When I blogged a couple of weeks ago I implied that I wanted to revisit this subject.
At that time I seemed to be overwhelmed in the media and in the surgery with patients that felt hopeless and were finding it very difficult to go on. One busy surgery on aTuesday morning I could feel the atmosphere of tension and anxiety that sometimes pervades the surgery and indeed during that morning 4 people got up and stormed out. On this occasion because of the way I perceived the vibes I decided to phone each one to see if I could give a telephone consultation or arrange to see them later. What shocked me was the fact that all 4 said they had been feeling desperate and that life was not worth living and waiting was the final straw. Interestingly each person was pleased I had phoned and in 2 cases the act of waiting then storming out angrily had made them feel much better and in effect had ‘snapped’ them out that of deep feeling. The other 2 wanted to talk and happy to reschedule an appointment at a quieter surgery time but felt better for the phone call.
That night I re-read a paper I had recently read on depression and decided to blog some of the ideas I thought would be good to share.
Following my stumbling across his secretary and family whilst at a gathering in France I was given the privilege of reading some papers written before 2008 by a Slovenian psychiatrist,Professor Andej Marušič who also worked at Kings College London before he died tragically from bowel cancer aged 43yrs.
He was brought up in the downtown area of the city Port of Koper,Slovenia and had been aware from an early age that the incidence of suicide in Slovenia was one of the highest in the World and most of his childhood friends from that time had become either dependent on alcohol or illegal substances, or had already died a violent death. He was the only one who somehow made it through. He made the point that if it wasn’t for his upbringing he had had, he probably would have been a good drug dealer. He made it his life’s work to research ways to prevent this tragic end of life.
He presented this paper to at least 2000 health professionals in a very humble, unassuming manner. He was passionate about de stigmatising mental health, making the point that if someone had been in hospital with pneumonia or a heart attack friends and family would be keen to visit enquire about jprogress but if someone had been in John Connelly wing, St Bernard’s there would not be so much interest and people would keep away and not get involved.
This rung a bell as from an early age I had a fascination for medicine and the workings of the body aswell discovering books about the ancient Egyptians and medicine. I also found myself listening in to conversations about ill members of the family or friends. Moreover, I always wondered what was the matter with those people who always came out of hospital with wooden trays displaying a chocolate box picture (a hunting scene or thatched cottage) and woven around the perimeter (the image of one below was found on eBay and being sold as a retro vintage tray!).
Years after this I then realised making the trays was occupational therapy following a nervous breakdown – and my observation was a display of the stigma of mental illness to cover up what the problem was which as a child seemed strange and somehow not right. It would be good to think that attitude like the tray has become retro and a vintage idea.
Professor Andej Marušič then gave the following example:-
A man; 47 years old; married, with problems, or married to problems; a father with worries – employed or waiting to be employed; low back pain; irregular heart beat; feeling low; no appetite but not losing any weight; a warning for those who want to loose weight with depression; no libido; using sleeping tablets; no hobbies; drinking too much, and sports – our Slovenians are losing! We will now try to diagnose the profile of our patient. What do you think his doctors will diagnose? Burnout? The cardiologist will say “arrhythmia”, as the patient is experiencing irregular heart beats; the orthopod will say “lumbago”; the psychiatrist “depression”; the psychologist “neurotic structure with interpersonal relationship problems”; the sociologist “weak social network”; the employer “if it wasn’t for Employment Tribunal law you’d have been fired a long time ago”: his wife “I can’t reach him” because he has lost his libido and his children will say “the old man is bothering us again”. That’s probably more or less the way his therapy would also go, although sometimes the therapies overlap, for example the general practitioner and the cardiologist would both prescribe sedatives. One would prescribe a benzodiazepine, the other a tranquiliser, while I must stress that these two are as similar as whisky and cognac – sedatives don’t cure. The orthopod would prescribe analgesics and give him back strengthening exercises, to which he would respond “I don’t have the time to do these”; the psychiatrist would prescribe antidepressants, as this is almost the only thing we know how to do; the psychologist would say “Be positive” – I am allowed to make jokes about psychologists, because I am one – The sociologists would say “If we had a left wing government you would probably feel better”; the employer would say “Place him somewhere I don’t have to deal with him”’; his wife will say nothing, until she starts talking about the divorce, while his son and daughter are too young to have acquired a treatment licence.
What is the main problem here?
The main problem we are witnessing here is that different people see health from different perspectives. One is looking at just the ground plan, another at just the elevation, while a third just sees the cross section. Nobody sees the whole picture – the overall health of one entire body. Have you heard the saying “When you are healthy, you have a thousand wishes, when you are ill you have just one wish” This unfortunate 47 year old, who is supposed to “Be positive”’ couldn’t care less who treats him, as long as he gets his health back.
Most of my medical career we have always assumed that patients are suffering from physical illnesses even contemplating it is ‘in the mind’ and patients want it to be physical and would be offended if it was implied that it was’ in the mind’ but now for some time as doctors we are following a biopsychosocial model and when we are assessing a patient we are taking into account all three aspects of a patients health and welfare.When I visited the nursing home a week or so ago I was asked to see 2 or the residents both unable to express themselves due to dementia. One Dorothy was quiet, not eating , withdrawn and it was thought that perhaps she had an infection or was going into a decline might have even had a small stroke. Had she had a stroke, or an infection or another physical problem she would she have to leave the home to be looked after elsewhere. Inevitably, the nurse in charge and myself pondered over physical reasons. Lets check their blood, start them on antibiotics ,get an ECG, call in the Palliative care nurses etc. Then we both said together could they be depressed and looking at it logically it was reasonable to consider that along with everything else. Indeed they were both started on antidepressant medication accordingly having examined possible physical and other mental problems and alerting staff to be attentive to their social needs within a few days they were both in the lounge chatting calmly sipping tea and enjoying a piece of cake! The nurse manager and myself just sat and watched them with sheer delight and the ambiance was now peaceful and calm. This wavs a demonstration of holistic care and it works!!
I feel we are making progress and I would love to have been able to tell Professor Andrej Marušič that progress is being made. I have seen a real difference in the way employers treat patients that are depressed and I hahve no difficulty in writing ‘anxiety and depression’ or ‘stress related illness’ as a cause of sickness absence. Also, most employers work actively with their employees to address issues that may be contributing or causing the problem and create good back to work plans. I now see patients who have had time off with mental illness and see them return to work and blossom handling their lives in a much healthier fashion.
In these cases we made the decision for the patient as they were lacking mental capacity:it is different when both the doctor and patient with insight and capacity are trying to make that diagnosis. It’s also a bit more than medication, cups of tea and cake but we have made some progress from secret hideaways and woven trays!
Yesterday, I read in the News the following proposed pilot scheme :-
Nurses are to go on patrol with four police forces across England to improve responses to mental health emergencies.
The pilot scheme aims to ensure fewer people with mental health problems are detained in the wrong environment, the government says.
Street triage teams are to be tested in the Derbyshire, Devon & Cornwall, North Yorkshire and Sussex force areas.
The patrols are part of an initiative funded by the Department of Health and backed by the Home Office.
Have you heard Ruby Wax’s take on this- yes another TED talk Stop the stigma of mental illness
I would like to be optimistic and feel that progress is being made in pdestigmatising Mental Health but I am sure there are cynics who are very guarded about that impression – lets watch this space!