mental health

Words are important

This is a guest blog written by the wonderful Cathryn Brown (@cathrynjbrown). Not only is Cathryn is an amazing community pharmacist, she's also involved in teaching pharmacy students at the University of Lancashire. She's smart, brave, honest, and a great friend. It's a pleasure to host her writings here. Hope you enjoy:

We were tidying up the office at home again the other day when I happened across an old Medicines, Ethics and Practice Guide. Flipping through the index, “Addicts” struck me as odd. There was no “see also: Drug misuse, drug misusers, or “people who misuse drugs and other substances.” Instead, a whole, diverse, nebulous group of people and stories, from all sorts of backgrounds, we summed up with one stark word: Addicts.

This got me thinking about how the use of language within pharmacy has changed since I qualified, and how we can make even more positive changes.

I've spent a lot of time over the past few years thinking about how I refer to people and patients. I've carefully avoided labelling people as “asthmatics” or “Epileptics”, preferring “people with asthma” etc instead. I assumed that this people-first language would apply across all groups. But my assumptions were challenged when I happened across an article which suggested that the opposite may be for the best for some autistic people. It made me realise that a blanket approach doesn't work, and that it is important to ask the patient themselves how they would like to be described. (As an aside, I found that article through the Emergency Chat app, which is amazingly helpful for anyone who sometimes feels overwhelmed.)

When I first started teaching on the UCLan MPharm course, we used to ask our students to identify “what a patient might be suffering from” in dispensing classes. Just that one little question presents so many problems. Labelling people as patients, assuming that they are suffering, that their illness defines them. Nowadays, we ask “what might the medicine on this prescription be used to treat?”. My hope is, that by changing the words, we can also change our students' perception about the people they will go on to look after. I'm hoping that they'll start to see people less as suffering patients, and more as fellow people with individual needs.

I also wonder sometimes whether our approach as a profession to patient and public involvement creates a barrier between them and us. Does the way we act cause our students to think of patients as exhibits? “These are the patients we’ve brought you to meet with today, none of the rest of us are patients, oh no…” And do these barriers affect our students, do they see patients as “other” and think that they themselves should never be unwell?

When I refer to my own mental health, I will refer to myself as “bonkers” or “crazy in the head”. That's okay for me to say about myself, but I would hate to think that a health professional would refer to me like that. I know that’s odd, and maybe if we discussed it, then I would let them join in with me, but I would hate to see a consultant’s letter that went to my GP saying “Thank you for referring this bonkers lady to me”. I think it’s easier for me to think about myself as a person with depression, rather than a depressive.

When a friend of mine visited his GP for depression, the doctor described him as “feeling a bit down”. Now, perhaps his Doctor was too scared to use the “D” word. Perhaps he thought he would be resigning the patient to a life of darkness and gloom. But instead, all it did was dismiss the hell he was going through, and on a practical level it also didn't look great on his sick note.

I guess I'd like asking how a person would like to be described to become as ubiquitous a question as “do you take any other medicines?”. Whether someone is gay, trans*, black, a person of colour, a person of faith, Christian, a diabetic, a person living with epilepsy or all of the above, we should be able to ask them who they think they are and respond appropriately. We also need to start being truly patient centred, and let our patients lead the conversations where they want them to go, and if that’s hard to begin with – let’s start a conversation within the profession and see where it goes. Don’t forget there’s lots of help out there, and lots of ways to improve the way we communicate with patients, the public, and other health professionals.


 

Cathryn xx

 

Thank you, Kate

I’ve still not quite been able to come up with an adequate phrase to describe having social anxiety. Sometimes the old clichés are the best, and so I go with the duck- calmly floating above the water, but paddling like mad beneath.

I can be so good at hiding the furious paddling that even my closest friends have doubts that it exists. But if I were to invite you under the water, you’d see constant, frantic movement. You'd experience my physiological reactions going mad for no reason, reacting to the unforeseen horror of merely having a pleasant conversation with someone.  You'd be hit with tidal waves of thoughts, rushing over and over in a jumble. You'd hear that nasty, mean little internal monologue of mine telling you what other people are thinking (although they are probably not), how stupid you look (although you probably don’t), how boring you are (although you’re probably not). Then you'd feel the confusion and shame of cutting all these thoughts up with a knife of rationality. You'd see how that knife then turns on yourself because you just can't keep up with all of the mean thoughts, and you feel so weak for letting them take over you. 

Eventually, this state becomes your norm. It becomes background noise, and the peaks of it get even higher in moments where you feel threatened. Our metaphorical duck spends his days thrashing relentlessly under the water every second of everyday, and the tiniest of waves sends him into free-fall. Of course, Kate, you probably know how this feels already to a degree: it is stage fright that kept you away from touring for so long.

Moments of true calm are few and far between when you reach this point. When they do occur, you start worrying about them- internal silence starts to feel alien. Constant anxiety becomes your default position, and the otherworldliness of calm feels dangerous somehow.

That’s how I was this time last year. Things have now improved somewhat- thanks to the CBT, thanks to those around me, and in no small part thanks to my own stubbornness. I’m now at a point where the peaks are still there, but they’re not quite as insurmountable. My default position is no longer fight or flight, and I'm more able to quell the thought onslaught. True moments of stillness are, however, still relatively rare.

I’m never usually able to lose myself in a moment, as this stupid anxiety makes me constantly self-aware. The other night though, I experienced several blissful hours of basically forgetting that I existed. All thanks to you, Kate.

You’ve always been able to lift me out of terrible moods. One of the joys of living on my own is that I can get home, and crank up your music as loud as I like. I can sing, I can let go, and I can dance about with the cat without anyone laughing at me. I often find that you’re able to lift me out of an approaching mist. You've been the manufacturer of one of my most reliable coping mechanisms.

I saw Before The Dawn the other night. I was scared of going in alone, but within minutes I was chatting away with other people. We couldn't believe our luck. I've honestly never seen so many utterly excited people in one place before.

I know that everyone else has loved it. I've read the reviews, and I've seen the tweets. I expected it to be good, but what I didn't expect was to be completely enraptured- with you, with the story of a woman in the water, of a dawning day, with the detail. I had expected a couple of tears, perhaps a couple of whoops if I was feeling brave. What I hadn't expected was to realise that I was so taken in by it all that I was no longer self aware. I sort of came to, whilst dancing madly away to Cloudbusting, and realised that the waves had stopped for me for 3.5 hours. Here I was, on my own, in a situation that would usually scare me, completely and utterly swept up in the world of your making.

Thank you, Kate. Thank you for that gift.

Hxxx

Making it up as I go along

What better way to spend a Sunday than an eight-hour long improvised comedy workshop?

Now, I know that there are a lot of people who would jump for joy at the suggestion. I also know that I am really not one of them. I can be pretty reserved, and of course there is my social anxiety to factor in.

My good friend Shandy suggested it. She had been to similar sessions before, and thought it would be good for me. I trust her judgement, so I signed us up for it before I had a chance to regret it. And what a day it turned out to be.

Social anxiety is an odd creature. Recently, I’ve been learning about the main thing that makes it particularly odd- self-focus. It’s a weird dichotomy- the same diagnosis that ruins your confidence and makes you want to disappear also manages to persuade you that you are the entire centre of everything that exists. It simultaneously makes you completely hate yourself, and become an insufferable narcissist in your own head.

I think I’m really pretty good at challenging myself. I force myself into social situations that I don’t want to be in on a fairly regular basis. More importantly, I force myself to social situations that I really do want to be in but am completely effing terrified of. I’ll say yes to parties in London where I basically know no-one at all. I’ll arrange and go to tweet ups. I go to lots of bake clubs, and I’m out of the house on most evenings of the week, seeing various different friends and going to all sorts of different events. I’ll merrily agree to SITP talks here and there. Yet no matter how much I push myself to do things, and no matter how well these things turn out, the fear remains the same.

I know the theory. I know that anxiety is supposed to lessen the more you are in a situation, and the more you are exposed to that situation. Yet mine.. doesn’t. I know that I have been in a similar situation before, and it was absolutely fine, yet I still end up a gibbering wreck each and every time. It’s the self-focus that does that. With my social anxiety, its not the other people who are scary, it’s myself, and that can be really difficult to get around. Its this aspect that makes it refractory to exposure therapy.

One of the most exhausting parts of it is self-censoring. I constantly dismiss my own thoughts as not being worthy enough of being said out loud. I’m scared of sounding stupid, boring, of being judged, of not being interested enough. Instead of allowing the person I am speaking to make those judgements, I do it myself, and discard things that I want to say before they leave my mouth.

These things do not make me an ideal person to perform improvised comedy. I am the person who will eventually come up with a killer comedic line about six hours after the opportunity to use it has gone, then will proceed to beat myself up about it for days, weeks, sometimes months afterwards. I have never performed any sort of drama or anything like that, and the opportunities for creativity in my adult life have been pretty limited.

Bev Fox, one of the wonderful teachers at the Improvisation Foundation and co-founder of The Suggestibles

Bev Fox, one of the wonderful teachers at the Improvisation Foundation and co-founder of The Suggestibles


So, you’re asking, how did it go?

Pretty well I think. I was completely exhausted and nigh-on broken afterwards, but it felt like one of the most productive things I have done so far to subdue my social anxiety monster.

The group of people attending the workshop were warm, welcoming, and kind. Bev, who was leading it, was marvellous. I didn’t feel pushed into anything at any time, though I spent the entire day not just outside my comfort zone but pretty much in another continent to it.

Luckily, my ultimate goal for the workshop fits in quite nicely with one of the fundamental basics of improv- turning off your self-filtering. I didn’t achieve it fully- I still felt pretty shy and reserved by the end of the workshop- but I did take some big steps towards it. I found myself taking part in the games much more enthusiastically than I had expected, and even managed to be funny on the odd occasion.

One of the most beneficial parts was towards the start. As part of a game, one of the guys asked who was nervous about coming today. As dictated by the game, this then led to a mass vacating of seats, followed by a scramble for another one. There followed “who has ever had stage fright”- again, mass movement.

When I found myself stuck in the middle of the circle, I went with the emotionally deep and existentially important question of “Who gets excited when they are about to eat spaghetti hoops?”

There followed a pretty amazing discussion with everyone in the group about their experiences of stage fright and nervousness. They were all so honest, and although I am constantly told that I’m not the only one, it was still good to see that perfectly well-functioning adults still suffer from the stomach-butterflies and brain-freezes just as much as I do.

There were games involving eye contact, which is something that I can sometimes struggle with. There was a really interesting part where you had to walk around in either a high status or a low status mode. It occurred to me as I was doing it that the way I naturally walk, giggle, play with my hair, hunch down etc was pretty much a text book version of the low status walk, whereas high status mode, striding around and holding eye contact with people, I felt really weird and unnatural.

So much of what we covered fits in with what I am covering in therapy. Even the terminology is the same. There was one task where we walked around the room and had to quickly name all the objects. Then we slowed down, and asked more questions about each object in turn, eventually getting to a point where we explored our feelings as well. It reminded me of mindfulness therapy- it was all about being in the moment, rather than rehearsing what might happen in the future or dwelling on what you said five minutes ago.

So it basically felt like an 8 hour long group CBT, mindfulness, and counselling session with a whole load of humour thrown in for good measure. Honestly, I have seen Paul Merton’s Improv Chums three times now and there were moments in this workshop which were just as funny.

I’m not convinced that I am destined for a comedy career, but I have taken a whole load of positivity from that one day, and I’m really pleased and proud of myself for doing it.

You can find out more about the workshops at www.thesuggestibles.com. Bev and Ian's improv group, The Suggestibles, do regular gigs in Newcastle upon Tyne so keep an eye out for a performance if you are in the area- they're a right good laugh, and a blummin' lovely people too.

Hxxx 

The Ultimate Christmas album for the Existentially Wounded

"It's why, it's why we hang lights so high
and gaze at the glow of silver birches in the snow
Because of the dark, we see the beauty in the spark
We must be alright  if we could make up Christmas night"
-Tracey Thorn, Joy. 


Now, I'll admit that at this time of year, I can get rather annoying.

I love Christmas, I really do. I'm often to be found wearing antlers and tinsel. I put my decorations up at the first opportunity humanely possible, and start on the mince pies in September. This year, I excitedly bought myself a Lego advent calendar, despite the incredulity of the guy behind the counter in the shop. I also have snowman hoodie which yes, I shall wear out in public.

As a child-free, cynical, atheist adult, it might seem like this is a hard time of year to enjoy. And, to be honest, you're probably right. It would be a whole lot easier to throw in the towel and grumble about how commercial it all is, and how I just wish it was over and done with and everything can go back to normal. But I refuse to give into this, and put quite a bit of effort into maintaining my child-like delight at the festive season.

Obviously, its nothing to do with god. And don't get me wrong, I love the presents too (dear parents, if you are reading this, please do take note that I shall never be too old for Lego). But my desperation to enjoy this time of year runs somehow deeper than all that. I don't need to link it to religion, nor do I need to experience it through a child or partner. Christmas reminds me of my own, hard-won personality.

For me, it is about traditions. And these traditions, as they shift and change slightly each year, somehow reinforce my own self to me. Back in what now seems like a lifetime ago, my ex-husband and I took joy in forming new traditions together at this time of year. It was a way of reinforcing ourselves as a couple unit, of forging our own little family ways. Small things, like buying a new special decoration for the tree each year, came to mean a lot to us.

When my marriage broke down on Boxing Day 2010, I had to start again. Everything I had known up until that point fell apart, and my hopes and dreams, which I had been carrying like a shield all my life, shattered in a matter of hours. I had to begin again from scratch, and it was often the smallest of things that seemed to make all the difference to me.

The next year, my new, empty Christmas tree seemed somehow symbolic of how I had to start to collect some traditions of my very own. These traditions would belong to me, and me alone. I started picking up little decorations here and there, and now I have a rather lovely collection of bits and pieces to adorn my home with. And I've done the same with traditions: baking certain things at certain times, (including my beloved Christmas pie), drinking startlingly strong fruit wine in a particular pub on Christmas Eve with my friends, seeing Rare Exports at the cinema, taking part in a gingerbread contest, and many others. Some of us even go so far as to throw ourselves into the freezing North Sea on Boxing Day which not only washes away any vestiges of hangover cobwebs, but also distracts me from the awfully sad memories I would otherwise be thinking about.

Winter is a dark and often terrifying time for many of us. Dark mornings and dark nights make it easy for the sadness and emptiness to creep in. Getting home to a cold, dark, empty, one-bedroomed flat can start to feel like a failure. But then I pop on the tree lights, and I have something to focus on, some little pinpricks of hope that, in the end, the world is full of good people, and I will be able to spend some quality time with those who I love most- my friends and my family. And I will have an excuse to fill my flat with sparkly things, and wear glitter eyeliner.

Christmas is, to me, an acknowledgement that times will be dark and hard ahead, but that I will get through those times, with the help of those around me. It reminds me of how far I've come, and how proud I am of myself. It reminds me of all the good I have found in the world, of all the little bits of help I have gotten from the most unexpected sources, of all the new people I have met and the pride I have in my oldest friendships. If humankind has the presence of mind to plonk a huge celebration in the middle of the darkest season (even if they have done so on the pretence of a god I don't believe in), then that's fine by me, and I shall do my damnedest to make sure I embrace it with gusto.

I love the standard Christmas songs. I'll dance about to a bit of Slade with the best of them. But the saccharine jingle bells of most of the tunes you'll find on Now Thats What I Call The Ultimate Best Ever Christmas Tunes In World... Vol 3 don't seem to quite catch the nuances of the festive season for me. I've only come across a few songs which do, and I have collected them here for your auditory pleasure. I'm keen to know of more, so if you have any you would like to recommend, please do let me know, either in the comments, by email, or by tweeting me (@SparkleWildfire). What I would like to do is create a playlist of genuinely good, beautiful songs that evoke both the joy and the darkness of Christmas.

Joy by Tracey Thorn.
Tracey Thorn's (of Everything But The Girl fame) Christmas album Tinsel and Lights, which she released last year, was a total revelation to me. Its a gorgeous, calming album which hits just the right pitch of melancholy and joy for this time of year. I think this song says it all really.

Snowglobe by Dean Owens.
I saw Dean play at the Tyneside Cinema just before that fateful christmas of 2010. This is a lovely, sad little song about having depression or mental health issues over Christmas time. It serves as a reminder that mental health issues don't instantaneously resolve over the festive period, and that this time of enforced happiness can be extremely hard for many.

December Will Be Magic Again by Kate Bush
You may already know by now that I absolutely adore Kate Bush. Even the title of this song is poignant. This song has the same theme to me as Joy: its about using tradition to cover the darkness of the winter.

Winter by John Smith
This is simply the best, most beautiful song about the baby Jesus that I have ever heard. I first saw John play as support for John Martyn, and I have since seen him live several times and been reduced to tears by him. I absolutely adore his voice. I don't mind that this is a song about the nativity: to me it is a song about a story, and I just love how plaintively he sings that "I was there" line.

A Christmas Fable by The Selecter
I love a bit of ska. I've spent a full day agonising over which song to go for from this single. Then it occurs to me: its a double A-side, so I can legitimately have both. The songs are supposed to symbolise the light and dark sides of christmas, so they're pretty perfect for my playlist. Skank 'Til Christmas is all about letting your hair down when everything else in life has gone to shit (I love the references to the current financial situation), whilst a Christmas Fable is about a rather distressing family breakdown on Christmas day.

River by Madeleine Peyroux & K.D. Lang
A cover of this track also appears on the aforementioned Tinsel and Lights album. Thanks to the ever marvellous Ian Robinson (@eyeswideshut75) for suggesting it.

White Wine in the Sun by Tim Minchin
Thanks to Steve Haigh for reminding me of this. There's so much truth and humour in this gorgeous little tune, and it really sums up a good old family Christmas.

The Atheist Christmas Carol by Vienna Teng
This is just gorgeous.Thanks to Jackie (@Jackpot73- one of those new people so I am so thankful for having met this year) for

Silent Night/ 7 O'clock News by Simon and Garfunkel
Pretty self explanatory.

Love is All We've Got by Paul Fisher
I have loved Paul's music since the first time I saw him at a folk night when I was still underage drinking. I can remember being completely astounded by the noises that were coming out of this guy on the tiny stage upstairs in the Egypt Cottage pub. Turns out he has made a beautiful, gorgeous, poignant Christmas song this year which I will be listening to over and over.

Candle Song 3 by Mojave 3.

Tar Barrel in Dale by Rachel Unthank and the Winterset
Another one suggested by the lovely Jackie. A New Year's song about a Northumberland tradition. This year has been so cruel to so many of my friends and people I know, so I listen to this hoping that the new one brings those who I love some luck.

Hxxx

P.S. Here's my Sparkle Wildfire Top Festive Tip for the year: mulled wine liquid soap might seem like a good idea in the shop, but its really not. You end up smelling like a wino.

So this one's for the friends

"So this one's for the friends
If not so for themselves
And this new life's directing us
Remind us in a town
You made us feel at home
We broke our backs on floors of stone
But I'd rather wake there any day
Than wake up here alone"
-The Chronicles of a Bohemian Teenager, Get Cape. Wear Cape. Fly

Today is World Mental Health Day. although this year the focus is on older people, I am in a nazel-gazing, emotional kind of a mood, and have found myself thinking a lot about my friends.

There are two aspects to this. Firstly, I know a lot of people with varying degrees of mental health problems. In fact, I would say that I probably know more people with some sort of mental health problem than those who don't. I find myself thinking of how much I wish I could change how they feel, draw out some of their pain or anxiety or depression for them and lighten their lives a little bit. I think of how wonderful and individual they are, and how amazingly brave and strong they are. The reasons for their problems are as diverse as they are- if there are reasons. I think of how badly they are treated by others, of the stereotypes that are applied to them, and want to shout from the rooftops about how wonderful all of these people are.

The other aspect is how my friends treat me. Its not big, sentimental gestures, nor is it anything to do with the length of time I have known someone. Its the bunch of flowers and bottle of wine that arrived in the post a few days after my marriage broke down. Its lending me an oil-filled radiator when the heating in my flat has broken and fixing my DVD player. Its letting me sit on the sofa in their house in silence because I don't feel like speaking but I don't want to be on my own. Its the rushing round to my flat to remove a spider because I'm too scared to do it myself. Its the constant sarcasm and good-natured banter at work. Its the tweeps who always cheer me up and check how I am when I am in a self-pitying mood, and the patient soothing of my drunken self via WhatsApp at 3am. Its the afternoons of laughter and the knowledge that, if I need to cry hysterically I could, and no one would think any worse of me. Its the quiet, unthinking hug when I am struggling to smile during someone's wedding, or the amazing poem written for my birthday.

These are the sort of things that I have built into my little emotional fortress. There are people out there who can't understand where I derive meaning from in life- I have no god, no children and no husband after all. But all of these little gestures, and all of these wonderful people form the basis of my meaning. Without them, I really don't know where I would be, but I'm pretty sure it would be an awfully dark place. This, for me, is the foundation of my humanism.

I don't tell my friends this kind of thing enough, but I'm so thankful and lucky to have them.

Hxxx

CBT: The first session

So last Friday I began a course of Cognitive Behavioural Therapy sessions, to help me deal with the social anxiety that I talked about in a previous blog post. 

I don't really expect to learn anything new from the course, to be honest. I'm pretty good at accepting, rationalising and challenging myself to face my fears, but what I'm finding more and more lately is that I reach breaking point more easily. I've always been able to keep the anxiety in check and have always just thought that I am shy, but various things- the bout of psoriasis I had, being single again, stuff happening with my friends etc has meant that I've been much less able to control it of late. So much of my brain is taken up by being anxious that there is little left over for anything else. My organization skills, which were poor at best anyway, are completely shot, and even the most basic problems at work leave me feeling totally overwhelmed. 

My friends are my world, and its hard for me to describe how much I love them and how much I love spending time with them. Since my divorce, when they rallied round and were totally amazing, I have made sure that they are the centre of everything I do. But this thing is getting in the way of that, and its making me miserable as a consequence. 

The best way I can think to describe it is like an energy bar in a computer game, but instead of life force, mine is a social bar. It gradually decreases, then eventually I run out and require recharging. In more stressful situations (like going to parties or meetings where I know no-one, or-horror of all horrors- dating, for example) it runs out a lot quicker than if I am spending time with by best friends. The recharging usually involves lying on my sofa watching old episodes of Dexter and not talking to anyone, although lately I've noticed a much more scary emptiness creeping in, and I can find myself lying on my bed staring at the ceiling with no thoughts or feelings or emotions at all. These hours are terrifying and are something that has never really happened to me before. 

So, having seen my GP, I got referred onto this group CBT course. The irony of being on a group course for social anxiety has not escaped me, and of course I found myself worrying about all aspects of the course. How will I get the time off work? Will I find the place? (this sort of anxiety stems from a fear of looking stupid if I don't know where I'm going) Will I have to make awkward small talk with the other people on the course? Will they think that my reasons for going are stupid? What if I have to speak about my emotions to them? etc etc etc. One of my biggest worries is whether I was bad enough to justify being on the course. The fact that I have spent several days if not weeks worrying about whether I am anxious enough to justify it has also tickled my sense of irony.

Anyway, I managed to find the place, and staggered in red-faced, dry mouthed, sweaty and with my heart beating (irregularly) out of my chest. The other folk in the waiting room looked serene and at home. The course started late due to technical problems, which rather than giving me time to calm down made me even worse.

Once I was in there, I felt somewhat better. The initial session is all about the causes and symptoms of anxiety and how it can manifest in different people, so we didn't really cover any CBT techniques. I was very pleased to hear the trainers talking about the evidence base for CBT, and they explained the pros and cons and process of what we would be doing over the next few weeks. I was starting to feel quite settled. It was nothing I didn't know already, of course, but its always good to know that there are other people suffering from the same thing as you.

Then came the two slides on medication. The slides just covered some really general points which I agreed with, but one of the women there talked about how she didn't want to try any medication as she was so worried about side effects. The trainers said they knew very little about specific medicines, and she should speak to her GP or pharmacist. Well, I tried to keep my mouth shut, I really did, but I couldn't help myself. I thought about just trying to make out like I was someone who knew a bit about medicines, but I could tell that this woman was really worried. She was wanting to try an antidepressant, and thought it could benefit her in the short term, but she was really concerned that they could amplify her anxiety permanently. I wanted to help and reassure her, and before I knew it, I could hear myself saying "I'm a pharmacist..." I explained a bit about how the drugs work, what sort of side effects could happen, and what the sort of terms used to describe how common a side effect is actually mean. She, the other attendees, and the trainers all listened attentively and said how great it was to have it all explained in context rather than to just look at a really long list of scary words on a patient information leaflet.

I left feeling happy that I had shared some of my expertise, but sort of worried about the rest of the course. I fully expect next week to walk in and be asked various different questions about the medicines people are taking. You get used to this happening when you tell people that you're a pharmacist. The problem comes from the fact that now I feel like I need to be "on", and in professional mode, when what I actually sort of want is a place that I can switch off my forcefield and fall apart, so I can put myself back together in a more rational, calmer way.

Hxxx  

The difference of a diagnosis

I have Social Anxiety Disorder. Its all official and everything, having just come back from the doctors' surgery, where all of my rehearsed, clear and concise explanations of how I have been feeling lately descended into some soggy, disordered sentences and lots of apologies. 

What, precisely does this mean? It means I feel weird, and I don't quite know what to do with myself. It's interesting, the effect of having a label. I imagine this particular effect is broadly similar for many diagnoses, to lesser and greater degrees. It's a waveform: you just start relaxing into it, and feeling relived by it, then you think 'oh shit, there's something wrong with me!', then it all starts again.

There is a satisfying feeling of loose ends being tied up. It's the explanatory scene at the end of every episode of Poirot, the metaphorical jigsaw pieces being placed. You think of all the things that you've been feeling over the years and you squidge all of your individual experiences into the shape of the words on the leaflet you've been given.

But its weirdly hard to relinquish the long-held belief that actually you're just quite shit at life, that its your own fault and you're just not trying hard enough, to something external like an Actual Real Life Diagnosis. Bits of what I thought were my personality are instantly explained and I can't quite accept that its not just me being defective.

There is also a fear that now I have an excuse, a reason to stop berating myself, I will luxuriate in it. Will I kick back and stop pushing myself as much as I have been, and retreat? Will it take even more effort now to venture out and smile, with a diagnosis weighing me down?

People who know me may be inclined to think that this is bollocks, that I'm just going through a rough patch and will be fine in a bit. I keep telling myself that too, to be honest. I'll shake it off and it'll be fine. but this is an underlying thing that has always been there. Most of the time it lurks, but sometimes it pushes itself into the front row, knocks out the bouncers, and jumps on the stage and dances naked. In other words, its pretty damn distracting, and it takes up a fair amount of my working brain. 

There are a few cruel dichotomies that I am the victim of in life. I love nothing more than lying for hours in the sunshine, yet I have the palest, most prone to burning skin, for example. And this is one too. I love being around people. I love my friends more than anything, and I rely on them for my very existence. But this thing, this bloody diagnosis, means I can end up spending the precious time I have with them fighting with my instincts to run away from them, even though I desperately want to be with them.

You could be the one person who I want to spend the most amount of time with in the world. You could be the person that I am most interested in getting to know, or the person who I most want to impress. I might be really interested in your opinions, and desperately want to know about your life. But what will most likely happen is that I will sit in awkward silence and you will think "she hates me", or "she's not remotely sociable" or "bloody hell, she's really boring". If only you could hear the things running through my head at these times though. In my brain, I am running through all of my most sparkling, wittiest, intelligent observations and quietly discarding every one of them as being too unworthy of your consideration. Yeah, I know I should let you judge that, and I think about it constantly afterwards and how stupid I have been for not saying anything, but in the moment, none of those rational thoughts help. Conversely, you could be someone who I know I will never meet again. You could be a random person on the street who asks me directions, or a train conductor, or a waitress in a restaurant I will never visit again, and I will still have the same reactions.

I can often mask it, but my body lets me down. I can be sat having a nice chat with someone I have been friends with for years, and I am internally in full on fight-or-flight mode. My heart is pounding irregularly, my brain is rushing and I blush extravagantly. If this is how I am with people who I know love me, and who I have known for years, imagine how I am when I meet new people.

Some of you might be thinking 'why in the hell is she writing about this in public?' Some would say that this is the kind of thing that should be kept under wraps, behind closed doors, under the carpet and all that kind of thing. Well, I say bollocks to that. I have written before about how stubborn the stigma of mental health is, and I just don't subscribe to the idea that we still, in this day and age, need to be embarrassed about it. It's actually really hard and scary to write about it all in public, but it makes me feel better and I don't want to hide it away. I have enough faith in you, Dear Reader, that you wont think any less of me for it or judge me too much. 

Hxxx


 

Homeopathic Harms 3.1 Addendum: C's Story

Imagine you're twelve years old.

You're on the cusp of adolescence, a time where you start to move away from the comfort and protection of your family and begin to forge your own way in life. Friendships become increasingly important, and you're in a constant process of trying to make new ones, maintaining old ones, and falling out with others. The world seems confusing, terrifying, and wonderful in varying measures, and you spend a lot of your time watching those around you and drinking in how they act, what works and what doesn't, deciding how to act yourself to fit in and be accepted. This is the time when, though the ground is constantly shifting beneath your feet. you start to put down little social foundations and try to make sense of the world. 


There is a wealth of evidence that suggests many benefits of connecting with people of your own age during adolescence. At such a crucial, tumultuous time of life, being socially isolated from your peers can have long lasting and harmful effects. 


What's this got to do with homeopathy?

I've written before about how poor advice from homeopaths can potentially cause a lot of damage, and through our Homeopathic Harms series of blog posts, Nancy (of the Evidence Based Skepticism blog) and I have hopefully managed to convey to you an idea of how it can sometimes be the seemingly innocuous and difficult to quantify harms that can be most worrying.

I received an e-mail the other day that I have since been thinking a lot about and which I wanted to share with you. Its a real-life example of just how much harm poor advice from a homeopath can cause. The chap who sent me the email has very kindly allowed me to share his story with you, but of course I am going to respect his anonymity and refer to him as C.

C's story

C. had delayed puberty. Now this is something that is fairly common, happening in about 3% of cases, and which can be caused by a number of factors, but the most common type is Constitutional delay in growth and puberty (CDGP). This is basically a technical way of saying 'Just one of those things, which might be caused a whole load of stuff or possibly just chance.'

Conventional medicine would manage CDGP by... well, usually just by waiting, really. Monitoring, and reassurance are often all that is required. Otherwise, short courses of sex hormones should be enough to do the trick. If the delay in puberty is caused by something, then ideally the underlying cause would be appropriately treated. You can see some good, reliable guidance on management here

Note, by the way, that the definition of delayed puberty according to patient.co.uk specifies '...in boys beyond 14 years old'.  Now, I have no way of saying what the definition of delayed puberty was at the time that we join C's story, but his experiences began when he was 12- well below the point where we would diagnose delayed puberty nowadays.

C's mother consulted a homeopath. He was given some homeopathic pills, which on account of just being made out of sugar, had no beneficial effects, but also no harmful effects. However, the homeopath also appears to have given C's mum some advice, the goal of which seems to have been isolating him from his peers between the ages 

C was:

  • not allowed to stay at school for lunchtime, but instead had to go home.

  • not allowed to stay at school after the school day had finished.

  • not allowed to cross the local footbridge over the motorway, which cut him off from the majority of his peers.

  • not allowed to go down the street of the one classmate who lived on his side of the motorway.

  • allowed and encouraged to socialise with one boy who was two years his junior.

The first question is why. Why on earth would a homeopath give such advice? We can only speculate that the homeopath in question thought- apropos of nothing- that since C was a late developer he should be kept away from people his own age and instead only socialise with younger children. I've had a look around some homeopathic websites on the internet, and found nothing that looks similar to this sort of advice. [I did, however, find this website, which amused me no end due to its impressive reference list. No, really, go and look at the link and scroll to the bottom, if you want a good laugh]. In fact, I couldn't find anything at all suggesting that enforced social isolation is good for anyone or for treating anything, really. 

C's case would appear to be one of a homeopath acting outside of their competence and providing bizarre and very harmful advice. In C's case, homeopathic treatment was certainly not safe, although this had nothing to do with the sugar pills themselves.

The result of this set of rules on C were, in his own words:

"a boy who was immature, shy and lacking in self-confidence. When it came to puberty I had significant mental health problems (starting with OCD due to high levels of anxiety) which have had an impact throughout my life....I didn't regain a sense of normality (in terms of socialising properly) until the age of 25-26."

Limitations

C's story is, of course, merely one anecdote, and as good skeptics we of course have to realise the limitations of it. There's nothing to say that, if C hadn't have followed these rules, he wouldn't have gone on to develop any mental health problems, and indeed delayed puberty itself is not without an increased risk of psychological problems.

Given our very human need to fit in, it may be the case that children with delayed puberty have a preference for younger friends, as they stand out less. This is entirely understandable, but in C's case it is clear that his situation was enforced upon him.

 But given the established link between social isolation in adolescence with mental health issues, I think we can pretty safely say that this is a case where at the very least homeopathy worsened his situation. His quality of life was undoubtedly affected when he had to obey the rules.


Thankyou to C
 

Many, many thanks to C for sharing his story with me. I think its so important to hear these stories, as they might help to raise awareness of the less obvious, nebulous harms that can arise from treatment by unregulated, alternative practitioners. Unfortunately, its really difficult to quantify these sorts of harms into cold hard evidence, and that's why I, and many others like me, keep banging on as loudly as we can about them. If you have any examples of potential harm caused by homeopathy, it goes without saying that I would love to hear from you. 


H xxx

Nelson's: Suggesting that your kids need mood stabilisers from two years old.

You know of Rescue Remedy, right? You probably had an aunt who would constantly swig a drop for her nerves, or might have even taken some before a driving test or exam.

Rescue Remedy has become a pretty well known brand- so well known, in fact, that most people don't bother finding out whats in it, or what principles its based on. You wouldn't want to know the recipe of Coca-Cola before you take a refreshing swig- you'd just assume that because its a well known brand, its probably going to work.

Rescue Remedy is, however, a whole load of woo nonsense. Sorry, but there's no other way of putting it. Some dude called Edward Bach decided- apropos of nothing- a good few years ago that some flowers, if left out in the sun and dissolved in alcohol,  will be able to balance physical and emotional distress. This is interesting, really, given that its taken the entire fields of neuroscience, psychiatry, and psychology many, many years to get to a point where there are still a vast amount of unknowns regarding mood disorders.

Science is getting there- slowly- when it comes to understanding things like depression. It's a vastly complicated subject. There's no perfect cure-all drug out there for treating such things- mainly because we don't yet understand it that well yet. So forgive me if I am skeptical that some random guy years ago has just randomly (without any basis in science) decided that, for example, mustard flower:

 "is the remedy for deep gloom and depression that descends for no apparent reason out of a clear blue sky. People in this state often list all the reasons they have to feel happy and contented, but still everything looks black and hopeless to them. The remedy helps to dispel the clouds so that we can once again appreciate the joy and peace in our lives."

Rescue Remedy is a blend of some of Dr Bach's made up flower remedies, diluted in brandy. You're supposed to reach for it in times of anxiety, as a soother. Funnily enough, brandy, being alcohol and all, it might make you feel a little bit better, but similarly to homeopathic remedies, they are dilutes such that very little or no levels of active ingredient are likely to remain. So even if Dr Bach were right about the flowers (despite evidence and science suggesting otherwise), there wouldnt be enough flower-stuff in a drop of it anyway to make a difference.

I can't quite get away from the fact that this is a cynical product which Dr Bach made up in an attempt to target wealthy women ("ooh! pretty flowers!") in the days where women were considered "hysterical" and many were labelled as having "problems with their nerves" based entirely on their sex.

Anyway, why am I on about Nelsons, and why am I on about children? Well, because the Bach Rescue Remedy brand- in all of its many, varying, and just-as-cynically money-grabbing-as-Big-Pharma- forms- is sold via Nelson's homeopathic brand. That's Nelson's who the FDA discovered weren't putting magic woo water in all of their magic woo water pills, but were happy enough to put particles of glass in there. That's Nelson's who are all "ooh, we care about you and your healthcare unlike those big meanie pharmaceutical companies who only care about money" all the time.

Well, I happened to stumble across this product of theirs today. Rescue Remedy Gummy Stars- aimed at children from 2 years and onwards. According to Nelsons:


"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. RESCUE® Gummy stars - The latest addition to the RESCUE brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains four drops of RESCUE, the famous soothing combination of five flower essences."

What's wrong with that? The fact the Nelsons are attempting to medicalise a perfectly normal part of childhood purely for their profit, that's what. Being nervous on your first day of school is entirely normal, especially for a little one. What they need to do is to develop normal coping mechanisms to deal with their anxiety. What they don't need to feel is that their anxiety is abnormal and something which only a medicine can fix.

When encountering the world of complementary or alternative medicine, I often like to stop for a moment and replace the names of the companies with those of Big Pharma. It gives a good indication of whether or not there really is a difference in practices between the two camps, and whether people's reactions would be different

"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. PROZAC® Gummy stars - The latest addition to the PROZAC brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains 10mg of PROZAC, the famous soothing antidepressant fluoxetine."

Icky, right?

Hxxx

How much of [insert drug name] do I need to take to kill myself?

I'm slightly obsessive over checking my blog stats, and I've noticed a trickle of people finding my site by using such terms as the above.

So, if you have found my site by searching for a similar phrase, I just wanted to say a few things to you. I'm not saying this in my capacity as a pharmacist, or skeptic, or anything like that, but just as a human. Don't worry, I won't keep you long. 

Firstly: I know and I understand.

Secondly: It feels like this will last forever, but it won't. Give it twenty minutes or half an hour, and in the meantime, please ring these people. No, really, please do. After all, in the grand scheme of things, a delay of a few minutes wont make a massive difference.
In the UK, the number is 08457909090. In the Republic of Ireland, its 1850609090. In the US its 1-800-273-8255. There will be similar numbers in other countries. 
If you  could just do that for me, that will be brilliant. 

Thirdly: I'm sorry, but you wont find that kind of information on this site. 

Fourthly: I care about people, and that means I care about you. If someone who has never met you at all cares about you, then its highly likely that some other people out there do too. I know that might not be enough, but it should count for something. I and many others don't want you to. 

Oceans of love, 


Hxxx


P.S. There is a lesson here for other bloggers/ website owners/ healthcare professionals too. Please be aware of what you are writing if you are covering anything about toxicology.

Antidepressants in pregnancy

This morning BBC News are running with this rather terrifying looking story about the dangers of antidepressants in pregnancy. This is an area that I deal with pretty commonly, so I thought you may be interested in my assessment of the situation. 

First thing to note: things can go wrong in even a normal, healthy pregnancy. There is always a risk of malformations or miscarriage, and unfortunately these things can happen for reasons that we dont understand. The risks are usually low, but are increased by things like increased age, obesity, illnesses etc.

One of those illnesses can be uncontrolled depression. "But how can feeling a bit sad harm an unborn baby?" I hear you ask. Well firstly, depression can be a very serious illness which should be taken seriously. It may even be terminal. Pregnancy is a time of massive changes, and as a consequence is a high risk time where someone's mental health can destabilise. If you have depression, you may not be looking after yourself properly: you might not be eating well, you might be avoiding exercise etc. In the worst, most tragic cases, suicide attempts might happen. We don't have enough data to put figures on how much of an increase in risk this all adds up to, but we do know that it can increase risks in a pregnancy if not sufficiently controlled.

Of course, this doesn't even take into account the more nebulous risks to both the child and mother- how will having a depressed mum impact psychologically on the child, how will the bond be affected, and what are the long term effects of this?  

So what of the SSRIs, the most commonly used type of antidepressants in pregnancy? Looking at the risk of cardiac malformations,, the BBC article claims that:

"Currently, prescription guidelines for doctors only warn specifically against taking the SSRI, paroxetine, in early pregnancy."

 It used to be the case that we were aware of the possibility of a cardiac malformation risk with paroxetine. Up until, oh, about 2010, when a large review was published whichsuggested that the increase in risk, if it exists, may be a class effect. The UK Teratology Information Service's Guidance was changed accordingly to be more practical, to remove a heirachy of one particular SSRI, and to make the drug of choice that which is the best for the individual patient (please note that UKTIS are a service for healthcare professionals only, and pateints should not ring them directly). The fact that NICE guidelines haven't yet been updated probably says more about NICE's workload and update schedule than any evil big pharma cover up. 

As an aside, you will notice that there are a lot of words in this post which suggest uncertainty. That is because there is a lot of uncertainty in teratology: because we cant do large robust trials on pregnant women because of ethical concerns, we have to scrape together what we can and make the best of it. There are few certainties in this area.

Strange then, that the BBC are quoting a Prof Pilling from NICE:

"He says the risk of any baby being born with a heart defect is around two in 100; but the evidence suggests if the mother took an SSRI in early pregnancy that risk increases to around four in 100."

I'd love to know where these figures came from. The current status of data on the risks of SSRIs is pregnancy is as follows:

  • There is lots of data, which has had various statistical analysis methods applied to it. 

  • Some of this data suggests no increase in risk

  • Some of it suggests a small increase in risk.

So, with some data saying there isn't an increase and with some saying there is, it is virtually impossible to say for certain if there is an increase. The only thing we can say for certain at this point is that we can't say anything for certain. But given that we have lots of data, and SSRIs are commonly taken in pregnancy, I think we can say that if there is a large increase in risk, we would have known about it by now. So any increase in risk, if it is there, will be low.

Of course the BBC are reporting the relative risk, which sounds more impressive: a doubled risk sounds much more sensational than a small absolute risk. But I'm not even sure where this figure has come from, given the conflicting state of the evidence at the moment. Needless to say, research is oretty much constantly ongoing. 

All of this is a very long winded way of saying: we dont know at the moment. But the fact that we don't know, in the face of how commonly used these drugs are in pregnancy, could be seen as reassuring.

As with all things in healthcare, this is a balance. A balance between the risks of uncontrolled depression and destabilising a mother's mental health during pregnancy, compared with the -as yet unknown but likely to be small- risks of SSRI antidepressants. Of course some women with minor depression might be taking antidepressants unnecessarily, but in cases where it is required, we need to look at the bigger picture. Just focusing on a drug's teratogenic potential is not enough: we need to consider the teratogenic potential of the illness itself, and the impact on everyone's lives that might happen if treatment is withheld. 


The bottom line is, if women are thinking of becoming pregnant or are already pregnant whilst taking an SSRI, and they are worried, they shouldn't stop it of their own accord, but should make an appointment with their GP to have a discussion about their concerns. 

Hxxx

UPDATE: I've been thinking about this 4 in 100 figure for cardiac malformations, and last night tried to find the reference source from it.

I've tweeted @bbcpanorama asking to know where this figure has come from, as have a few others. I've also tweeted @shelleyjofre, the journalist who has mad ethe programme, and have been met with a stony silence. This is really unfortunate, given that to be able to deal effectively with any enquiries from patients relating to this programme, I -and all the other health care professionals dealing with worried mums to be- need to be able to see and appraise the evidence for ourselves.

I have managed to find this document from the MHRA, which does mention a 4 in 100 figure. However, I sincerely hope that this isn't the source in question, given that:

  • The document refers to paroxetine alone, not the whole class of SSRIs

  • There is no date on the document, meaning we have no way of knowing how up to date these figures are.

  • the 4 in 100 figure cited refers to the risk of ALL malformations, not just cardiac ones.

  • the risk cited for cardiac malformations is 2 in 100. Half that which the BBC and Professor Pilling are quoting.

  • The background risk of all malformations cited is 3 in 100, and the background rate of cardiac malformations is 1 in 100. So yes, the relative risk is doubled, but the overal risk remains very low. 

As I say, I really do hope that this isn't the source, and that @bbpanorama or @shelleyjofre are able to provide me with the reference soon.  

Needless to say, I never heard back.

 

Homeopathic Harms Vol 1: Medicalisation

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we've decided to write a series of blog posts about a number of points we covered in the talk. Here is the first:   

Doctor's appointments: often you feel like you're in and out before you know it, and they can't get you out the door quick enough. They have a target number of minutes to spend with each patient, and sometimes you can feel like they don't have as much time as you'd like to discuss all the things you want to with them.

There is, then, one aspect of homeopathic practice which can be superior to that of conventional medicine: the consultation. A homeopath might spend an hour or more assessing each individual, not just asking about particular symptoms but about their personality as well, how they think and feel about the world. I've never been to see a homeopath, but I'd imagine this is really valuable to a patient, particularly those with minor mental health complaints. I know myself that when I've been to see a good GP who I feel has really listened to me, I leave feeling a bit better already. 

I suspect that the consultation itself may be part of what provides benefit to patients, rather than the sugar pills that are given out at the end of it. I'm not aware of any evidence that compared individualised homeopathic treatment to the OTC stuff though, which would be the only way to tease out and quantify any benefit from the consultation.

So what's the problem here? If a consultation with someone who appears to listen to you and care makes you feel better, where's the harm in that? The sort of subtle, indirect harms that we'll be discussing in this series of posts are often theoretical and would be very, very difficult to assess via hard, clinical evidence, so you'll have to bear with me while I discuss them with you and see if they make sense at the end of it. Consider the following story: 

Imagine I'm quite an anxious person (in actual fact I am, so it doesn't take that much imagining to those who know me). Imagine I'm particularly anxious at the moment because I maybe have a public speaking event (something like Skeptics In The Pub, say!) to deliver in a few week's time. I might be finding it hard to sleep, I find I'm worrying about it quite often, and getting some physical symptoms- my heart is beating quite fast at times, say, and my stomach hurts at times, but it's nothing too serious.

I go to visit a homeopath (admittedly, this would be an unlikely thing to do if I was actually talking about myself) who takes time to discuss with me my problems. I get on well with them, and feel like they are really listening to me. During the discussion, I find that vocalising my anxieties helps me to rationalise them and my fears are allayed somewhat. Just the act of talking about it makes me feel better- in other words, the homeopath is delivering a talking therapy service to me. By the end of the consultation, I'm already feeling more in control of my anxieties, yet I'm still given some tablets to take home, and I dutifully follow the instructions I'm given.

As I've discussed elsewhere, there is a stigma about mental health issues. This also, unfortunately, extends to talking therapies too. Its quite likely that some people would be happier to declare "I'm seeing a homeopath" than "I'm seeing a counsellor" in front of their friends or acquaintances. The handing over of the sugar pills at the end of the consultation will no doubt suggest the talking bit is more "justified", and they can convince themselves that they're not mad, or the sort of weak person who would have to resort to a talking therapy. And thus, the stigma is reinforced. Talking therapies shouldn't be something to be ashamed of. You don't need some inert sugar pills to justify and hide the fact that, now and then, you just need to be able to talk to someone about your problems or feelings.

There are wider issues with this kind of thing too. The visit to the homeopath has made me feel better. I've been to see someone, left with some pills in my hand, and I've improved, reinforcing the fact that I feel better when given something to take. Let's say that in the next few months, I feel a bit rubbish because I've had a bit of a cold and I'm left with a cough that's been there for a couple of weeks. I go to see my Dr, who tells me that my chest is clear, and the cough should clear up of its own accord. However, I've expected to get something out of the visit- I don't want to leave the surgery with no pills in my hand, as I know that last time I left a consultation about my health I was given pills at the end of it and I felt better. It's left to the Dr to explain to me that I don't need antibiotics, and this can be a notoriously difficult thing to do. Some Drs might relent and give me a prescription for an antibiotic, contributing to the catastrophic situation we're in now with antibiotic resistance. If the Dr doesn't give me a prescription, I'm left with a bad taste in my mouth and a bit of mistrust in the conventional health care system. 'Next time I'm feeling ill', I think, 'I'll go back to that homeopath. They take me seriously because they gave me pills'.

And so the cycle goes on.... 

Hxxx

 

Lets have some honesty, shall we?

Stigmas. They're stubborn things aren't they? 

I've seen a few folk tweeting this article: Hooked on Happy Pills? in The Independent this week about the sort of language used to describe medication for mental illness, and this has started me thinking a bit about one of the seemingly most stubborn stigmas: mental health. When you've worked as a community pharmacist for a while, you sort of start to see the sort of numbers of people who are taking mental health drugs, and you start not really thinking twice about them, so its interesting to see how pervasive the stigmatisation of mental health issues even in this day and age. 

Now I'm a pretty normal person, to be honest. I'm not particularly exciting in any way shape or form, I have a stable, loving family background, and a truly wonderful circle of friends. I'm not rich, nor am I completely destitute. I work a 9-5, five days a week job which I rather enjoy. I function pretty well in daily life, to be honest, despite living up to my nickname of Simple Dog. I've been subjected to few major traumas in life, and whilst I've been certainly affected by my divorce, even that went pretty smoothly to be honest.

So what am I doing writing about mental health then, eh? Well, like pretty much everyone else in the world, I'm affected by it. And I'm tired of this stigma, and I think its becoming time to just start talking. I know that my contribution to the party is going to be very, very tiny, but I'm also naive enough to think that very, very tiny bits all add up to a change. Lately, I've just started being honest about myself with other people. It started imperceptively, but seems to have grown to the point where I'm merrily discussing my anxiety issues with colleagues that I would never have dreamed talking to about such things with.

I'm generally of a pretty anxious constitution, and I think I always have been. When I was much younger, maybe 12-13-ish I started having panic attacks which led to a period of bulimia, which had nothing to do with my weight but was to do with a fear of vomiting in public. It seemed logical at the time (and to be entirely honest, I still think its a bit logical now). Anyway, I overcame all that, and am left with a sort of residual anxiety which raises its head now and then, but most of the time is fairly easily kept in check. In recent months its resurfaced a fair bit, and its not being helped by my increasingly monstrous appearance of late as my guttate psoriasis continues. What helps? telling people about it. If I'm getting palpitations, I'll tell people that I'm getting them, and that in itself makes me feel a bit better. If I wake up early in the morning filled with vague, formless fears, I'll tweet about it, and there's an instant bit of relief, and usually someone there to say something practical or funny about it.

I'm surrounded by people who also have mental health issues of varying degrees, from some of my nearest, dearly loved and oldest friends to momentary acquaintances. There are people I have never met, but who have been some of the greatest pillars of support to me in less than 140 characters. There are people who I hope I've helped a bit, and some I wish I could help more. And guess what, everyone else is surrounded too. The more open I've been, the more open people have been with me, and I think this is a privilege and a right that everyone should have. There's been some  who haven't handled these things as sensitively as they could have done, but I figure the more I bleat on about things, the more normalised it becomes.

At our Skeptics In The Pub talk the other night, there was one lone voice in the crowd that believed and spoke up for homeopathy. I'm reminded of him when writing this because he was getting a pretty thorough grilling from myself and other folk who were there, and was being asked about his particular experience with homeopaths and he had little hesitation in talking openly about his depression, and how he felt it was helped by having a homeopath with whom he felt he could talk to. His bravery is quite staggering really, given he was in a room full of people who disagreed heartily with him, and yet he still told us all.

I know this has been said already in bigger and better ways, but this is my tiny contribution. I guess what I'm trying to say is lets be rational about this whole thing, accept that these issues are everywhere and everyone has them to some degree or another, and just be honest about it. The more matter of fact we are, every day, even in the tiniest of ways, the more difference we can make to everyone. I sort of feel like its the people like myself, the "normal, functioning" folk who can maybe make the most amount of difference here. I'm guessing people with milder mental health issues may be more able to mask it, and more reluctant to be open about it lest something terrible happens. But they key thing here is that we have to be open, so that the something-terrible-that-might-happen-if-we-do-let-on doesn't exist anymore.

Hope this makes sense,

Hxxx