Christmas and Depression

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It’s distinctly emptier in our office this week. I don’t think it’s necessarily the snow – although that hasn’t helped with some of the time-keeping – it’s just a very popular time for annual leave. Next week will be similarly if not more sparse. I quite like working around the Christmas period. I haven’t ever taken the days between Christmas and the New Year off work. I suppose in a warped kind of way, I enjoy the atmosphere and the pace at this time.  I like that other offices often close between Christmas and the New Year and sometimes they assume that our service is closed as well so the bureaucracy winds down a tiny bit and it can be a good time to catch up with paperwork.

A part of the skeleton service that covers these weeks, involves obviously picking up work that is allocated to those absent colleagues. And so it happened that I ended up visiting someone that is usually seen by one of the CPNs who is currently the other side of the country.

Although I wasn’t officially covering the ‘duty system’ of types that we have in place, everyone else was bogged under and I knew the man in question – having previously been allocated to him.

The circumstances of my de-allocation were, at the time, purely due to some geographic reconfiguring rather than a request either on his or my part so it seemed obvious that I should go as I knew him well.

They were difficult times for him.  We spoke about lots of things but one of main themes was the imminent arrival of Christmas and the pleasures and joy of Christmas past.

This is one of the themes of this time of year for me. Christmas is drummed into us as a ‘family’ time – a together time and a joyful time. I’m far from a grouch (well, ok, I can be at times) but the cultural expectations around Christmas can be exceedingly painful for those whose lives, families and circumstances don’t conform to these social norms.

The advertising and the programming that sloshes through the television networks, posters in the streets, supermarket layouts and just about every kind of media that we consume tells us that this is the time to celebrate family and friends. This is the time to spread joy (and consume to the infinite degree).

It is generally the time that not-conforming feels so difficult. And for this man, like many others I have seen over the years, Christmas, like birthdays and anniversaries, compounds more pleasant memories of Christmas’ past urging our collective and individual consciousness’s to compare and contrast those happier times with current, more difficult situations.

It doesn’t take a genius or a great deal of research evidence to have an understanding that this might trigger greater depression as those who don’t comply with this cultural norm can feel excluded from society in a way that may go unnoticed at other times of the year.

I didn’t have any particular words of wisdom for him except to acknowledge his concern, anxiety and stress. We talked through the day itself and what he would do – looked through the Christmas television schedule and even managed to find a few interesting films and programmes to highlight. It is a lonely time though. Sure, going out for a walk is good and healthy and would no doubt, help ones mental state but when there is black ice outside and you have a dodgy hip at the best of times, it isn’t necessarily a panacea.

It’s rare that I have the answers but I felt satisfied that I was a little less worried about him when I left than when I had arrived. Sometimes that’s the most I can ask for.

I said I’d go back again later in the week. I’m trying to fill this week and next up with the people who will be alone over the so-called festive period.

I’ve often said that one of the most precious things I take from my job is an understanding and gratitude for those things that I have in my own life. I never remember that more than this time of year.

Inside View

Just a quick post this morning as I had a little and completely non-serious accident involving my thumb  and a fast-closing door meeting an an uncomfortably fast speed and thus am finding typing more painful than usual..

But The Times prints a story by Edward Monkton detailing  his personal experience with depression. It’s a good piece and helpful to see the ‘male’ perspective. Hopefully more detailed coverage of the experiences of others will assist in the ‘destigmatising’ process.

The government also announced a programme of extending the IAPT (Improving Access to Psychological Therapies) programme freely available on the NHS to couples facing relationship difficulties.

The idea is that it will tackle potentially much more serious mental health difficulties by ‘nipping them in the bud’.

However the scheme is already short of practitioners and has not met targets set initially so the announcement might be a little overambitious.

Wow, I didn’t realist how much more time it took to type with 9 digits when you are accustomed to touch-typing..

The Price of Stigma

It has been said that the fight against the generally felt stigma about those with mental illnesses is a vain fight. Particularly, there was an article I alluded to about a  month ago that comes to mind.

And this was one of the points that came to mind when considering Robert Enke, the German goalkeeper who had been suffering with depression since 2003 who died by walking in front of a train on Tuesday and was, according to his widow, scared of his mental health difficulties becoming public as he felt he might lose his adopted daughter, Leila, after the death of their own child, Lara.

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I wonder how much the pressure of firstly being a public figure and well-known sportsman and secondly trying to keep hidden a depression that is obviously profound, added to the distress. Obviously enough for him to be driven to act.

His wife gave a deeply moving interview with the media which brought to light some of the pain that he and his family had been suffering and had been hiding from the glare of the media spotlight.

Teresa Enke said: “I tried to be there for him, said that football is not everything. There are many beautiful things in life. It is not hopeless. We had Lara, we have Leila.

“I always wanted to help him to get through it. He didn’t want it to come out because of fear. He was scared of losing Leila.

“It is the fear of what people will think when you have a child and the father suffers from depression. I always said to him that that is not a problem.”

Stigma, shame and misunderstanding of mental illness possibly are particularly burdensome in a ‘sporting’ environment where pressure is so intense and everything revolves around supreme conditioning of mind and body.

As the Times reports,  suicide is the highest cause of death for men under 45 in the UK. I wonder how much the gender perceptions that women are more likely to want to talk through things than men play in the role of treatments. Sometimes depression can be perceived as a ‘women’s disease’ and men may be  more likely to downplay the symptoms in general conversation until crisis level is reached.

So the general perceptions of mental illness and attitudes and assumptions about those who may suffer is not just thinking of terms of ‘the other’   – it is more than sympathy and empathy – it is about regarding seeking help and treatment for mental health in the same way that we might be guided to for physical health – and while I accept that it more likely to happen if you work in a supportive environment and have a strong network to support through difficulties, it might be more difficult in competitive environments that exist in the professional sporting circles. That makes it more painful, I would expect. Moving towards a more open discussion about mental illness has to be done for the sake of the societies and communities that we live in and work among.

In the meantime and for what it’s worth, I definitely have some positive thoughts towards Enke and his family and the pain that they have suffered and continue to.

Capacity to die

This story from the Telegraph today gave me food for thought. Kerrie Wooltorton, age 26, had a history of depression and decided that she wanted to die. She, according to the story, drank poison and then called an ambulance.

She had written a note to medical staff saying that she did not want her life to be saved  but wanted only to be made comfortable. The doctors treating her, concerned that they would face charges of assault if they took action against her directions and feeling that she had had capacity to make those decisions freely, treated her (or failed to) according to her wishes and she died.

These seems to stem from the introduction of these ‘living wills’ or advance directives under the Mental Capacity Act 2005.

It raises some interesting points though about capacity and how much one can respect a wish to die. How much does the illness that is depression impact on the ability to make a rational decision. I say this resonates with me because I have been asked to assess in situations where someone has made logical plans to die and there isn’t necessarily an obviously apparent mental illness. It is a distinction that is fine and sometimes goes against our gut instincts to battle for life at all costs.

And is the quality of that decision different when the circumstances and ages change? I don’t have an answer that sits comfortably with this myself – would we say that a person aged 94 whose partner of 60 years has died and who has no other family and deteriorating physical health when making a decision to die is in a different position to a 26 year old woman who has been told she can never have children?

It feels different, although logically it shouldn’t.

The intention of the Mental Capacity Act was not to allow this kind of circumstance so it will be interesting to see which way the GMC goes with the complaints against the doctors involved. I wonder though if they had taken a decision to intervene, how far an assault case against them by the complainant would have gone.

The Mental Capacity Act seems to make allowances for ‘life-saving’ decisions to override all other pre-decisions made. However one of the doctors at the hospital is quoted as saying

“I would’ve been breaking the law and I wasn’t worried about her suing me, but I think she would have asked, ‘What do I have to do to tell you what my wishes’

And, rightly, I think, the coroner did not blame the hospital for her death saying

“She had capacity to consent to treatment which, it is more likely than not, would have prevented her death. She refused such treatment in full knowledge of the consequences and died as a result.”

I suppose there is an issue of how much her depression clouded her judgement but it doesn’t necessarily indicate a lack of capacity in itself – perhaps, on a decision-specific case, it could be queried though.

It seems that the advanced decision was valid as long as Ms Wooltorton had capacity and thus any medical professionals that acted on it are protected by the law from any action taken. The law is clear that no advance decisions can be made requiring someone to assist with suicide but that was not the case in this situation – the advance decision revolved solely around a refusal of active treatment in a specific circumstance.

The only paragraph in the Code of Practice for the Mental Capacity Act which covers people who feel suicidal reads as follows

9.9 Healthcare professionals may have particular concerns about the capacity of someone with a history of suicide attempts or suicidal thoughts who has made an advance decision. It is important to remember that making an advance decision which, if followed, may result in death does not necessarily mean a person is or feels suicidal. Nor does it necessarily mean the person lacks capacity to make the advance decision. If the person is clearly suicidal, this may raise questions about their capacity to make an advance decision at the time they made it.

So looking at that paragraph, would it be possible to determine that because this advanced decision related specifically to a suicide attempt (I am guessing here and might not be correct) that it is possible to infer a lack of capacity because of those suicidal thoughts?

I think the only answer there is that this situation might ‘raise questions’ which in my mind seems to imply the decision could be made either way with protection from legal liability.

It just makes me glad I’m not a doctor in that situation..

I’d be interested to know what others think though.. because I really am unsure about this one.

Depression and Disclosure

My brain is slowly chugging back into something akin to functioning mode – after just a few days away it is always surprising how quickly it is possible to switch off.

Fortunately (or not, as the case may be) I don’t have much of an opportunity to stand still as my working week starts with a 9am Mental Health Act Assessment which was set up for my return.

So I’m charging my work phone in order to check the messages so that I’ll know if I’m still needed.

In the meantime there seem to be a gaggle of stories worthy of comment of which I can only touch on a couple which link in a way to depression, work and stigma.

A report in The Independent yesterday notes that

The blight of depression affecting hundreds of thousands of people across Britain is costing the nation’s ailing economy £8.6bn a year, £3bn more than a decade ago

Of course, there is no doubt about the debilitating nature of depression but I was curious as to why the costs relating to depression should have increased so sharply.

The research quoted by the Independent, allays this  figure  not to increased costs for treatment of depression through the price of medication or treatment on in-patient wards but rather the cost of lost labour due to the difficulty of managing return to work although all those factors would contribute to an increased national cost.

The ‘New Horizons’ strategy which is due to be published later in the year is said to have a stronger focus on ‘public mental health’ and broader preventative measures and until anything is published it is hard to comment or critique any potential plans.

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Interestingly though, Margaret Wallace, the Chief Executive of SANE is quoted as saying

There has been continued loss of psychiatric beds for inpatient care, the closure of day centres and impoverishment of occupational therapies. While the Government is planning to increase the availability of cognitive behavioural therapy for those with mild to moderate depression, we are aware from the many thousands of people who contact Sane that there will continue to be many with complex diagnoses who may not be included in such programmes, and who continue to struggle without the necessary psychological support

It’s an interesting and useful insight into the measures that have been promoted by the government towards shifting money to more CBT (Cognitive Behavioural Therapy) and preventative work at the milder end of the ‘depression’ scale – but the gap remains with those who are suffering more acutely.

The trouble is that working in the secondary health care services, it’s always difficult to know about the people who you don’t see or know about – although there is no doubt that between mild and severe, is a large group of people who may be unable to work but not able to access sufficient support.

It leads me on to another story that had been rumbling in the background relating to Christine Laird – the Chief Executive of Cheltenham Borough Council – who, in the words of The Guardian,  was taken to court by the council that

claimed Christine Laird fraudulently or negligently withheld details of a history of depressive illness when she became its managing director.

To sum up, Laird was employed in 2002, underwent significant stress at work including allegations of poor treatment at the hands of some in the  and left in 2005 requiring a period of treatment at a psychiatric hospital.

The key to the case revolved around a medical questionnaire that Laird had completed when she applied for the job in the first place.

To the question: "Do you normally enjoy good health?" she replied "Yes". To: "Do you have a mental impairment?" she replied "No".

The court was told Laird suffered "three episodes of depression with associated anxiety" between 1997 and 2001. But she saw it as "stress-related illness and not depression" linked to "non-specific, non-recurrent events".

I wonder how much work-related stress and depression are linked to be honest. I know a few people personally who  have what I would consider to have suffered from bouts of depression but have insisted that it is recorded as work-related stress on any documentation for work purposes. I suppose the hope that the stigma related to ‘depression’ is still too high but this case doesn’t really help matters. 

The Court highlighted the ridiculous nature of those specific questions – ‘normally enjoying good health’ can be interpreted so broadly as to be largely insignificant. It is also a completely value-based judgement. As for asking about a mental impairment – again, is it asking for a legal definition in accordance with Section One of the Mental Health Act (1983 as amended 2007) or is it asking for an ‘average man on the street’ definition which would probably stigmatise ‘mental impairment’ to a much higher degree.

Laird won her case but was instructed to pay partial costs amounting to £190, 000 but leaving the council with a bill for £1.6 million.

Of course, it is always important to be truthful on medical questionnaires but it is possible to see where the discrimination can fall.

It is hard enough for work to be found at times without giving employers more reasons to refuse to employ someone with a history of mental ill-health. The questions were poorly structured and perhaps a more straightforward way of asking where no doubt could have incurred should be and probably is now, written into the application forms but I wonder how much influence they would have on the appointment of a perfect potential employee who has, in the past, suffered from a depressive episode.

Quite rightly, campaigning groups have welcomed the court ruling against Cheltenham Borough Council but I wonder how many councils will be more wary to employ someone with a similar background in the future – maybe reports from medical professionals will be relied on more strongly in these circumstances and a type of ‘well note’ will emerge where it is possible to explain what can be done rather than where problems lie although to be honest, that is a little fanciful.

Would an employer make this effort for a potential employee when there is another potential employee without a similar medical history? Realistically it is unlikely and that is a cause for sadness.

The ease at glossing over any past problems can be all too tempting in a culture that judges health and competence so narrowly.

Tips for Good Mental Health

The Mental Health Social Worker pointed me to a campaign being run in the US by Mental Health America to ‘equip people with tools to deal with stressful times’.

The campaign is called ‘Live your Life Well’ and has a nicely designed webpage with some surveys, tips and ‘success stories’.


I took the ‘stress screener’ myself and came out it told me ‘I could be doing better’. I guess no surprises there because I do have a fair bit going on at the moment!

They explain that

The Live Your Life WellSM program details the 10 tools and many of their benefits, including:

  • Connect with Others. Research suggests that people who feel connected are happier and healthier – and may even live longer.
  • Stay Positive. People who regularly focus on the positive in their lives are less upset by painful memories.
  • Get Physically Active. Exercise relieves tense muscles, improves mood and sleep, and increases energy and strength.
  • Help Others. Research suggests that those who consistently help other people experience less depression, greater calm and fewer pains.
  • Get Enough Rest. People who don’t get enough sleep face a number of possible health risks, including weight gain, decreased memory, impaired driving and heart problems.
  • Create Joy and Satisfaction. Positive emotions can boost a person’s ability to bounce back from stress.
  • Eat Well. Eating healthy food and regular meals can increase energy, lower the risk of developing certain diseases and influence mood.
  • Take Care of Your Spirit. People who have strong spiritual lives may be healthier and live longer. Spirituality seems to cut the stress that can contribute to disease.
  • Deal Better with Hard Times. People who get support, problem-solve or focus on the positives in their lives are likely to handle tough times better.
  • Get Professional Help if You Need It. If the problems in life are stopping a person from functioning well or feeling good, professional help can make a big difference.
  • The site goes through each of these points and explains some pretty substantial and extensive tips so it’s well worth going to the site and having a nose around!