I have never had so many people concerned for my mental welfare before. Health visitors, midwives, doctors. Everyone is worried about me getting depressed. Apparently women with traumatic births and complications are more likely to slip down into the dark well, and seeing as I’ve had a couple of episodes of mild depression in the past, I’m a super prime candidate.
But actually, despite quite a lot of hormonal tears about my boyfriend only being home for one day before going to work in the big smoke for two weeks (he’s back in 3 days, thank shit!), I’m actually doing ok on that front. But again, depression is much easier to deal with as a doctor, if you’ve experienced it as a patient.
When I first started my stint as a GP, I found depressed patients pretty hard work. They certainly take longer than the average patient, because there’s a whole raft of questions you need to ask to gauge the depth and nature of their illness, and crucially – their risk of suicide. Men are more likely to succeed in committing suicide than women. Especially very young men and very old men. If they have a history of previous attempts, or self harm, or any issues with drugs and alcohol, this ups their risk. Social isolation and lack of relationships ups their risk, as does suffering from a chronic illness. A family history of mental illness again increases their risk. So the scariest depressed people are the 60-70 year old men who aren’t married, and who like a bit of booze and don’t have anyone to talk to.
As a doctor there are really only two treatment options you have up your sleeve: medication and counselling of some description. And ideally you get to use both. There are a whole raft of anti-depressants on the market, but essentially what the most popular ones do is stop the natural neurotransmitters in your brain being reabsorbed. So there are more of these natural highs sitting round in your cerebral cortex. I’ve lost count of the number of hippies I’ve had rows with on beaches in India over the years about the use of antidepressants. They contend that they are a modern day mogadon, used by pharmaceutical giants to sedate the masses, and enslave them into relying on their product for the rest of their lives, while keeping the drug companies in profit. Of course, I don’t doubt that there’s a whiff of this around – like any good conspiracy theory, it has to have some truth in order to be persuasive. But I have also seen how they can turn people’s lives around. How they can get people out of bed and back to work, how they can enable mothers to look after their children, students to go back to university. They don’t work for everyone – but if they do work for you, the effect can be stunning.
Secondly we’ve got talking therapy – whether that’s CBT, or psychoanalysis, or retraining the way your eyeballs work, or whatever the flavour of the month is, Again – it doesn’t work for everyone – but I have seen people’s lives turn around in just 6 sessions. And it’s an amazing change to witness.
So when you have a depressed person who comes in wanting some help, this is what you can offer. And usually people opt for one or other option, and then end up getting interested in both options, and then after 6 months of having regular appointments with a counsellor, and the right dose of the antidepressant that suits them, they start to come out of the mire. And this is such a privilege to witness – and as a GP, one of the very few things you can actually cure in your own surgery, without needing to refer the patient to a consultant, so can be highly satisfying.
On the other hand, when you get someone coming in week after week, who ‘doesn’t like taking pills’ and ‘wouldn’t feel comfortable talking to a stranger’ it can get extremely frustrating. And as each of these patients is likely to need double the appointment time that they have booked, they result in a whole waiting room of frustrated patients outside, who’s appointments get knocked back as a result.
As I said – the ultimate thing I guess we are trying to prevent is suicide. And if you think someone is at risk of suicide, you need to decide how ‘at risk’ they are. If you think they’re going to do it today then you can try and keep them in your waiting room until the emergency mental health team can be found and persuaded to get involved. More usually, you’re worried that they could do it in the next day or couple of days. This again means a referral to community mental health. In reality, this means phoning a number around 15 times until you get to speak to one of two case officers for your whole area, who is massively overworked and underfunded. You then have to spend 15-20 minutes trying to convince them why this patient deserves some mental health follow up (as the delayed patients fume in your waiting room) and if you are lucky – they will take a contact number for the patient and agree to phone to assess them at some time in the near future. It isn’t a very satisfying or reassuring process. And leaves you feeling very vulnerable.
But I guess the other point is, that if someone really wants to end their life then they’ll usually manage it. My only patient that succeeded wasn’t someone I expected to do so, but was well plugged in to the acute mental health service. It was awful when I heard what they’d done. And I fine tooth combed over our encounters, wondering if there was anything I could have done to prevent it. But on reflection I realized that I had done everything in my power to help them, and that as a doctor you can’t take responsibility for everything. You just do what you can.