Day 522


Andrew Kirkman was the same age as Saagar. He was a second year physics and philosophy student at Oxford. He ended his life in December 2013. Earlier that week he had seen the college doctor who had prescribed antidepressants for him. His parents had no knowledge of his illness.

Andrew’s mother, Wendy Kirkman has been actively campaigning for a directive that makes it possible for university doctors to inform parents of their children’s mental illness if they are at all concerned. She hopes this would save the lives of other students. “People seem to be frozen into inaction by the fear of disclosing information to the parents of students who are over 18, when they have always had the legal right and perhaps obligation to do so anyway.”

Dr Geoff Payne has issued new guidelines advising university doctors to contact parents if concerned for a students’ mental health.

The argument against this guideline is that merely telling the parents doesn’t fix the problem. That is true. However parents can provide additional support. Close monitoring of such cases and intensive talking therapies also have a very important role. Non-disclosure by itself is not a problem but it does translate to further lack of support in a system that has long waiting lists and inadequate capacity to provide optimal care for patients in need.

The other argument against it is student’s right to privacy.
Can the right to privacy be more important than the right to life?

Day 506


Last week I attended an appointment at the new GP surgery with our (new) GP for my annual review of Rheumatoid Arthritis. It was more like the doctor had a consultation with the computer. He looked at the blood results, the prescriptions and notes. He measured my weight and blood pressure but he didn’t ask me anything about the condition I was there for. How are the joints doing? How long have I been in remission? He probably knows as do I that we might never see each other again. He is not ‘my’ GP. He works at the GP surgery where I am registered. I suppose he did what he could in the 10 minutes he was given. The achievement of the day was that I got the prescription of medications.

Last week I met a young man who has recently lost a parent to suicide. He went to his GP asking for help and was instantly offered antidepressant medication. He was dismayed as he knew that is not what he needed. He needed someone to talk to. “People in the UK are consuming more than four times as many antidepressants as they did two decades ago. Despite this, we still do not fully understand the effects of these drugs” says an expert from UCL.

The UK has the seventh highest prescribing rate for antidepressants in the Western world, with about four million Britons taking them each year — twice as many as a decade ago.

According to the analysis conducted by Nordic Cochrane Centre in Copenhagen, the clinical study reports on which decisions about market authorization of these medicines are based often underestimate the extent of drug related harms.”

Four deaths were misreported by one unnamed pharmaceutical company which claimed they had occurred after the trials had stopped. One patient strangled himself after taking venlafaxine but because he survived for five days, he was excluded from the results because it was claimed he was no longer on the trial while he was dying in hospital.

More than half of the suicide attempts and suicidal thoughts had been misrecorded as emotional instability or worsening of depression. In summary trial reports from the drugs giant Eli Lilly, suicidal attempts were missing in 90 per cent of cases. It appears that big pharmaceutical companies reap profits while carelessly tossing aside all human costs and ominously covering them up.





Day 427

It’s done.
The facts have been established.
Not all, but a few important ones.
It would have taken a few weeks of deliberation to get all of them out in the open.
I was not looking forward to it and wanted to jump to the other side of it asap.

The inquest was once again conducted in an open and investigative manner. Everyone was given time to say what they wanted to.
The verdict was:

“Took his own life while of unstable mind.”

Contributory factors identified were:

  • Poor communication with the family about Saagar’s illness, the seriousness of it and the side effects of the medications he was on.
  • Poor discharge summary and handover from psychiatrists to the GP – diagnosis and warning signs for a referral back to the psychiatrists not clearly mentioned.
  • Poor judgement on the part of the GP to have not sought specialist help for him on seeing his highest possible PHQ-9 score, possibly causing him to prescribe inappropriate medication which might have added to Saagar’s suicidal ideation.

All the things I have been going on about! 

The one person that struck me most was the witness from SLaM (South London and Maudsley) Trust who was in-charge of patient pathways and improvement in services. He had been a nurse but now is a ‘manager’ of sorts. He uttered nothing but jargon, office-speak, absolute rubbish, completely devoid of any heart or clinical sense. He claimed to disseminate the lessons learnt through ‘business meetings’. I don’t understand how the two things are connected. That is the true face of modern NHS.

While the verdict was what I had hoped for, I don’t have much hope for change as the people responsible for improvement are nothing but pimps.

I feel completely scooped out, as if my insides have been hollowed out with a blunt knife. It’s time for some rest.

Good night.

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.