The Trouble with Doctors: Part One - Getting the Buggers to Listen

A snazzy new report courtesy of the good people of the London School of Economics hit the headlines recently, suggesting that whilst mental illness is now thought to account for half of all illness in the UK, only a quarter of those who suffer receive any treatment. Well, jolly good and about time. The bit that really interested me, however, was barely touched upon in the press bar a few sweeping statements about 'doctors not taking patients seriously'. It transpires that GPs, in the vast majority, do no mental health rotation during their training whatsoever. This despite the fact that they are – in the words of the report – the 'ongoing physicians for nearly all mentally ill people.' This is particularly striking as it reflects one of the principal issues I and many of my peers have continually come up against, and which is evidently still widespread. The ignorance of many GPs when faced with a patient suffering with a mental health condition is a huge barrier to receiving a correct diagnosis, let alone correct treatment, and can be especially confusing and demoralising if you are seeking help for the first time and/or when you are relatively young. As a now-hardened mental health service user, accustomed to navigating the murky waters of the NHS in pursuit of a treatment that actually works, I thought it might be useful to throw in my two pennorth on the subject. The experience of seeking help will be different for everyone, so I don't wish to sound prescriptive (a pun! A doctor pun! Ahahahaa, ugh.) but there are a few things I've learned along the way that I wish I had known ten years ago, so I thought I'd set them down in the hope that someone else might find them helpful too.

Chances are that when you were very young, diagnoses were a piece of cake. You're ill: you get taken to the GP. They know all about ill. They'll give you some of that banana flavoured stuff and you've probably got a half-decent shot at some Calpol too, brilliant, yum. Better now! As you get a bit older, you realise that although it is not unknown for your GP to misdiagnose a physical complaint, the onus is on them to look at what's wrong and tell you how to fix it, perhaps referring you on to a specialist in the process. It therefore comes as something of a shock to realise that mental diagnoses operate in the opposite way.  This fact alone is, I believe, one of the least-understood facts about the struggle to get help and treatment.  If someone has never received treatment for anything other than a physical ailment, it is understandable that they would have the same view of doctors as we did as children: all you have to do is turn up with your symptoms and they will fix them. For example, when I turned up at my surgery with an achy back and trouble weeing, I had no idea that it was a kidney infection, or that I would need to see this doctor in that hospital and take this drug to get well.  I just said 'I've got an achy back and trouble weeing, any chance you could sort it out?'  In stark contrast, the entire mental health diagnostic process relies on you, the patient, telling the doctor exactly what is wrong and exactly what you need, often writing your letter of referral to the appropriate specialist yourself. Say this is the first time you have ever experienced symptoms of depression, or psychosis, or mania: it is very unlikely that you will have the knowledge of they metal health system, or even the vocabulary, to articulate this.  There are also two further issues specific to bipolar which I have outlined below:

1. Attempting a visit to the doctor in the first place when in the throes of either depression or mania is tricksy to say the least. For a start, when manic, it is highly unlikely that you will even recognise that you are ill and in need of intervention. You will probably be too busy bouncing around in the manner of a sleep-deprived, inhibition-haemmoraging pinball, throwing out all your clothes and furniture and declaring that you have decided to live forevermore without the hindrance of material possessions (ahem). In the opposite state, meanwhile, you will probably be rocking in a corner under a duvet and unable to leave the house, let alone get dressed and be in a waiting room with Other People. In the short windows of clarity between this state and depression, chances are that you're so ashamed, terrified and relieved it's over you decide to file the episode in the box marked 'This Never Happened' and carry on.

2. So help-seeking is generally limited to times of depression. This brings with it its own set of barriers, and generally if you do summon up the courage to make it down to the GP (no mean feat), you run into murky waters again. In some cases, the terror of going out in public may have spurred you on to discard the Holey Leggings of Depression (HLD) and reach for actual clothes, makeup and sunglasses the size of Russia. In practice, this often leads to the irritatingly common objection that 'you don't look depressed'. Even when in full possession of HLD, weepy and horribly anxious, many GPs will seem suspicious of the fact that you have come at all, working on the logic that if you are un-depressed enough to have actually left the house then you are clearly not in need of help. 


3. There is probably a fairly sizeable part of you that doesn't actually want to believe that something is wrong. You've heard stories about this kind of thing but you'd really rather it didn't apply to you, even if it has being going on for years: after all, being bipolar means you must be Proper Mental and you're not sure you're ready to face up to that. In the case of my peers and I, you're also British. This means that when they give you one of those godawful questionnaires, you know the ones: 'how depressed are you from 1 – 10, 1 being fine and dandy and 10 being suicidal' even if you are in fact a 9, you are hardwired to reject melodrama and most importantly, not to want to be any trouble to the nice doctor. For those not familiar with our peculiar Limey ways, this cartoon should illustrate it perfectly:

In reality, of course, any drowning metaphors are liable to be much more Stevie Smith in nature. On a slight tangent, Smith managed to pack what is for me the truest and most haunting evocation of depression into twelve lines:

Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning.

But I digress. The merry dance illustrated above is one that many sufferers of mental health conditions lead with their GPs , leading them to be 'bounced back' from accessing the treatment they really need as they never even get to the referral stage. At 'best' they might be fobbed off with some Cytalopram (for the uninitiated this is the cheapest available anti-depressant on the market and the go-to drug for the symptoms of anxiety and mild depression at GP stage. Of course, these symptoms are often only a fraction of a wider condition and it is actively dangerous to prescribe it to those with bipolar as it can induce a manic phase: in my case Cytalopram had no effect whatsoever, so my GP bumped me up to Fluoxetine – Prozac, basically – which, being a stronger 'upper', sent me spiralling off into hypomania.).   My October 2011 trip to the GP shows how rife this potentially very damaging course of action is: even with my entire mental health history - suicide attempts, crisis team interventions, manic episodes and all - literally at his fingertips, my GP nodded at me for three minutes as I faltered through my symptoms before interrupting me to attempt a Cytalopram prescription rather than look it over. 

Essentially, there is a huge Catch 22 at the heart of the system: a correct diagnosis is to a sufferer what an Equity Card is to an actor - you can't get one until you're deemed ill enough, and when you are ill enough you're too ill to seek one. This can go on for years and lead to the situation we are now in, i.e. 75% of us going without treatment for some pretty disabling conditions, unless the cycle is broken.  Hopefully GPs will indeed be required to undergo mental health training at some point, but the worlds of academia and politics move slowly, and policies such as these take years to show any real results. So until then, it's down to us crazies to make sure we get the treatment we need. As a young adult knocked for six by the onset of my condition, I really was pretty ill-equipped for this task. Over the years, however, and with a bit of help from the most unlikely of places, I discovered a few things that helped me through the barriers above and got me the diagnosis and treatment I needed: I'm putting them into some kind of coherent, legible form for my next post, so watch this space!