Changing the Conversation.

First versus second.

Medical versus human.

Symptoms versus experiences.

Problem-based versus Trauma-informed.

Here is an example of language, describing the same thing in two different ways.

First:

“I was 15 when I started to suffer with mental illness. I went to see a psychiatrist who told me that I had something called Schizophrenia. For a couple of years my symptoms got really bad and people were afraid I was going to hurt myself so I was hospitalised. They stabilised me on meds and shock treatments and sent me home. For a long time, I didn’t get sick again.

Later, as an adult, I started to get symptomatic again. I got pretty psychotic and once again got put in hospital. They told me there that I was really sick and should go on disability. For a long time, I was pretty sick but then started to be able to manage my symptoms.”

Second:

“I was 15 when I started feeling different than others and really alone. For a couple of years after that, I would do things in pretty extreme ways. They made sense to me based on what I was thinking and feeling but I guess it was scary for others who didn’t really understand what I was thinking and feeling. I got put in a hospital. There I really lost hope and beliefs about being a ‘regular’ person. They put me on a lot of medication that made me sleepy all the time. After I left, I threw out all the meds and put my intensity into music.

Years later, coming out of a difficult marriage I started to have similar kinds of experiences as the ones I had as a kid. I had really strong feelings and felt pretty separate from others. I got put back in the hospital again. I was told I had a major mental illness and that I should go on disability. Though I did that for a while, I realised that I was just going along with their beliefs rather than looking at how I’d come to think in certain ways. Little by little, I figured out what to do with my intensity and I’ve been really growing ever since.”

Each one of us is simply at a different place in our growth and development. Using language that is personal and descriptive of our experiences enables shared understanding. It forces us to think of ourselves and others more broadly as human beings, free of labels and assumptions.

Reference:

Intentional Peer Support: https://www.intentionalpeersupport.org/?v=79cba1185463

Poverty and the Mind

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Vikram Patel is a psychiatrist and a Professor of Global Health who works tirelessly to improve the mental health of people living in low and middle income countries like India and Ethiopia.

His recent research has found that all countries are ‘developing’ countries when you look at the low proportion of the health-budget they spend on mental health. Some wealthy countries may have better systems of care for maternal and child health but overall, mental health remains universally, at the end of the queue.

At present, COVID has overtaken all other agendas. However, now more than ever before, there is a recognition of the two-way relationship between poverty and mental ill-health. This may be a historic opportunity to get this right.

The relationship between poverty and mental ill-health is a complex one. How can we distinguish a normal response to poverty from a disease process? Poverty can increase the risk of poor mental health via multiple pathways, for example, poor physical health, high levels of noise pollution, violent neighbourhoods, insecurity and humiliation.

Can an increase in income improve mental health? Yes. It can but it needs to be sustained.

The fact that having a mental illness may induce poverty is less well recognised. It may affect one’s education and hence, employment opportunities. In low and medium income countries, health care is paid for by people. Due to the length of time it takes to find an effective treatment, much effort and money is wasted in doctor-shopping. Depression is inequitably distributed in society but not recognised as such because wealthy individuals also get it. We accept that long term expensive therapies cannot be delivered to the poor, so what’s the point in studying them?

After nearly a year of job-losses, the number of people below the bread-line all over the world will increase by tens of millions. In India alone, the gains made in economic growth over the last decade are predicted to be wiped out this year. The historically disadvantaged will fare worse, suffer more.

We can expect a surge in mental health problems like we did after the 2008 global financial crisis, mainly led by suicide and drug misuse. Sir Angus S Deaton, a Nobel prize winning economist wrote extensively about these deaths of despair. Economists and global health experts warn that this one will possibly be far worse.

In India, while the state is spending all its energies on the pandemic, livelihood-based organisations are finding very poor mental health in their members. Taking a broad, multidisciplinary approach to depression and anxiety rather than viewing it through the lens of a medical specialty is the need of the hour. Policies all over the world need to de-medicalise the emphasis on specialists and empower front-line providers and communities to enable them to foresee, identify and address this problem.

The bi-directional relationship between mental health and finances means that appropriate mental health interventions can improve finances. Can we persuade policy-makers world-wide to listen to global health experts and economists, look at this fast-approaching avalanche and steer policies to protect those who are being and will be hit by it?

Talk: Poverty and Depression (https://voxdev.org/topic/health-education/poverty-and-depression-how-improving-mental-health-can-help-economic-wellbeing) – this talk was available till last night but has since disappeared.

Research Papers:

Angus Deaton on the Financial crisis and the well-being of Americans (June 2011):

https://www.nber.org/papers/w17128

2. Vikram Patel on Causal evidence and mechanisms of Poverty, Depression and Anxiety (May 2020):

https://www.nber.org/papers/w27157

Shushshsh…

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In June 2020 Sher et al said “Social isolation, anxiety, fear of contagion, uncertainty, chronic stress and economic difficulties may lead to the development or exacerbation of depressive, anxiety, substance use and other psychiatric disorders in vulnerable populations including individuals with pre-existing psychiatric disorders and people who reside in high COVID-19 prevalence areas … COVID-19 crisis may increase suicide rates during and after the pandemic.”

This possibility is slowly starting to unfold. The number of calls being made to crisis help-lines of all kinds is up by about 40%. Economic uncertainty, insomnia, stress and suicidality feed into each other. The previous financial crisis of 2008 had a tragic outfall in terms of the toll taken on human life, essentially due to job losses. Now we are heading into another one. Unless governments all over the world wake up now, lives lost by suicide over the coming months and years could be more than those lost to COVID-19. As per the ONS data from last year, the England and Wales suicide rate remains statistically significantly higher than the rates seen in recent years.

Active outreach is necessary. If you know friends or family who might be struggling or worried, please do reach out to them with your time and open up supportive conversations. Sending a text or WhatsApp message is not enough. Having a proper check-in by telephonic or video link, possibly meeting up for a cup of tea or a drink fosters proper connection. If you find yourself in a tight spot, please know – this too shall pass. It is a temporary problem. Life still holds promise and beauty. Do reach out to your friends and family for support. More than ever before, in the present times suicide prevention is everybody’s business. Take care of you and yours.

Blue Rose

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She was the colour of almonds. Her smile so bright, it made the sun shine. Her hair waist-length, wavy and a very dark brown, like a heavy veil down her back. Her petite frame, shy, smelt of sandalwood. She was only 19.

Her friends had rebellious red, pink and green highlights in their hair. Some had happy multi-coloured beads and braids woven in. Others had playful ribbons platted in, like flower-girls at hippie weddings. She sat on her aquamarine blue sofa with her laptop, peering through colour-charts. She wanted her hair dip-dyed. She hadn’t picked a colour yet.

It was going to cost a bit but her mum had agreed to pay for it. She often did.

When alone in her room, unable to sleep at 2 am, Rose had looked up Helium and what it does. She didn’t know why. It was an involuntary act. It was nonsensical. Her body and mind were no longer of her.

Her hair appointment was in a couple of hours. She had to decide now. It was important she got this right. It was an expensive decision. The staid Royal blue or the scintillating Moroccan Turquoise? Silky peacock blue or the majestic sapphire? She wanted a straight horizontal line to run right across the dark sheet of her hair. The bottom one-third of the length a startling shade of blue, like a designer curtain.

She played classical music on the violin. Her ears didn’t particularly savour the Blues. They jarred her. She didn’t have a taste for blueberries. She preferred the ‘rasp’ variety with big dollops of double cream. Her wardrobe was a smattering of whites, pinks and reds. No blues there either, except the denim jeans and shorts. She was a proper girlie-girl. Blue skies made her spirits soar. But they left blue stains on her heart. She hid them like children hide pretty pebbles in corners of drawers. Her smile kept feeding the sun through the blueness.

She hand-wrote letters to the people she shared the house with, in blue ink. To her mother she said how wonderful a mum she was and she should take better care of herself. To her sister she expressed her appreciation for her companionship, friendship and laughter. Her little brother never left her side. She never turned down his invitation to play any kind of silly game with him. The dogs were all hers. They didn’t know they weighed as much as her. She had to sit down when they clambered all over her saying ‘we love you’.

The blue stains on her heart were expanding like drops of ink drip-dripping on a white blotting paper. She knew it was happening but didn’t know what it was. It’s creepiness had no name. It made her want to escape. It compelled her thoughts to convince her that her deepest desire was to implode. She had no say in the matter. It made her hands look up Helium on the internet. It kept her eyes wide open at night. It made her tummy churn, her legs restless and her head hurt. She now had 2 hearts and she moved between them. One blue. The other not. One wanting out. The other wanting blue hair.

“I am finding this difficult Mum.”

‘We need to leave in about 20 minutes for the hair-dressers my darling.’

“Yes. I am thinking about it … looking up the options on the internet.”

‘Good idea. We can take your laptop with us. I am sure the hair-dressers will have some ideas for you. Don’t worry.’

“I have some ideas but haven’t decided yet.”

‘Take your time. No rush.’

Midnight blue was the final choice. She was happy.

Over the next year that wretched blue embedded deeper into her heart and from there, leached into every cell of her body. Then it burst out, released itself and merged back into the midnight, the sky, the ocean.

That was 5 years ago. Till this day, her mother’s mind twists into painful knots when she remembers that day. How could her lovely Rose have wanted to live with blue hair and at the same time, to not live at all? At nineteen! How?

No one knows. Sometimes it’s like that.

———————————–

A video for every parent: https://www.youtube.com/watch?v=3BByqa7bhto

Human rights issue – Families Matter

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Hundreds of times, in waiting rooms outside Intensive Care Units I have looked into the eyes of sons and daughters, spouses and partners of patients, held their hands and said, “We did all we could. I am so sorry for your loss.”

When Saagar died, no one looked into my eyes and said that to me. They had not done all they could for him. The hospital carried out a sham investigation, a futile exercise in ‘being seen’ to be doing the right thing.

The GMC found everything to be hunky dory. The doctors ‘looking after’ Saagar had done their jobs to perfection. Just too bad the patient was dead. They did not deem Saagar’s case worthy of an investigation. GMC’s role in its own words:

“We work to protect patient safety and support medical education and practice across the UK.”

The Coroner’s report shone some light on the holes in Saagar’s care. It clearly pointed out the things that South London and Maudsley (SLaM) Hospital got wrong.

There was a general failure to identify the diagnosis on the discharge summary from the Home Treatment Team to the GP.
There was a general failure to communicate thoroughly enough with the parents about the relapse symptoms, what to watch out for and where to go for help in the future.

Last June, I wrote to the CEO of SLaM, requesting an update on the changes that had been made in his organisation in response to the Coroner’s findings above. He said someone would get back to me and I heard nothing. This June, I sent him a reminder and again he said someone would get back to me and I am still waiting.

What are my rights as a parent? Is this too much to ask?

What were Saagar’s rights as a young man with a mental illness?

Are our lives not as important as anyone else’s? Black or white or brown? With Cancer or Diabetes? Or Bipolar Disorder?

Everyone deserves to be heard and seen. With respect.

It’s not charity. It’s a human rights issue.

Ref: Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers

India – talking Mental Health.

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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.

Nowhere to go.

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On the 9^th 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 16^th, 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.

Who knows?

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12 days ago I left my home and husband with a strange sense of ‘last-ness’. Si and I are familiar with that uncomfortable feeling. We know that the whole world can change in one second. 12 days is a long time.

Melbourne, Australia, was my final destination when I left home to complete my Churchill fellowship. On the way, I broke my journey for a week in India. I find it impossible to fly over India to go to other places without stopping. There, I watched in horror how much India’s centre has moved to the right. It has gone so far that the words ‘liberal’ and ‘secular’ are now bad words. My closest friend there is a Muslim gentleman whom I have known for the last 23 years and have never thought of him as a Muslim. But now I fear for his safety. I fear for the safety of all my family as I know that when there is fire, some are damaged by flames but many more by smoke.

So, here I am, in Melboune, at a house, rented through AirBnB and so much has happened in these 12 days. I have never understood the need for 24-hour News Channels as they endlessly repeat themselves, induce panic and heighten pre-existing anxieties. Many people are petrified. They are understandably worried about themselves and their loved ones. The restrictions being imposed are causing more isolation and angst. Italian prison scenario is a very sad example.

This is a good time to observe the effect news has on you, pay attention to your feelings and take a break when you need to, from the constant ranting of various media. I am doing that. I am keeping myself informed, connected and calm. I am not willing to allow the situation to affect my mind too much. I am taking all the precautions as advised and that is the best I can do. WHO sensibly says let’s look after our bodies and minds.

I suspect that death rates from this virus are being hugely exaggerated. They are based on projections from those who have been tested, but many people, all over the world have had a cold or flu over Jan and Feb and have not been tested. So, where does the truth lie?

No one knows. That is the answer. No one knows.

Momento Mori – Unpopular Thoughts on Corona Virus

Patients first.

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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:

https://www.bma.org.uk/advice/work-life-support/your-wellbeing/sources-of-support
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.

Men and boys

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International Men’s Day is designed to help more people consider what action we can all take to “Make A Difference” and “give men and boys better life chances” by addressing issues such as high suicide rates, sexual abuse and health.

I had no idea when this day was until yesterday morning, when I received 4 photographs from Aidan who lives in Malasia. He is one of Saagar’s close friends and he shared a house with him at Durham. His comment read “Delivering a Mental Health talk to Schlumberger in conjunction with International Men’s day.’

Invaluable, undying friendships.

Here’s another set of friends. Rene’s friends, who are racing across the Atlantic later this month in his memory – Race for Rene. They are raising a huge amount of awareness and funds for 2 charities: PAPYRUS and Child Bereavement UK. They say, “We lost Rene to mental health in 2017. We don’t want anyone else to have to feel what that’s like.” That is a vision worth having.

Here’s a conversation with James, one of Rene’s friends: https://www.youtube.com/watch?time_continue=4&v=Aerqfealiwk&feature=emb_title

Good luck to the crew. Here’s to all the men and boys we love: