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 312

Today I met this lovely little 70 years old lady at work. She had come in as a patient for a minor procedure under anaesthesia. She was well dressed and I couldn’t help but notice her hair. It was as though she had just walked out of a hair salon. It was beautifully styled. I could imagine her sitting with her rollers on under the hair dryer reading a magazine. I was impressed by the effort she had put into looking so good to come into a hospital for cancer surgery.

Instantly my mind flashed back to 2 days before Day 0. That day we had an appointment to see the GP. I had requested my son to shave as I gently woke him up reminding him of our planned visit. 10 minutes before we were to leave the house he came down the stairs. He had not shaved. I sent him right back and insisted he shave even if it meant we were a few minutes late. He really didn’t want to but he did. (Now I know how terribly difficult it must have been for him.) I was pleased to see him looking so neat and tidy.

The doctor’s report to the Coroner says – “He was well dressed, shaven and fresh. He made good eye contact. His speech was coherent and we had good rapport throughout. He said he had had a recent ‘set-back’. On being asked if he had suicidal thoughts he said yes but he had no plans. He said that he felt he would never recover from this illness. I reassured him that he would. He asked me how long it would take……. If other patients had returned to work….. There was nothing to indicate a relapse of psychotic features. The Citalopram was increased from 10mg to 20 mg daily.”

Despite the fact that during the previous visit 2 weeks prior, his PHQ9 (Patient Health Questionnaire 9, a monitoring tool for depression) score was 27/27, indicating the worst possible level of depression, the GP did not repeat the test on this visit. Was it because he looked ‘well dressed, shaven and fresh’? Would it have made any difference?

We will never know.

What we do know is that there is a huge need for education. Pills alone do not save lives.

Day 286

Ignorance is a good thing.
It allows for wonder, exploration and learning.
Not knowing something and having an insight about it, is healthy.

For instance, let’s say there are 2 doctors. One of them has been practicing for 30 years and the other one has recently qualified. When the former sees a patient, he is highly unlikely to doubt his judgement. The latter however, is more likely to admit that it might be worth taking a second opinion as his experience is limited. Which one of these two is better for the patient?

My son was unwell. I knew.
How unwell? I did not know.
For at least 4 weeks before he died he was severely suicidal. I did not know. I was told by his doctor that the drugs would kick in soon and I trusted him. I read up about it but did not find anything to make me think differently. I did not seek a second opinion. Was that ‘willful ignorance’ on my part? Did I not want to know? Although it was painful to watch him suffer, that last month was beautiful. We spent a lot of quality time together – going for walks, cooking, going to the gym, for movies, dinners and drives, talking, being silent and watching TV together. I will always treasure that time. It was special because I was relaxed while taking care of him. I was blissfully oblivious of the fact that he was so close to the edge.

Is ignorance bliss?

Day 279

It was fancier than I thought it would be.

Broadcasting House was intimidating but once we stepped in we were met with nothing but politeness and sensitivity. They even arranged for a taxi to pick us up. I am not used to being so spoilt.

The cups of tea were much needed and lovingly offered. The inside of the premises were as modern as the outside of the building was old. A multitude of wall mounted flat screens, computer terminals, autocues, cameras and all kinds of efficient looking people walking around with headsets and hand-held radio sets filled the space in an elegant manner. I am not even sure of the proper names for some of the things that were there.

There were many interconnected corridors, mostly dotted with what seemed like a lot of make-up rooms. I was guided into one of them where a lovely lady called Julia made me BBC camera worthy.

I was at the studio for the live screening of a 17 minute slot on ‘Suicide’. There were 3 other panelists who shared their stories. Very moving and insightful. Although the format was informal, I was glad to note that the conversation had a definite suicide awareness and hence prevention emphasis.

On getting home from work, with slight nervousness I turned the TV on to watch the recording of the programme. I was happy but sad. I would have much preferred to spend the morning with my son at home. I wonder where the strength comes from! One part of my brain says, ”This cannot be happening. It is terrible!” Another says, “Something has to be done about this.” Yet another part is just vacant and wandering and watching the other two combat each other. The result varies from minute to minute.

I don’t know how I carry on.

It must be ‘Grace’. It is bestowed upon us for no particular merit. It flows through me as a result of the blessings of my parents and my Guru, the love and best wishes of near and dear ones, the support of all you good people out there and the good deeds of my fore-fathers and my son.

The first 17 minutes of the programme might be of interest to you.

Day 278

Suicide is a permanent fix to a temporary problem.

It is preventable.

The thought is complex, confusing and overwhelming.

It can affect anyone.

It does affect many of us –men and women, young and old.

It is nothing to be ashamed of.

It is not insurmountable.

It leaves behind utter devastation.

It sends out warning signs.

We’ve got to watch out for it.

Watch out for it as individuals, as friends, as family, as schools, as work places, as a society, as a country and as a world.

It strikes when no one is looking. It is devious and cunning.

It narrows down the mind to one and only one possibility when many exist.

It claims our most sensitive, creative and beautiful gems.

It defies the youth of the young and the wisdom of the old.

It drives us against our very grain.

Please let us not let it win.

Let us listen. Let us talk. Let us open up and reach out.

It’s ok to be vulnerable. Inside, we all are.

Suicide, suicide. Go away! Don’t come back another day.

I am honoured to be invited to participate in a TV show about suicide prevention tomorrow morning on Victoria Derbyshire’s talk show on BBC2 between 9.15-9.35 am.

Day 268

Successfully completing medical school was an exhilarating experience but confusing at the same time. I figured that becoming a doctor was just the beginning. I had no idea where I wanted to go from there. What did I want to specialize in?

After a year and a half of trying this and that I found my vocation. It sounds cheesy to say that I did not choose Anaesthesia, it chose me. But that is true. It was just right for me. I learnt to comfort and reassure patients and their families just before their operations when they were vulnerable and worried. I developed delicate practical skills in the form of medical procedures and sensitive difficult conversations. I learnt a lot about patient safety as, when under anaesthesia, it is completely up to us to ensure that every patient is safe in every way possible. Maintaining good blood circulation and keeping the blood well oxygenated, hence keeping the patient alive is the very basic requirement.

In addition, we worry about the smallest things – a slight drop in temperature, a little scratch on the cornea of the eye or a tiny chip on a tooth, causing pressure sores or nerve injuries as a result of lying in one position for a long time or a bit of nausea or sore-throat after the operation. Many other seemingly tiny considerations are borne in mind to avoid the smallest possible complication.

Death directly related to anaesthesia is a highly unlikely event. A cause for much concern if it happens! Especially to a fit and healthy 20 year old lad.

Clearly, not all specialties think like we do. Every disease process is different and what is applicable in one field is not in another.

When it comes to safety there are many parallels drawn between medicine and the aviation industry. Martin Bromley is a pilot  who lost his young wife Elaine, when under anaesthesia. He has used that experience to educate a lot of people about the importance of Human Factors in medicine.

This video tells us his story and the lessons learnt. It is humbling to hear him speak. I have watched it many times and also used it for teaching junior medics. It is called “Just a Routine Operation”. A lot of learning in 14 minutes.

Day 264

“Youth who feel suicidal are not likely to seek help directly.”

This is clearly stated on the Suicide Prevention page of an American organisation called National Association of School Psychologists (NASP)

It also says: “Parent notification is a vital part of suicide prevention. Parents need to be informed and actively involved in decisions regarding their child’s welfare. Even if a child is judged to be at low risk for suicidal behavior, schools will ask parents to sign a Notification of Emergency Conference form to indicate that relevant information has been provided. Additionally, parents are crucial members of a suicide risk assessment as they often have information critical to making an appropriate assessment of risk, including mental health history, family dynamics, recent traumatic events, and previous suicidal behaviors.”

This document is written for students up to the age of 19. But it is equally applicable to older ‘children’.

One set of parents bereaved by suicide discovered after the death of their young son that he had spoken with most of his friends about his suicidal ideation. It is well known that the parents are the last to find out. They have now set up a foundation with this sole message to young people: “if your friends share suicidal thoughts with you, please tell someone older who is in a position to help. Anyone.”

This afternoon I spent a few hours with one of my son’s close friends from university. I was amazed at his level of empathy and maturity. He shared this website with me on which he is a Listener. It is called 7 Cups of Tea, an on-demand emotional health and well-being service. Their bridging technology anonymously & securely connects real people to real listeners in one-on-one chat. I was impressed by the range of topics, languages and countries it covers.

It sounds perfect for those of us who may not wish to speak to anyone in person.
It must be an impossible subject to talk about, but it is amazing how many people are willing to listen.

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.