Day 410

Parents, partners, friends and siblings of those lost through suicide can take forever to get back to ‘normal’. They are haunted by events and memories associated with it for many years. This is especially true for those who are unfortunate enough to be the ones to find the bodies of their loved ones. The unimaginable pain stays with them like a dagger in their hearts forever.

Even today, the sound of fast moving trains completely rattles my being. The events of ‘Day 0’ replay like a film in my head many times a day. Most often it’s the first thought in the morning. I break into a sweat and my heart pounds violently. I hold back from screaming outwardly but inside I am wailing. I have millions of screams stored up inside me. I fear one day they will explode into a deafening wail that will enfold the whole world.

Direct experience of horrific events; witnessing trauma in others; learning that traumatic event(s) occurred to a close family member or a close friend, especially where the actual or threatened death is violent; repeated or extreme exposure to aversive details of the event – a history of all of these is DSM-5 criteria for the diagnosis of Post-traumatic Stress Disorder or PTSD.

Talking therapies (Cognitive Behavioural therapy and EMDR, Eye Movement Desensitisation and Reprocessing), Group therapy and self help strategies are very useful for management of PTSD.

Guidelines from the National Institute for Health and Care Excellence (NICE) suggest that trauma-focussed psychological therapies should be offered before medication, wherever possible.  UK Psychotrauma Society has published an evidence based guide for management of stress caused by trauma.

Following on from yesterday, is it any wonder that mental illness is rife in war torn countries?

I am no psychiatrist but I don’t think what I have is PTSD. I have an understandable response to a catastrophic event. I am gradually getting better at handling it. I can keep a semblance of ‘normality’ in my day to day life even though I am hurting deeply.  Some recently bereaved ‘patients’ are started on antidepressants within weeks by their doctors. One of them said to me, “I don’t feel anything. Just blank.”

Day 388

Depression is not one thing. It is not just sadness.

The opposite of depression is not happiness. It is vitality.

There is a total lack of interest in anything. The smallest of tasks seem like climbing a mountain.  For instance, answering the phone or getting food out of the fridge, putting it on a plate and eating it.  The person suffering from it knows that it is ridiculous and yet they are in the grip of it and cannot seem to find a way around it.  Often it is accompanied by acute anxiety – being afraid all the time without knowing what of. The state of anxiety is often more unbearable than depression and it too can last for months.

While we think that the person with major depression must be shrouded in a grey veil and cannot see things clearly, the person often feels that a veil has been taken away and they can see clearly. When their mind tells them, “You are NOTHING! You are a NOBODY!”, they believe it. But, their “truth” lies.

I wonder what it must feel like to be diagnosed with a mental illness. It must force one to completely rethink one’s identity. Who am I?  How does this illness and the meds affect my integrity and character?  Are these medications making me someone else?It must be very confusing.

The science behind the treatment choices for depression is still very primitive considering that it is one of the leading causes of disability in the world and people die of it everyday.

Our vocabulary is poor as we have don’t have words to describe various degrees of depression. A rainy weekend is depressing as is not wanting to live anymore.

“Depression, the secret we share” is a TED talk by Andrew Solomon. It explores the issue in great detail through his personal experience, explores treatment options and gives hope.

Day 348

If anyone you know came to you and said,

“For the last few weeks I have noticed that nothing gives me any pleasure; I don’t feel interested in anything; I feel quite hopeless and I sleep all the time. Some days I can’t sleep at all and feel terribly restless and fidgety; I feel wretched about myself all the time and hardly feel like eating anything. I feel really tired and can hardly focus on anything. This has been getting worse for a few weeks but for the last 2 weeks, almost everyday the thought has occurred to me that I would be better off dead or hurting myself in some way. All these things have made it extremely difficult for me to do my work, take care of things at home or get along with other people.”, what would you think?

They are suffering deeply.

This is what a PHQ-9 score of 27/27 looks like.
This day last year, my son’s score was 27/27.
It had been 19/27 two weeks prior but had since risen.
I had noted the deterioration in his state of mind.
The words my son could not utter, he indicated on paper.
He was suffering deeply but sadly his suffering was not acknowledged by the professionals who we trusted to care for him.

If clinical judgement had been astute enough, we would have picked up on it and possibly turned it around – escalated care, reviewed medications, reviewed dosages, taken him to A&E.

If a patient with diabetes had a dangerously low blood sugar or another one with Hypertension had a sky rocketing blood pressure, would we just ignore it?

The investigation report mentions the PHQ-9 test as a ‘blunt instrument’. If that is the case, why is it used so widely? Why is it a well-recognized monitoring tool for patients with depression? How can it be ignored when a patient has the highest possible scores?

A baseball bat is a blunt instrument. But it has its uses. It can take a team to victory and crack a skull.

In the light of what I know now, it is not surprising that my son died of severe depression. In fact, it is surprising that he hung on for as long as he did.

Just because the patient is sitting and talking to us and there are no lumps and bumps, no obvious bleeding or pain, does not mean they are not suffering. They are slowly dying in front of our eyes. Their suffering is so unbearable that they will do anything to get rid of it. They are ashamed of it and can’t bring themselves to talk about the extent of it.

We need to learn to pick up on subtle signs.

When it comes to suicide, prevention is the only cure.

Day 339

In a special little box highlighted in a greyish shade of blue the BNF (British National Formulary) says:

“The balance of risks and benefits for the treatment of depressive illness in individuals under 18 years is considered unfavourable for the SSRIs citalopram. escitalopram, paroxetine, sertraline, mirtazapine and venlafaxine. Clinical trials have failed to show efficacy and have shown an increase in harmful outcomes. However, it is recognized that specialists may sometimes decide to use these drugs in response to individual clinical needs; children and adolescents should be monitored carefully for suicidal behavior, self-harm and hostility, particularly at the beginning of treatment.”

This has been known for 10 years.

GlaxoSmithKlien came under heavy criticism when they were accused of ‘concealing’ important information from the public at the risk of harm to patients in the US.

In the UK, criminal action was taken against GSK and these medications were labeled as ‘suicide pills’.

Adolescent brain development studies have shown that the structure of the brain continues to change from the teens till early twenties before it assumes adult form.

In different countries, the definition of ‘adolescence’ differs. In America, consumption of alcohol is illegal below 21 whereas in the UK it is illegal under 18. In a medical setting, does ‘under 18’ mean that if the patient is a few days or months over, the rule does not apply to them?

My son was ‘around 18’, at the beginning of treatment, not monitored carefully and not under specialist care. This side effect of the medication that he was taking was not mentioned, leave alone ‘emphasised’ to me. No safety plan was put in place.

Could the choice of medication be responsible for what happened?

Or was it the way it was used that contributed to it?

Questions, questions and more questions.

The report of the joint investigation between the Mental Health services and NHS England is delayed again. They are also probably grappling with many questions. The Coroner’s Inquest is in less than 2 weeks.

Let’s see if we can find any answers.

Day 311

This time last year, I had applied for a job in one of the most beautiful parts of the UK, the Lake District, with the idea of moving there with him as soon as possible.

I was somehow convinced that the hectic lifestyle and the chaotic energy of London were no good for him or for me. I thought the move would allow us to be closer to nature, live in a bigger and brighter house and be a part of a smaller and closer community. It could also mean better access to proper healthcare and support services. The high density of population in big cities can overwhelm the demand for Mental health services leading to a poor quality of care.

Having looked at these issues more closely now, there is evidence from India, a rapidly urbanising society to support these two facts:

  1. Psychiatric disorders are rising across the world in line with urbanisation.
  2. Cities are lonely zones. They breed psychiatric maladies. Increasing urbanisation means more loneliness and its collateral damage, depression.

The more cluttered our lives are with work, information, entertainment, technology and other trappings of worldly success, the less room we have for authentic intimacy and sharing of life’s challenges with those who really care. Until recently, the extended family and neighbours used to act as emotional buffers. Today, our cities are more crowded, yet more people live alone. Divorce rates are rising. There are more single person households. More people have fewer children. Work or education takes us far away from our families and communities. We constantly navigate between our needs to be on our own or with others. Over time, relationships thin out.

“Driven by the ‘cult of busyness’ we work more, sleep less, and allow technology to become the prime architect of our intimacies”, writes Sherry Turkle, MIT professor of Social Studies of Science and Technology, in her 2011 book, Alone Together: Why We Expect More From Technology And Less From Each Other. Loneliness also acts to increase our stress hormones, inhibit our immune system, stress our heart and is also a known factor for suicide.

Given that the rate of suicides and the use of antidepressants is steadily on the rise and so is urbanisation, there must be a co-relation. It is for us to recognise this malady and find a way of looking after ourselves and each other while living in big cities.

Day 228

All day today 55 years old Charles Kennedy has been on the news – a prominent political figure found dead at his residence yesterday. He struggled with alcohol, his father passed away earlier this year and he lost his parliamentary seat of 32 years in the recent elections. Police are treating his death as ‘not suspicious’.
Interesting description. Isn’t it? I, on the other hand, am very suspicious.
My thoughts and prayers are with his family. For them the nightmare begins.

From the documents that have been sent to me for the inquest, it is revealed that my son’s depression score on PHQ-9 was the highest possible, ie. 27/27, sixteen days prior to Day 0. It indicates severe depression. It doesn’t get any worse. Yet, no alarm bells rang for anyone and he was sent home on the same medication and no escalation of care, despite it being requested. On the follow-up visit 2 weeks late, the test was not repeated. Wonder why?

PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression and it is a validated tool for monitoring depression.

Eli Robins and colleagues at Washington university studied 134 suicides and came to this conclusion: “If we had found that suicide was an impulsive, unpremeditated act without rather well defined clinical limits, then the problems of its prevention would present insurmountable difficulties using presently available clinical criteria. The high rate of communication of suicidal ideas indicates that in the majority of cases it is a premeditated act of which the person gives ample warning.”

Identification through proper assessment of suicide risk must precede any attempt to treat psychiatric illness. Asking the patient directly about suicidal thoughts or plans is an essential part of history taking. Other major risk factors that need to be evaluated are: the presence of severe anxiety or agitation; the type and severity of psychiatric illness, the extent of hopelessness; presence of severe sleep disturbance, current alcohol or drug abuse, ease of access to lethal means, lack of access to good medical and psychological treatments (!), a recent setback, family history, close proximity to a first episode of depression, mania or schizophrenia and recent release from a psychiatric hospital.

Once identified, acutely suicidal patients need hospitalisation as a protective measure and for further evaluation. It does not prevent all suicides but definitely saves lives.

Hospital beds are like gold dust. Patients verbally and clearly proclaiming suicidal intent are sent home due to lack of beds. ‘Length of stay’ is another criterion for assessing how well a hospital is doing. So, even if they do manage to find a bed, patients are discharged earlier than they should be. There is tremendous pressure on the system and the carers at home.

There is almost nothing doctors can do about major stresses in patient’s lives as they are difficult to predict and govern but there are things that can be done to influence the underlying biological vulnerabilities to suicide. The proper management of mental illnesses, especially those closely linked to suicidal behavior, is vital.

Day 205

Depression can have various physical manifestations.
One may feel “sick” or weak and worry about ones health. Back pain, headaches and muscle aches are the most common complaints. Depression is one of the most common reasons for people visiting their doctor and for missing work.

“People with migraines are two to three times as likely to have depression as the general population,” says Richard B. Lipton, MD, Director of the Montefiore Headache Center in New York City. People who experience migraines 15 or more days of the month are about twice as likely to have depression as people with episodic migraine, meaning those who experience migraines less than 15 days a month.

The research on migraines and depression shows that the relationship goes both ways: People with depression are more likely to get migraines, and people with migraines are more likely to become depressed. In fact, 40 percent of people with migraines also have depression. “Migraines and depression have common underpinnings in the brain, which can develop due to environmental factors, genetic causes, or a combination of both,” Dr. Lipton says. “Migraine pain and depression are also linked because both conditions respond to some of the same medications.”

Chest pain, joint pains, sleep disturbances (too much or too little), fatigue, abnormal appetite (increased or decreased) causing a gain or loss of weight, dizziness, diarrhoea or chronic constipation are other physical symptoms. They are not “all in your head.” Depression can cause real changes in your body. For instance, it can slow down your digestion, which can result in stomach problems.

Depression seems to be related to dysregulation of nerve cell networks or pathways that connect brain areas that process emotional information. Some of these networks also process information related to how the body senses physical pain. Many experts think that depression can make you feel pain differently than other people. Medicines that treat depression “tweak” the chemicals involved in how these nerve cell networks communicate, making them work more efficiently, hence reducing the pain.

As these symptoms occur with many different conditions, a lot of depressed people never get help because they don’t know that their physical symptoms might be caused by depression.

Unfortunately a lot of doctors miss the symptoms too.

Day 193

“Antidepressants (Citalopram) may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. An increased risk of suicidal thinking and behavior in children, adolescents, and young adults (aged 18 to 24 years) with major depressive disorder (MDD) and other psychiatric disorders has been reported with short-term use of antidepressant drugs.”


My son was on Citalopram for the depressive phase of his illness for 4-6 weeks before Day 0. We could call it ‘short term use’. He was 20 years of age. He also had a major depressive disorder. The dose of Citalopram had been increased from 5 to 7.5 mg 2 days before Day 0. Were any side effects mentioned to me? No. Was he warned about this? No. Was he being monitored for this? No. Was he under specialist care? No. How many others out there are in the same situation? We don’t know. We do know that in some parts of UK, such as Blackpool, as many as 6 out of 10 people are on antidepressants.

Brain is the most poorly understood organ in the body. Hence it is not surprising that the drugs that are designed to treat a particular ‘brain disease’ might make it worse for a period of time.

“The bottom line is that rather than an enlightened and compassionate mental health system attending to the needs of our young, we have a dangerous and coercive system that stands impassive, not only in the face of repeated failures, but, unbelievably, of child deaths due to treatment.”

Jan Eastgate, International President Citizens Commission on Human Rights. USA.

Apparently it is not very different in America. Here is a detailed account: