Doctors' Support Network 2017 Reflections (photo Angelika Luehrs) mental health
Photo: Angelika Luehrs

Author, Dr Cathy Wield, on stigma and mental illness

August 2017
It seems that recovery from mental illness is not enough. Well that’s the impression I get from our stigma filled world. It was really bad when I was suffering from depression – when you have a low self-esteem as a result of your brain chemistry, then often those who you know well, like family & friends unwittingly betray their ignorance with ill thought out advice or banal platitudes. Most of us try to do the right thing and seek advice from our GP and/or various other health professionals. Even then we cannot guarantee that we will be treated with the dignity and respect that we deserve. I was fortunate in that respect most of the time during my illness, with the exception of some of the nursing staff during my inpatient stays and of course the various different specialities that I had the misfortune to come across after bouts of self-harm.
Doctors' Support Network 2017 Dr Cathy Wield mental health
Dr Cathy Wield
But all that was years ago and I have been well, apart from a less serious relapse which led to me taking antidepressants for life. I have now been completely well for the best part of ten years. That is - well in terms of my mental health. 

Delay in diagnosis of appendicitis due to mental health history 

Unfortunately, physically I haven’t been so lucky. I have needed various surgeries and medical treatment completely unrelated to my previous psychiatric history. Take for example the time when I suffered from an acute appendicitis. So, having had classic crampy abdominal pain for 36 hours, I am then woken suddenly at 03.00 am with severe right sided lower abdominal pain. By morning, I manage to get an emergency appointment with my General Practitioner (GP). Well, I say my GP, but the truth is that he is a GP at the practice where I am registered and I think it’s no coincidence that he is available. He is always available and perhaps here’s why. So, I come in and explain my symptoms and as if by magic, his first thought is “Could this be a touch of Irritable bowel?” Well, I know someone put this diagnosis on my notes nearly thirty years ago when I had diarrhoea for several months. The fact that it all cleared up and I had none of the other symptoms, not have I ever complained of anything similar since, rather suggests to me, that this was an inaccurate diagnosis.

But of course, why consider something physical in a 55 year old who has had a past history of depression? Despite doing my best to avoid having to go to Accident & Emergency (A&E) where I was working, by the time I drove home, I realised that I was not going to be able to drive any more that day. I waited until my husband got home from work, which meant a call to the out-of-hours service. Unfortunately, they wouldn’t see me, so I ended up being admitted from A&E. I was septic by the time I had my appendectomy the following day, but no further mention of my past history had been made or so I thought. 

Medical record error correction – or not

I have a scar from a mini abdominoplasty performed several years after the dreadful depression from 1994-2001, when I was in a psychotic state and repeatedly cut myself. The procedure was to remove scar tissue that had become problematic after my self-mutilation. I almost bled to death from one of those episodes, so being the fool that I am, when asked by the surgical Foundation Year 2 doctor why I had the scar, I told the truth. I find out several weeks later that she has requested a CT scan stating I have a ‘self-inflicted wound’. This request is seen by those who I work with on a daily basis and not only is it totally untrue – I have a scar from an abdominoplasty- but it is there, indelible on my record. I tried to get it changed, but it cannot be deleted – a note was put that this was false, eventually, but only after I persisted, having first been threatened with the possibility of disciplinary action for viewing my own CT scan! 

Sjögren's syndrome / anxiety – discuss!

I had the misfortune to meet the same GP over a year later, this time when I had been referred to him, from my dentist suspecting Sjögren's syndrome. I have dry eyes, mouth ulcers and sores as a result of the dry mouth and his diagnosis this time is anxiety, because he gets a dry mouth when he’s anxious! I have to instruct him on what blood tests need to be requested. There follows a whole series of consultations with maxillofacial surgery for a biopsy and rheumatology. I also contact the psychiatrist who I was seeing to get him to put in writing that my symptoms are not psychogenic. He also asks if they would please do the decent thing and do proper investigations. It all ended badly, with a doctor being incredibly rude to me. My complaint is dealt with in a similar incompetent manner and seven months later, I receive the answer to it, where the doctor in question has fabricated a story accusing me of forcing her to do the biopsy. Of course, the whole tone of the letter is far from apologetic. Instead, I feel as if I did something wrong by just being a patient. By the time I received this, I am in the USA, having emigrated to Denver, Colorado. Thankfully here no one has questioned the validity of my symptoms and I am receiving appropriate treatment for Sjögren's syndrome, but at a cost! 

Practising as a doctor with a mental health history in the USA

Sadly, though the US also takes a dim view of those who have had mental health problems. You can be refused entry to the country if you have self-harmed in the past and are deemed likely to repeat this in the future. While studying for the United States Medical Licensing Exam (USMLE), I found out that if you are suffering from depression and see a doctor when you are working, you have no right of confidentiality and you are not allowed to work, regardless of whether or not you are performing well or have no potential safety issues………………Apparently, in Texas, you will not be able to gain a licence to practice at all, if you have had a history of mental health problems. 

Of course, my attempt to get life insurance a few years ago when I was still working in the UK was also thwarted. My GP stated that although I had been well for years, in the past I had self-harmed on multiple occasions – it was true, but that’s it – my life wouldn’t be covered if I committed suicide – well of course not, but in fact my life cannot be covered at all. It was refused and that’s the end of it! 

Future plans
This sounds rather depressing, doesn’t it? There is still a long way to go to eliminate not only the stigma of current mental illness, but also of the past. It does fill me with sadness and it also makes me feel angry. But I don’t want to become bitter and unforgiving. While I worked in A&E until August last year, I did my utmost to be open about myself and to educate my colleagues. We are whole people, the mind and body are not separate entities and we all deserve respect and care regardless of our past or present symptoms, or what brought them about. But changing attitudes takes more time than I first thought. 

I have not pursued the complaint. It devoured emotional energy and although the head of the complaints department suggested that I enlist the help of a solicitor, it is not such an easy thing to do from here. But I am in two minds. Will the NHS only listen if litigation occurs? If so then maybe it’s worth it, but I don’t want to deprive an already overstretched system of precious resources. At the same time, it does worry me. I am articulate and a doctor and this happens to me, so what about those who are less able to speak for themselves? Sadly, I am increasingly of the mind that I should record consultations, because for some reason, I seem to be the loser when it comes down to who said what. From a legal point of view, a patient is at liberty to do so, even if they do not divulge the information. From a doctor’s stance, I think it would be good if everyone assumed that whatever we say was being recorded. It may just help the vulnerable to not be taken advantage of. 

I hate to admit it, but I am still vulnerable as a result of what happened to me in the past. None of it was my fault, I never chose to be ill and I did my best to get free from it. Unfortunately, it follows me, but now, as much as ever, I wish to put the experience to good use to help others. I am far from perfect, but I hope that someone, somewhere will give me a chance. At present, I remain unemployed, hoping, looking and waiting for opportunities here in the USA. Pray or wish me luck, it looks like I need it!

Dr Cathy Wield 

Author of Life After Darkness: a doctor’s journey through severe depression 2006  and A Thorn In My Mind: mental illness, stigma and the church 2012

Author and psychiatrist Dr Linda Gask speaking about &me and her recent Guardian column

'There are many people working in medicine who have mental health problems, but currently few feel able to speak out. I’ve had mental health problems throughout my career. I’m not ashamed to say so in the hope that this will help others. The &me campaign is a powerful way for us to stand up together, support each other and challenge stigma.' 

Linda's recent Guardian column describing how her psychiatrist told her that a mental health history did to preclude a medical career :

Follow Linda on Twitter :  @suzypuss
Dr Linda Gask (left) at the launch of the &me campaign
Linda's book about her own experience is The Other Side of Silence' - details in the link on the right.

Admitting to a mental health diagnosis as an MP

Doctors' Support Network 2016 Kevan Jones MP at the DSN 2013 conference mental health
Kevan Jones MP is the son of a miner from Nottinghamshire. He has a long association with the North East having trained at Newcastle Polytechnic in Government and Public Policy. Kevan was a Newcastle City Councillor for many years before being elected as MP for North Durham in 2001. He was the Shadow Minister for the Armed Forces and is also a Commonwealth War Graves Commissioner.  
Kevan spoke at the 2013 DSN conference in Newcastle upon Tyne.
Depression is an equal opportunity condition 
Depression and mental illness can affect any of us. It is an equal opportunity condition, which will affect one in four of us in our lifetime. 

After first speaking publicly about my own depression in the House of Commons in June 2012, I received literally thousands of messages from individuals thanking me for my speech, including from people who I’d known well for a number of years who told me about their struggles with depression. These included a chief executive of a major local authority, a former army general and a captain of industry. Asking for help is a big step, but doing so is a sign of strength rather than weakness. Doctors, like politicians, are not supposed to suffer from mental illness, being there to help solve the problems of others, rather than to admit they have them themselves. The House of Commons has now set up a dedicated service for Members of Parliament, allowing them to seek help without the fear of the unwarranted publicity which might result from accessing local services. 

It is important that we have a system for doctors in the North East, similar to that which already exists in London, in order to ensure that they can get the specialist support they require. I will be meeting in the New Year with NHS England to discuss this further.

 Doctors’ mental health support makes economic sense 
The NHS needs to look at support for doctors’ mental health not just because it is the right thing for a good employer to do, but it also makes economic sense. Writing off individuals after spending millions on training them is a mistake.

 Changing society’s views on mental illness takes time, and we will only continue to get that change if we keep talking about it.

Describing the grey tortoise to a Springer Spaniel

Doctors' Support Network 2016 Dr Phil Button mental health
By Dr Phil Button

Phil is an associate specialist anaesthetist who suffers from depression.
Phil says 'I have to admit that I am not well read on personal accounts of depression. This is, in part, due to an inherent disability with, and a secondary dislike of, reading. The notion of trawling through others' experiences of misery is also an uninspiring thought and one that fills me with inertia.  Despite this I have decided to inflict this upon you with no obligation or expectation that you read any further.'
Part 1
I believe the term "Black Dog" is attributed to Winston Churchill.  I have been in a quandary as to whether this is an accurate title for my personal observations as most contact I have had with dogs has left me with the distinct impression that they are happy souls. Whilst I have nothing against carapaced quadrupeds, I feel a closer analogy is with a “grey tortoise”.  The lower case initial letters are deliberate. This, for me, better illustrates the global psychomotor dysfunction that is my depression.  The “Springer Spaniel” is the reader who has never experienced a depressive illness.  I started this account when I was just emerging, touch wood, from a 7 month period of this mental plague.  In some respects words are the problem and any account is restricted by the sufferer's vocabulary.  There are, I think, also limitations to the human language in this respect.  The process of perception to description is a complex one and as thought processes are affected by this condition, possibly a flawed one. That said, this is what it felt like to me at the time.
Perception is as good a place as any to start. The effect I observe is one of a multi-sensory damping. This could be described as a blunting of the senses or of the filtering of input.  All of the senses are affected.  I hear things as if underwater, I see things in greyscale, I smell things through charcoal and touch is as though wearing gloves.  This is not unpleasant and I postulate a sort of involuntary sensory inattention brought about as a result of a diversion of brain resources elsewhere.  Periodically, input will be totally overwhelmed by thought, such that I cease to exist in my physical environment.  This could be described as a feeling of detachment, depersonalisation, being half alive and half dead or being a passive observer of what's going on around.  All these descriptions are inadequate linguistic approximations. Indeed there exists a paradox as there is much activity in the head but little interaction with the outside, as if somehow the balance between these two is disturbed.  Thinking about thinking itself can ensue and it is this phenomenon, also known as metacognition, which resulted in my jottings.  I did attempt to use mind mapping, as processing the thoughts into words was difficult.  Unfortunately my ability to concentrate made learning a new thing impossible.
Part 2
Concentration balance 
This rather conveniently leads me to remember one of the classic diagnostic criteria used by doctors. We are asked if we have loss of concentration but that is the observed effect. I would suggest, however that what I experience is a diversion of concentration into an internal place. It is as if the full cognitive functions of the mighty organ in the head are diverted into resolving the turmoil or malfunction. In doing so, the outside world has to go on hold. This could be regarded as an exaggerated normal trait of the male sex, the tendency to internalise problems, whereas the female sex is widely described as preferring to talk things out in search of an answer. So the man shuts down, goes quiet and turns his exhaust on himself whilst the woman wails vociferously and makes a dramatic overdose in an attempt to communicate their distress. Sorry for the simplistic and sexist characterisation, but I had a flight of idea! So there is a limitation here, whereby I can only account as a man. My feeling is that it is possible that the apparent lack of concentration ability is only an external observation, secondary to the preponderance of compulsive, obligatory, irresistible and unstoppable thinking, which diverts finite mental capacity to the detriment of external functioning. 
Presently, I believe the primary dysfunction of this disorder is of thinking. Thought becomes pervasive and continuous but is disorganised, and this may be the root issue, that because thought itself is dysfunctional, the ability to explain one's predicament, look for answers, is impaired. This inability to provide an answer invokes an internal struggle to resolve a problem for which one temporarily has no answer. It is exhausting and frustrating. Once again male / female differences could lead to separate manifestations of this disorder, as we are told that the male strives to solve problems internally for the good of his mate. A deficiency in this innate function could easily emasculate a man and cause feelings of inadequacy. 
For me, the hyper cognition is, on occasion, stimulating.  The circular un-resolving thought process however, I could easily describe as a state of misery.  Perhaps this dichotomy goes some way to elucidating the term bipolarity.  There lies a key difference between sadness and depression in my view.  The "misery" of depressive illness is as a result of the disordered internal thoughts whereas sadness is an emotional reaction to an external event.
Part 3
Coping strategy
I have been aware of a quite incredible ability to hide the severity of my condition from others.  Even my wife is spared from the worse extremes of my feelings although she will often say in retrospect that she saw it coming.  This may stem from my reluctance to give in to emotion, particularly to crying.  It is not to say that my wife does not suffer, indeed I am periodically aware of being a burden and causing distress, although this tends to come to the foreground as my thought processes clear.  Even at my worst I am able to have seemingly quite normal interactions for short periods of time with friends, relatives and acquaintances.  I am an honest man and matter of fact about mental illness.  I have no difficulty discussing it or admitting to having it and do not feel the stigma but am aware of its effects.  However, I somehow and for some reason strive to hide the symptoms from others.  The feeling is one of not wanting to bother others with it and so burden them or cause awkwardness.  There may also be a contribution to these efforts made by my belief that no one else can understand my situation or can help.  This mask is almost impenetrable except to my wife and after some fighting, my psychiatrist.  This is undoubtedly a cause of delays in my diagnosis and treatment.
Negative thoughts abound within this inner melee and a further battle is present to suppress these.  Approximately fifteen years ago, I underwent hypnosis as an adjunct to antidepressants.  I appeared to be susceptible and my experience was very satisfactory.  My abiding memory of this is that I was "implanted" with a suggestion during hypnosis that I would recognise negative thinking and not allow it to continue.  I believe that this really does provide me with an almost automatic "booting away" of negative thoughts.  This facility however, appears to be overcome during my depression, possibly as a result of the impaired resource of thinking.  Negative thinking festers when I am at my worst to the observer; this is when emotion can appear and in my own experience has resulted in the agonising symptom of morbid jealousy.  I know, absolutely that this is my disordered thinking, as when well; I eulogise about how important trust is in a relationship and genuinely feel immovable in my trust of my wife.  Another strongly held belief of mine is that there is nothing after death and my simple scientific foundations allow me to accept that memory ceases at death so it holds no fear.  However, again, at my worst and to a point even now, I am apprehensive that death will occur and I am not "ready".  I have been able to assuage this negative thought up to now but it initiates itself several times a day.  It could be postulated that the fear of death, in my case, is what protects against suicidal intent.  It does not stop suicidal ideation, which at times seems a logical solution to my predicament.  Possibly, it is when the fear of death goes that suicide attempts are considered more actively.  My feelings were that I would like the pain to stop and if that meant death then so be it: effectively passive suicidal ideation.  I am thankful that I have only felt suicidal for fleeting moments.
Part 4
This physical manifestation of anxiety troubled me enough to attract the label "agitated depression".  Most notable was the churning stomach.  I have not thought a lot on this subject but felt it significant enough to mention.  I tend to think of it as secondary to the "misery".  It could simply be that anxiety is a reaction to the panic associated with not being able to resolve thoughts or that panic is a direct complication of circular thought.  Certainly, it is a real feeling that the problem is not going away and fear of what the future holds is reasonable.
Precipitating factors
I am by my very nature cynicism personified.  I say this merely to add dimension.  Immediately prior to my current exacerbation I can recall factors that could have combined to precipitate a metaphorical overload of my thought mechanism.  I have always felt "out of place" in medicine.  I am from a modest upbringing but have always shown above average intelligence and achieved exam success without effort.  I am extremely shy and to this day still have difficulty overcoming this in my everyday interactions with everyone, but specifically patients.  Being a doctor has been helpful in learning to manage this, but it involves significant effort to keep it up.  I feel somehow exposed to others and doubt my abilities.  Being a doctor however is so rewarding and interesting that it is easily possible to build up a belief in one's ability.  I continually get positive feedback and am sure that patients appreciate me.  I am compassionate and considerate.  I think that I can suffer fatigue from the demands of the job particularly because some patients take advantage of my willingness to listen.  Further insight into my vulnerability here is that I feel bad that I have just said that about my patients.  In retrospect, my depression had resulted in me, quite inappropriately, feeling under acknowledged by my colleagues.  There have been specific disagreements between myself and a younger but more senior consultant colleague which have frustrated me and I have decided will necessitate me dropping an area of my practice.  This makes me sad and I have railed against it internally for some time.  However, this area of my practice, chronic pain management, does involve contact with patients who I will describe, uncharitably, partly as a result of their predicament, as demanding.  It’s probably wise to restrict my contact with these patients.  I have started a period of my practice where younger doctors are less experienced than me, but more qualified - my facility with exams stopped after undergraduate level.  I have no difficulty accepting my lower position of authority when I am well.  I am completely disillusioned with the state of the NHS and of hospital management locally and nationally.  I therefore, feel an element of walking up the down escalator.  I am bitterly opposed to the encroachment of people’s civil liberty in the name of public health, specifically smoking bans, but inclusive of all dictates demanding life style changes.  The smoking ban has seriously affected my daily life and caused social separation for my wife and me.  The effects are everyday and every way invasive and diabolical.  I am financial wreckage as a result of an inequitable divorce and no education into money management.  I suspect these factors are enough to cause a derangement in thought.
Part 5
As a discrete observation I will describe my experience with crossword completion.  I enjoy a simple crossword and tend to attempt those that I know I have a fair chance of completing.  These are the Sun, Times2 and short Daily Mail non-cryptic crosswords.  Occasionally I will start the Daily Mail cryptic and get half the solutions.  However, during this last depressive episode I felt more attracted to the Mail cryptic and doggedly pursued the answers despite cloudy concentration abilities.  I would come back to it, after a rest, repeatedly and despite completing it only once, I kept going back for punishment!
Serotonin - Brain
I am almost convinced that, in my case, and by inference many others, the primary fault is with the handling in the body of serotonin and its precursors.  I have read and read and will continue to look for the best scientific understanding of “Depression”.  Essentially, the key factor is serotonin supply.  Its existence is evanescent and so a continual supply or turnover is occurring.  The situation is therefore dependant upon a supply of the substrate for its production, the essential amino acid tryptophan.  Much is written about non-pharmacological methods of managing depression, but the key to these alternatives has to be producing or maintaining serotonin levels.  Serotonin exists as an almost humeral neurotransmitter all over the brain and certainly has a place in maintaining motor activity, mood, thought and sensory information processing.  Depression is a decline in performance in all these areas as witnessed by the global “depression” of all these functions.  Depression is a wholly inadequate handle for this condition and belies the pervasive effects it has on the sufferer and the undeniable fact that it is a physical illness, a derangement of brain physiology.  The non-pharmacological methods of managing depression no doubt can play a part.  Mood enhancement, happiness training, the avoidance of negative thinking (Cognitive Behavioural Therapy), counselling to help resolve problems and exposure to light, in my opinion are almost certainly helpful.  Exercise, I reserve judgement about, as the balance of opinion is still equivocal, and my experience is negative in this respect. Tryptophan availability however, I suspect, could be key and very significant.
Tryptophan competes with other large amino acids for transport from the gut and across the blood brain barrier.  Dietary manipulation using tryptophan rich foods is therefore of doubtful benefit as the tryptophan is available in the protein content of these foods.  This means that it has to compete with the other amino acids also present in high levels.  To increase absorption, therefore, the tryptophan content has to be increased differentially, as L-Tryptophan.  Furthermore fructose malabsorption syndrome, which exists in at least thirty per cent of the population, can cause malabsorption of dietary amino acids, probably due to increased intestinal motility.  High glucose/fructose content ratio foods are recommended in this condition.  In addition irritable bowel syndrome (IBS) will cause a reduction in efficiency of amino acid absorption.  The incidence of IBS in depressed patients may be higher than the rest of the population.  Serotonin has a neuro-axial regulating effect and a direct effect on gut function and selective serotonin reuptake inhibitors (SSRI’s) have been used specifically where bloating, pain and flatulence are predominant.  Tryptophan may therefore be important to regulate bowel function in depressed patients in order to maximise serotonin availability for bowel function and therefore tryptophan availability itself.
The End
Here ends the gospel according to Phil. Not meant so much as a seminal work, rather anecdotal meanderings.
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