India – talking Mental Health.

Asian countries account for more than 60% of world suicides.

According to the WHO, in the year 2016, suicide was the most common cause of death in the 15-39 age bracket in India, the highest in the South-East Asian region. India’s own official statistics, which map the number and causes of suicides in the country, have not been made public for the last three years, hindering suicide prevention strategies and efforts to implement the WHO’s recommendations in this regard.

In 2014, the WHO released a report with a series of recommendations for successful suicide prevention. It proposed a public health model for suicide prevention, consisting of four steps:

  • Surveillance
  • Identification of risks and protective factors
  • Development & evaluation of interventions
  • Implementation

India has not progressed beyond the first step. Lack of political will, social stigma and inadequate mental health awareness in the general and medical communities contribute to the continuous rise in the death rate of young people by suicide in India.

A Junior Doctors World Congress was held at my alma mater, Christian Medical College Ludhiana in April 2019. Si and I ran a Mental Health Workshop that was attended by 75 medical students from India and the wider South and South East Asia region. 

Motivated by this event, some students have established community mental health support networks and mentorship programmes at their respective institutions.  I am impressed with their passion to make a difference.

Here is an example:

Early March I was back in Delhi and was honoured to be invited by Shruti Verma Singh, the founder of a Youtube channel, Zen-Brain.com. She is determined to increase the emotional awareness in India and does it gently, through a series of interviews. We met one afternoon to talk about Saagar. I hope her work will help wake up the government, break social stigma and drive understanding and compassion.

A phone call.

Last week we got a call to assess a patient for a possible transfer to ITU. Our team of three anaesthetists went along with all our kit and PPE. From a distance, he didn’t look too unwell. And he looked young. I hoped he wouldn’t need too much intervention. We donned out protective equipment and looking like aliens, entered his cubicle. I checked his name and date of birth. He was born in the same year as Saagar. After making a quick assessment, we decided that his breathing needed support. We spoke to him about getting him off to sleep so that we could place a tube in his wind-pipe and assist his breathing. We explained to him that we would transfer him to ITU for further care.

By this stage he was shaking, his eyes swollen with fear. He asked to make a call to his mum. We stood back while he called her. He held the phone to his left ear while oxygen hissed through his face mask. We waited, watching his face slowly relax, his fear melting into tears that dripped down his cheeks. After what seemed like a long time, he said bye to her, told her he loved her, composed himself and said he was ready to go to sleep.

It was like watching the dance of life and death. Love and separation. Help and helplessness. I was grateful and pleased that this mum and this son could connect at this crucial time.

Saagar didn’t have this luxury. He didn’t get to call his mother. No words of comfort fell into his ears. No tears of relief spilt from his eyes. Nobody offered him their understanding. I felt sorry for his mother too. She didn’t have a chance to say good-bye, to tell him that she loved him, that she would pray for him and that she wished him the very best.

When there is political will, governments can bring countries to a shrieking halt, the world can come to a stand-still.

When it is a physical illness, millions of pounds can be spent in seconds. New hospitals can be erected within weeks. Multiple trainings can be put in place for the front-line staff. Awareness campaigns are everywhere. What to do, what not to do, repeated endlessly. Retired doctors can be redeployed. National economies can be allowed to crash. Everything else can be put on hold.

When it is a mental illness, there isn’t enough money. There isn’t enough time. Not enough people. Very little expertise. No effective awareness-raising campaigns. No appropriate spaces. Not enough beds. Not enough research. The bottom-line is that there just isn’t enough respect for the fact that people with mental angst suffer the same, if not worse than those with physical ailments. That on many occasions they too, die alone.

 Its about Respect and Political Will.

The Sliding.

Ryan woke up at least twice every night to run to the loo. But last night he moved like a little whirlwind under the sheets. Sue slept through most of it but found it peculiar. She didn’t say anything, lest it disturb him but he disturbed her at least every hour without knowing it.

She woke up feeling tired at 6.30 am. It was a Monday morning. The day of the week didn’t matter much any more as both of them had recently retired. She as a head-mistress of a primary school and he as an accountant.

Their daughter lived in Liverpool with her boy-friend. Her job as a personal trainer at David Lloyds was less than they’d hoped for her. Her boy-friends spoke funny but for a living, wrote speeches for prominent people. The phony politicians who couldn’t even write what they wanted to say to the people they represented.

Sue put the kettle on and freshened up while it whirred. She put two green and gold Wedgewood cups and saucers on a tray along with a matching milk pot and a tea pot large enough to hold 4 cups. She entered the bedroom with the tray. Instead of sitting up in bed thumbing his phone, Ryan was flat on his back. His eyes red and fine vertical lines above his nose.

‘Morning!’ she sang, ‘You ok darling?’

With a smile, she placed the tray on his bedside table and placed her hand on his forehead.  

“Yes. I’m fine.” Said Ryan.

‘Did you sleep well?’

“Not really. The temperature in this room was all over the place. Couldn’t settle.”

The temperature was just fine, she thought but decided to stay mum.

‘Care for a cuppa?’

“Yeah. Sure.” Ryan raised his head off the pillow. An oval wet patch was imprinted on the white cotton pillow case. He quickly turned it around and stood it up against the cushioned head-board. She noticed but did not comment. She poured the golden-brown tea into the cups and added a few drops of milk for him. Over this first month of their retirement they had been falling into a nice little routine. Opening the day with a shared pot of tea was a special pleasure for them both. It made space for the rest of the day to slide into their lives.  

“What shall we do today?” she asked Ryan.

‘I miss my work. All the friends I had. My clients. The window in front of my desk. The 11 am coffee with colleagues. The laughter. I even miss the commute. I never thought I’d hear myself say that but it was nice. I miss all that.’

“Yes. I am sure. I miss my work too but not much. Shall we go to the garden centre and get some saplings? This is a good time for planting. The Organic Café does some nice coffee too.”

‘Let’s see. I might just enjoy the sun-shine in our garden today.’ He got up to visit the loo again. This was not like Ryan. He was the one who normally put ideas forward and she was the one who normally said yes or no.

As soon as he left the room, she put her cup down and stood up to get a closer look at the other side of his pillow. It was definitely damp. She peeled back Ryan’s side of the duvet. The bedsheet underneath him was certainly moist. It smelt of him. Only stronger. This was unusual.

Sue’s pulse quickened. She’d heard of people working really hard all their lives and then dying soon after their retirement. She shoved her silly thoughts aside and waited for Ryan to come back, trying to focus on the delicateness of the tea.

When Ryan came back, she was surprised to hear the puffing sounds of his breathing. His brow had started to glisten.

“Would you rather have a lie-in Ryan?”

‘No. I am ok. Nice tea. Don’t make an old man of me. I’ll be fine once I’ve had a shower. It’s funny. My left arm feels strange. Must’ve slept funny.’

Now she could hear her own heart pumping in her ears. But she kept it cool.

She managed a fake smile. A polite false agreement. She wanted to jump at the phone and dial 999 but didn’t want to scare Ryan.

“There’s no rush to have a shower. More tea?”

‘No. Thanks. I’ll get myself a glass of water.’

“Don’t worry. I’ll get it for you.” She jumped.

At the kitchen sink Sue stood like a statue, staring at the water pouring down the hole in the stain-less steel basin. Is today the day my life changes for ever?

She debated with herself on what to do next. A tug of war went on within her. Does he know he’s unwell? Is he really unwell or am I imagining this? Is that new virus in him? In our house? In our bed? Will he be terrified if I tell him what I think? Is he just having the blues? Or a heart attack? Or an infection? Or nothing at all?

She carries the glass of water back to Ryan. He glugs it back and slowly slides back inside his duvet. She walks around to her side of the bed, slips under the covers and lays down right beside him, holding him with both her arms, a little bit tighter than usual.

Like a couple of soft cuddly toys, they snuggle up. In that moment, she has all she needs. Ryan breathing, resting right next to her. Her tears meld into her pillow. The past and the future disappear. In that moment, life is whole and complete.

Nowhere to go.

On the 9th of March, I reached Melbourne for the second leg of the Churchill Fellowship. I had been looking forward to it for ages and just couldn’t wait to get started. I had the taken the whole month off. Despite the long journey I didn’t feel any fatigue. My AirBnB was homely and comfortable. After a good night’s sleep, I was ready for work.

The Beyond Blue Office was easy to find. After a brief introduction to the team, we all went out to get coffee together. I was already one of them and the coffee was great. The following days flew past with meetings, interviews, presentations and briefings. A trip to Headspace. Despite some background murmurings of a virus, I was having the best time, learning and exchanging thoughts and ideas. Then Australia closed its borders. Meetings and conferences started getting cancelled.

On the 16th, I took a return flight to London.  My trip shrank from 3 weeks down to one. I had to miss Sydney altogether. Now, I am back here with a blank diary for 2 weeks and I am loving it. I have volunteered myself to work and I am on standby.

I can now research and look up things I’ve been meaning to for a long time. I can clear out one cupboard every day and get rid of stuff I don’t need or use or get joy from. Unclutter and create space in my house and my head. I can go to bed without setting an alarm. That pile of unread books that’s been sitting atop my table, feeling ignored and giving me dirty looks, can now be tackled.

Part of me is rushing in to fill the time with a list of a hundred things to do but I am consciously slowing down. Having an easy routine. Fitting in things I love doing, like arranging flowers. Making time for friends. Cooking. Walking. Not getting hooked to the media but keeping an eye. Writing hand-written letters to loved ones. Sitting still. Enjoying our home. Truly appreciating the weirdness of our cat, Milkshake. Cherishing having breakfast, lunch and dinner with Si as he works from home.

Simplify. Make easy. Make plain.

The Way Back – supporting attempt survivors – an idea worth adopting.

Gullyboy (Street boy)

A Hindi film about young boys growing up in slums, turning into rappers.
(Nominated for the best foreign film at the Oscars 2020.)

Angst escapes as words and song,

To a simple metre they belong.

Expression is art.

Connection at its core.

Honest.

Straight from the heart.

Stay in the flow Bro. Stay in the flow.

Keep working at it.

Be proud of what you is.

Know that all will change.

Nothing is too strange.

Dig deep and dig deep.

Be the shark of the deep.

Not a gold fish in a bowl. Yo.

Stay in the flow Bro. Stay in the flow.

Our day will come

Every dog has his day.

Doesn’t look great right now.

But it will go away.

Respect …. yourself. Yo.

Stay in the flow Bro. Stay in the flow.

The heat of strife will melt your chains

And set your spirit free.

Your friends will stand by you

No matter what may be.

Stay rooted and look high.

Like an eagle. Fly.

No fright. Just flight. Yo.

Stay in the flow Bro. Stay in the flow.

Know. Just know.

It’s okay to show.

The wounds that hurt you so.

Someone will understand.

Trust in life and let go.

Stay in the flow Bro. Stay in the flow.

You are not all alone.

Though it may seem so.

Prayers and blessings galore

Are sewn into the seams of your clothes.

You wear them all the time

But you just don’t know.

You are a rare diamond.

You are my heart and soul.

You are the sun, the moon,

The galaxy to me.

But you could never know.

Stay in the flow Bro. Stay in the flow.

Mental – I – zation

He was 15 when his Hungarian parents thought it would be best for him to come to live in the UK with another family. His parents were refugees in Paris and he in London. World War 2 had ended a few years prior. The times were turbulent and many people were having to make difficult decisions.

This boy did not speak English. He landed up amongst strangers, completely inhibited, unable to do well in school. He was teased and taunted by his contemporaries and no one understood him. At 16, he became seriously suicidal. He had a plan. One day a neighbour noticed that he didn’t look great and encouraged him to speak to someone at the Anna Freud National Centre for children and families.

 “The therapist who saw me could see beyond the struggles and see another person, see they had certain competencies and capacities, and that, if you removed some of the inhibitions, the self-defeating behaviours, and got access to my more positive side then I could do quite well,” he remembers.

Prof Peter Fonagy is now a leading contemporary psychoanalyst who has propounded and researched the theory and practise of ‘Mentalization Based Therapy’ (MBT). He is also Chief Executive of the Anna Freud Centre for Children and families. In simple words, mentalization is the effort an individual makes to understand someone else’s thoughts, feelings, hopes, beliefs, desires and behaviours. It is the ability to mind other minds, to understand misunderstandings, to see the impact of our behaviour on others, to see oneself from the outside and others from the inside. MBT is said to be especially helpful in the management of Borderline Personality Disorders.

The things that block mentalization are, firstly, the strong feelings of anger, shame and fear. And secondly, defensiveness, not wanting to know what’s going on in another person’s mind.

I can see how mentalization could make each and every relationship work. Not just the ones we have with others, but also the most important one, the one we have with ourselves.

Working from the heart.

I had taken the day off work. The nurturing, peaceful, green lap of Amaravati Buddhist Monastery at Hemel Hampsted was where I wanted to be. It was a day of rest, solitude, silent contemplation and meditation. Autumn was at its prettiest best and despite everything, it was time to receive beauty. Receive time.

It was the fourth anniversary of Saagar’s passing. The most difficult day of the year, despite my belief that time means absolutely nothing. But this day always stares at me like the enemy. A wretched, horrid, cruel, ugly thing. A brown sludge that I have no choice but to drag myself through.

Slowly, slowly … most of the day drew itself behind me. I returned home, gazing at the sky from the train window, still looking for answers. Still nothing. Just the unbearable pain of longing.

Switched myself back into practical mode, as the next day I was meant to be working. Opened my inbox and found an e-mail from someone called Dan.

“I hope you don’t mind me contacting you out of the blue like this, my name is Dan, I’m a third year medic at Aberdeen University and also the Vice President of the Anaesthetics Society. 

I actually attended your talk at the AAGBI conference this summer. I hope you don’t mind me saying, but I found it incredibly moving. The very day before I attended I had been diagnosed with Bipolar Disorder and was worried about how this would indeed impact on my studies and working career as a Doctor. 

After your talk, I met with one of the Consultants who was offering a ‘mentoring’ session where I discussed the recent diagnosis. She spoke to me about what I need to do to stay well, one of the things was accepting treatment, which initially I admit I was not that open to doing. 

Anyways, I find myself rambling on, I suppose I just wanted to email and introduce myself. If you have any advice for someone with Bipolar who is wishing to pursue a career in Anaesthesia then I would love to hear it!

I just saw an email which was saying that you are giving a talk in Aberdeen next week about this particular topic, which I certainly hope to attend! If you would be about afterwards and free for a coffee I would certainly love to meet you!

Best Wishes and sorry again for emailing like this out the blue!

Kind regards,

Dan.“

Another green moment – tears mixed with joyful smiles. What a way to end the day. What perfect timing.

We met in Aberdeen a few days later. He was all smiles. Friendly, generous and sensitive. We got on instantly. Had a nice long chat. He dropped me in his little red car to the airport. I told him I was hoping to write a book at some stage. He offered to help me with the research that might be needed.

Last week, I was back there in Aberdeen at Dan’s request, to run a 2 hour-long Mental Health Workshop for a bunch of medical students, junior doctors and researchers. It was a good day. I had to smile when Dan talked about Saagar as if he was an old friend.

1+50+176+?

Merchandise at the Manchester Firing Line. Manchester New Hampshire. USA.

On a board of chess, both sides stand face to face

Using wise moves, strategies and tacts.

No drones, no justified assassinations   

No sneaky cyber-attacks.

Two rooks, bishops and knights, both sides have by rights.

Those are the rules of the game. For both sides, the same.

Some things are clearly wrong and others that are right.

Whether your pieces are black, or brown or white.

The way the moves are made,

the way the game is played,

a knight is often not the first to be slayed.

A murder in plain sight

Yet, everyone kept quiet.

No criticism. No outcry?

The killers had good reason. That is why.

They always do.

But do they speak the truth?

Who knows? Do you?

Vietnam, Iraq and now this.

For what? For who?

He was someone’s dad, someone’s son,

A military leader, not holding a gun.

This was an act of cowardice, just for fun.

Guns are a sport in the land

from where the assassin came.

The killers proudly laid claim

To this, their ‘good deed’.

Knowing full well that yet again,

they are sowing a seed.

A seed of death and conflict.

Within a week, a stampede.

Multiple counter-strikes

Hitting innocent planes and passers-by.

Who are the ones that die?

People like you and I.

While the international bully

Keeps on keeping on fighting

In the name of self-defence,

‘Freedom and Liberty’?

When a gun is fired, two people die.

The one hit by the bullet

and the one who let it fly.

War is not the answer. Please.

How can we tolerate this?

Instead of wrapping the world in daisy-chains,

We are covering it in wreaths.

(Footnote: Sixty thousand war veterans, many of them young men, have died by suicide in the USA in 2008-2017. On an average 17 to 20 suicides per day and the rates are not falling despite massive efforts.

https://www.military.com/daily-news/2019/09/23/alarming-va-report-totals-decade-veteran-suicides.html)

Simply 2020

The impeccable house we were invited to, shouted out the immense efficiency of our hosts. It was spotless, warm and welcoming. But every few moments something ‘not right’ was vociferously highlighted by our wonderful hosts. The unacceptable way the red silk cushions were left scrunched and squashed, compressed into corners of the plush golden sofas by the rude backsides that had been resting on them. The panic about the imminent possibility of too high a quantity of left-overs. Or the worry over a small chance that there won’t be enough. The width of the cake wedges was either too thin or too thick. The imperfect consistency of the gravy, the flatulence inducing artichoke soup, the highly undesirable heat generated by the log-fire, the terrible noise coming from the television, the spot of annoying stickiness left behind on the jar of honey by an inconsiderate user, the five brown crispy crumbs of bread left shamelessly sticking to the neat rectangular slab of butter on the gold-rimmed china butter dish, the uncouthness of the incorrect placement of the ornate silver by the staff, the inconvenient timing of a phone call with a relative abroad and so on …

Despite the absolute beauty of this home, the air was imbued with the smell of ‘dissatisfaction’, the well-known fundamental state of most human existence.

Do we change overnight or just carry on with the desire for things to be different? Time is a continuum going in waves, up and down and round and round. The ‘start’ and ‘stop’ points are nothing but artificial. The solstices and equinoxes mark time, connecting us with the movements of nature and linking various planetary bodies with one another.

Ordinary events present us with gems. Its up to us to spot the gems, pick them up and drop them in our pockets.

This year, I wish you and me the ability to appreciate and adopt Deep Simplicity. The ability to recognise the futility of being in a constant state of dissatisfaction, to switch our attention from imperfection to gratitude for all that is, to compassion towards ourselves and others, to patience with others and ourselves as we evolve. It takes time.

Patients first.

Credit: Mario Sanchez Nevado (www.aegis-strife.net)

When I speak with gatherings of doctors, I often start with asking them to shout out whether they think the statements below are True or False. What do you think?

  • Sick doctors know when they are sick.
  • Doctors are good at asking for help and following advice.
  • Doctors take good care of themselves.
  • Doctors have strong support networks.
  • Doctors are kind to each other.   

Irrespective of which country I am in, without fail the auditoria flood up with a big resounding ‘FALSE’ for each of the above, accompanied with some sniggering. Isn’t it shocking? One would expect that people who work in ‘healthcare’ would know a thing or two about their own health as individuals and as a community.

These are the highlights of a survey conducted by the Royal College of Anaesthetists in 2016-17:

The NHS Sickness statistics consistently show that NHS hospital doctors have the lowest rate of sick leave as compared to any other staff group.  Here is a list of personality traits of doctors (a broad generalization, of course) that might explain this:

  • Perfectionism (I must do this right!)
  • Narcissism (I am good at what I do.)
  • Compulsiveness (I can’t give up till I finish.)
  • Denigration of vulnerabilities (If I need help, I am weak.)
  • Martyrdom (I care for my patients more than myself. Their needs come before mine.)

The very traits that make us good doctors are the ones that may not be very good for us. But our seniors have not been aware of this and hence they have not been able to help us understand ourselves. This tradition has been going on for generations of doctors. There is a nobility associated with such self-sacrifice, which we all have bought into. The fact is that if your own cup is empty, you cannot serve others well.

Things add up – a dysfunctional department, work pressures, lack of support outside work, ill-health, emotional burden of the job, a traumatic adverse incident, lack of sleep, fatigue, a complaint made against you, poor diet and no time to exercise or pursue hobbies, impaired judgement of one’s own symptoms, fear of letting others down, difficulty in admitting that they have a problem.

Burnout among medics is not unusual. It looks much like depression and sometimes ends in devastating tragedies. But help is available. Sadly, unlike other illnesses, for mental health issues, the onus of getting help lies with the sufferer. It takes courage to acknowledge one needs help and seek it out in good time. It might be the best thing a doctor can do for themselves and their patients.

Sources of support:

  1. https://www.bma.org.uk/advice/work-life-support/your-wellbeing/sources-of-support
  2. Doctors in Distress, a charity set up by Amandip Sidhu in memory of his brother Dr Jagdip Sidhu who was an eminent cardiologist and tragically died by suicide on 27th November 2018.