
I haven’t suffered a mental illness but, as a GP I have witnessed the effect of mental illness on patients and their families. I cannot truly understand what it feels like to endure these distressing symptoms day by day but I can share my experience of mental illness in general practice and how we can do better to support these patients.
I have used the following headings as I wanted to draw attention to the many misconceptions and off hand comments that are used every day to describe ordinary people that might be going through extraordinary anguish.
“You don’t look ill”
Unfortunately, there is still stigma, inequality and poor understanding of mental illness within our society and healthcare systems. In general, these conditions are ‘invisible’ – i.e. there is no plaster cast to see, no stitches to remove and no rash to soothe. This makes it difficult for patients to understand that they are experiencing mental illness and in turn makes it harder for their family, friends and colleagues to support them.
“What has he/she got to be sad about?”
I did a 6 month psychiatry job as part of my GP training and to be honest with you, I was dreading it. I knew it would be useful but I didn’t think it would be my cup of tea. How wrong was I?! It was one of the most useful 6 months of my career. I did a community role which meant I saw patients that had mostly been referred by their GPs to the community mental health team for more input. I can still vividly remember the first tutorial my consultant (Dr Paul Blenkiron) gave on ‘diagnosing depression’. He used a mnemonic (BMJ 2006 Mar 4; 332(7540): 551.) that I will share with you to show that depression is so much more than simply low mood.
D = depressed mood
E = energy loss (feeling fatigued or lethargic)
P = pleasure loss (not enjoying hobbies or socialising like you once did)
R = retardation/excitement (slower or faster movements/speech)
E = eating has changed (increase/decrease in appetite)
S = sleep changed (waking up very early in the morning, struggling to get off to sleep)
S = suicidal thoughts
I = I’m a failure (loss of confidence)
O = only me to blame (guilt)
N = no concentration
These symptoms tally with the ICD 10 (International Classification of Diseases, i.e. book of diagnoses, used a lot in psychiatry) features of depression.
I see a lot of patients with depression; guilt and loss of confidence/self esteem are common principal features and they can be difficult to unpick. A patient will sometimes avoid presenting as they think ‘why should I be depressed, I have a rich life with friends and family’ but depression doesn’t work like that. It can affect any one, at any stage in their life. It does not always need a big obvious trigger, like bereavement or a relationship breakdown, sometimes it is caused by a slow accumulation of minor stressful life events or it can even creep up on you from seemingly nowhere.
Someone with depression probably won’t tell you they’re sad and cry all the time (which is a common mistaken belief). They might appear quiet and subdued or the opposite; irritable, with a short fuse. They might not be able to focus on their normal work tasks or make mistakes that they wouldn’t normally make. Maybe they have isolated themselves and stopped going out with friends and family.
I have been told that depression feels like you are walking through thick mud, with a woolly head, feeling like you are sinking lower and lower with no hope of climbing out of that dark chasm. So imagine feeling like that and being told to ‘move on and get on with it’.
“I am a born worrier”
When do you cross the line from someone who was born a worrier to someone with an anxiety disorder? It is a difficult question to answer but certainly one could argue it is when that worrying is enduring and impacting on daily life.
Think back to a time when you are sat in a room waiting for your driving test or an important school exam. Do you remember those butterflies in your stomach and the sweaty palms? What about the constant toilet trips? Maybe you felt a little lightheaded or a bit sickly? Can you recall how you felt after the test, whether you passed or failed? There was relief, there was an end to those pre-test symptoms.
Now imagine feeling that dread, worry and the physical manifestations of anxiety all day, every day. That is generalised anxiety disorder (GAD). It can be miserable and really stop people enjoying their lives to the full. There are several different anxiety disorders (as well as GAD)… panic disorder, phobia, obsessive compulsive disorder and specific anxieties, like health anxiety, all can be hugely debilitating.
“I just need to pull myself together”
Many of my patients feel embarrassed that they have had the need to come and see me. They think they should have been able to get better on their own. Would they have thought the same if they had a chest infection? I am not going to lie, the first consultation with a new face, a GP you might never have met before, can be a hugely daunting. The anticipation is worse than the actual event. It can take 2-3 appointments to build up rapport and feel comfortable enough to share how you are really feeling. That is OK. Try to book in with the same GP for follow-up, it makes the whole process either for both of you. We are good people who just want to help you.
We won’t force you to take medication; we will offer you support and treatment as appropriate for YOU, giving you choices, one treatment plan doesn’t suit everyone. If medication is suggested it is because it may help. Anti-depressants, for example, can allow your brain and body to cope while you try to manage the stuff in your life that is causing you distress. They are by no means a ‘quick fix’ as they take up to 4-6 weeks to take peak effect and they don’t suit everyone, but I have seen these drugs change people’s lives for the better.
Medication is just one aspect of treatment, it is also important to consider psychological therapies also known as talking treatments. CBT (cognitive behavioural therapy) is the commonest form used in the NHS at the present time and it can be enormously beneficial. Undergoing CBT is not a passive process, it requires you to think about how you respond to things and how you can change your behaviour….sometimes you are given homework. Counselling can be useful for some people, it takes a different approach and can suit some personalities better. A lot of my patients do want to engage with talking treatments but only feel able to once some of their depression/anxiety symptoms (such as energy levels and concentration) have improved.
The other important part of a treatment plan for depression is what life changes need to be made. Is there something in your life perpetuating your depression? Do you need to take more time for yourself? Do you need to exercise more? Do you need to drink less alcohol? Is your relationship unhealthy or your work place a problem?
I am a huge fan of self-care, as I mentioned in my Spring post, our lives are hectic and it is important to take time for ourselves as well as looking after the family, the job and the house. I sometimes don’t enjoy a run but I always feel better for getting my trainers on and getting out. I was injured over the winter and was advised not to run for 6 weeks, it helped my hip heal but I definitely noticed a change in my mood and general wellbeing!
“He/She just couldn’t handle the pressure”
My last section is on work related stress which is a condition I am seeing more and more of. It is a problem, I admit, I can get frustrated by. I want to help people who feel unwell due to stress at their workplace – but the patients have to want to help themselves. Sometimes they want an easy, quick solution rather than to address the crux of the problem (which is, I concede, very difficult). I cannot simply sign you off work without a plan of action. Yes, a fixed period of time off from work can make you feel better, but if you return to the same situation without any change, this distress will only happen again.
Ideally I need to put ‘work related stress’ as the diagnosis on the note as this informs the employer there are issues to deal with at their level. As a GP, I cannot repair the root cause of work related stress: I can only support a patient to have to confidence to raise the issues to their line manager. Fit notes can be useful in this scenario ‘this patient IS FIT TO WORK if…’ and put some suggested work place adaptations on the note.
Work related stress doesn’t happen to people because they are weak or unprofessional. It happens because a system is broken. This can be related to poor communication, lack of support, unreasonable workload or disjointed management. Next time a colleague seems to be drowning or tells you they’re struggling please listen and give them the space to share their concerns.
To finish off, I can’t help thinking about a poem (Not Waving but Drowning, by Stevie Smith, 1972) that I first heard in a school assembly. It is a little morbid but I think an important point is made…
Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.
Poor chap, he always loved larking
And now he’s dead
It must have been too cold for him his heart gave way,
Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning.
We should all be attentive; be looking out for family, friends, colleagues, that cheerful chap at the bus stop or the lively lady at the gym. You never know when a kind word or a ‘how are you’ could make the difference. Think about the terms you use to describe people, are they really crazy, mental, lazy or are they suffering in silence? Mental illness can and will affect us all at some time in our life. It is Mental Health Awareness Week but there’s 52 weeks in a year, not just one. Stay aware. Stay well.
As an appendix I have put together some useful resources:
MIND – a mental healthy charity with an excellent website offering information and support. Locally we have MIND workers that have helped some of my patients get and stay well
Northumberland Tyne & Wear Leaflets – excellent self-help leaflets on all sorts relating to mental health (good and bad) including specific mental illness, sleep disturbance and addiction problems
Mood Juice – self-help website for help in addressing emotional problems
Living Live to the Full – a self-help website with online courses to help with low mood, stress and resilience
Headspace app – an excellent app for your phone or tablet taking you through meditation and mindfulness
Improving Access to Psychological therapies – for patients local to York this is the link to the IAPT (cognitive behavioural therapy) self referral details
Young Minds – a charity supporting young people with mental health problems
Kooth – online support/counselling website for young people
And for the doctors reading this
- The British Medical Association has a 24/7 Counselling and Doctor Adviser Service if you are struggling with your own mental health.
- NHS GP Health Service which GPs can self-refer to. You can get confidential mental health advice and support if you think your symptoms may affect your work
And other employers may wish to check out the HSE work related stress website