Tag Archives: Mind

Anger, violence and mental health: a response to Deborah Orr

I’d noticed some outrage on twitter about a comment piece by Deborah Orr, published on Friday afternoon, but had avoiding reading it until this morning. The headline is incendiary enough, but it was a sentence in her final paragraph that made me really furious:

It seems to me that lack of mental health, not gender, is the defining motivation of all violence.

At its most basic level, this statement is unsupported by evidence. Women are 40% more likely than men to have mental health problems, and yet over 85% of perpetrators of violent crime are men. If there really was a causal relationship between poor mental health and violence, we would expect women to be the majority of perpetrators of violent crime.

It’s in attempting to make such simplistic causal links that Orr’s analysis falls down. Fifteen years ago, Lori Heise proposed the now widely used ecological framework for explaining violence against women. Heise’s model recognises that men’s use of violence cannot be explained by identifying a single causal factor, but that it is the interplay of personal, situational and socio-cultural factors that result in violence.

Ecological model | Image from Centers for Disease Control and Prevention, 2004. Sexual violence prevention: beginning the dialogue. Atlanta, GA: CDC.

The ecological framework doesn’t discount poor mental health as a factor, but it makes it one tiny piece of the puzzle. And like any puzzle, one piece can’t operate on its own. When a person – usually a man – makes the choice to use violence, that decision is a product of factors at the individual, relational, community and societal level. In a country where the state is sanctioned to use violence to resolve conflict through overwhelmingly male military and police forces, where perpetrators of violence against women are rarely convicted for their crimes, and where sex and relationships education isn’t mandatory on the curriculum (let alone education about consent), identifying poor mental health as the primary causal factor for men’s use of violence seems absurd.

So Orr’s argument frustrated me in its absurdity. But it made me furious because it’s personal.

I was diagnosed with Borderline Personality Disorder in 2004. The first time I’d ever heard of it was when my male psychiatrist gifted me with the label. The diagnostic criteria for BPD is changing, with the publication of the DSM-5 last month, but in the previous version (DSM-IV) there were nine criteria. One in particular stood out and made me believe the diagnosis was incorrect: “inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).” I was being told that not only was I angry, I was potentially violent. That I was a danger to others.

Earlier this year, I requested my patient file from all those years ago. It shows that we discussed the diagnosis over three sessions and although I strongly resisted the diagnosis, after three sessions the psychiatrist’s notes still recorded that I met 6 of 9 criteria for diagnosis and a letter was sent to my GP informing her of the diagnosis. The barely legible scribblings over the many following sessions contain notes like “gets angry – self harm”, “holds anger in onto self”, “showing anger by rebellion, appearance; passive aggressively; repressed.”

And this leads me back to Orr. The pathologising of my anger and being told that I was potentially dangerous to others was about the least helpful thing anyone could have done for me. While my psychiatrist interpreted my anger in his notes, I did my best to avoid addressing my anger in therapy, because I didn’t want to meet the diagnosis I’d been given. I dropped out of psychiatric treatment after 18 months and got on with my life. But I never dealt with my anger.

Nearly ten years later, I’m back in therapy again. I have another diagnosis: moderate depression – an improvement on the BPD, major depression, alcohol dependence and anorexia nervosa I was labelled with last time. Hopefully older and wiser, I’ve found a female counselling psychologist through Mind who I know doesn’t do diagnosis. And what have we been working through over the past several sessions? Finally, after all these years, my anger.

So guess what, Deborah Orr? I’ve got a mental health problem and I’m angry: but I’m not violent. I choose not to be. And that choice has nothing to do with my mental health and everything to do with hundreds of overlapping personal, situational and socio-cultural factors in my life.

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This is a new day.

This time last week, I felt pretty rubbish. The counselling I’d been waiting for for five months had fallen through after I found out that my counsellor and I knew each other professionally. That evening, I told my partner (P) that I was thinking of giving up on counselling. I felt that that even if they found me a new counsellor who I don’t know, I may run into them professionally at some point in the future. I would find uncomfortable and compromising.

Our conversation went badly, to say the least. Given that I’d admitted that I’d also stopped my medication, P was anxious about me abandoning treatment altogether. He tried to engage me in a ‘rational’ discussion about pros and cons, and challenged me on whether it’s really such an issue if I know my counsellor professionally. I clammed up and the conversation ended when I burst into tears. I felt like he thought I was overreacting and that he was making no effort to understand how difficult the experience that afternoon had been. I felt isolated and alone. The discussion may have been helpful in a few days time, but a few hours after the abandoned appointment, I needed someone to listen to how upset I was.

The following day was a friend’s wedding, which was lovely, but socialising with lots of people I barely know is draining and at weddings I always drink far too much free wine, leaving me feeling even lower for the next couple of days.

I started the week with a plan to call Mind and take myself off the waitlist. I figured it would be weeks before another evening slot came up anyway and I didn’t want to risk the blurring of my personal and professional life again. But before I got around to it, the counselling coordinator called me with an offer for a slot with a different female counsellor, starting next week. It caught me by surprised that this felt like good news, and I accepted the appointment. I start my 12 weeks of counselling with Moira* on Thursday, and I’ve been feeling more positive since then.

And I got some more good news: a job interview. It’s a dream job and I’d submitted an application with the attitude of ‘you’ve got to be in it to win it’, but not expecting to ever hear from them. But I’ve got an interview. And if I was successful, I would be much less likely to run into my counsellor in that role. I know it’s still a long shot, but it reminded me that there are other jobs out there and that abandoning counselling because of my job is probably not the most rational solution to my problems.

I walked out of work on Friday evening, the sky was blue and the sun was shining. I was listening to Sally Seltmann, and with this song, I felt like things might just get better.**

 

* Still not her real name

** On the borderline is a pretty problematic song. Seltmann says that she wrote it as an ode to Princess Diana, who apparently had BPD. Whether Diana had BPD or not, the lyrics suggest Seltmann’s complete misunderstanding of what it feels like to have problems with low mood, seeming to prescribe to the notion of ‘drag yourself out of bed by thinking happy thoughts.’ Nevertheless, for some reason, it worked for me on Friday so I’m putting it here anyway.

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Today is the day.

Today is the day: my first counselling session. I would like to write about how I feel, but truthfully, I don’t feel anything. It’s been nearly five months coming, and today, I feel much like I did five months ago. Numb. Empty. And exhausted. Exhausted by the daily grind of depression, the heaviness of trying to get out of bed, the dissonance of putting on an enthusiastic face for the outside world, and the pressure of wanting to be ‘getting better’ for the people in my life who were so relieved to see me getting professional help.

I ran out of citalopram a week ago and can’t find the prescription slip to order a repeat. I could go back to my GP to get a new prescription,  but I’ve explained to myself that since I didn’t want to be on medication anyway, this is a good opportunity to see whether psychological treatment alone is enough. That’s the rational explanation. The truth is, the thought of seeing him again makes my heart beat through my chest, so I’m avoiding it.

Now today, I have to talk. But what to say? My life is good. I have a well paid, interesting job; a partner who I love deeply and have fun with; a nice flat in an area lots of people wish they could live in; good relationships with family; and lots of friends who I love and who care about me. There is no good reason for me to be unhappy. I could dig out supposedly traumatic events from throughout my life, but in my experience, that’s true of pretty much everyone. So that leaves me back where I started: what to talk about? In my last go at psychological treatment, I remember endless silences because I didn’t know what I was meant to talk about.

A couple of months ago, I requested a copy of my patient file from the psychiatrist I saw in 2004-5. It was hard seeing things written down about myself, things that I didn’t recall being spoken in the room. Words like “anorexia nervosa: partial remission”, “drunk today”, “borderline personality traits: see for further assessment”. There were also the letters between my psychiatrist and my GP, which I’d not seen before.

I feel she is suffering from a mild to moderate Borderline Personality Disorder. She describes a long history of labile mood, and has been self lacerating for the 2 years. She also bites her fingers to cause pain, and can also be reckless with spending and sex.

And a year later:

If she remains engaged in therapy she should continue to make slow but steady progress.

I dropped out of treatment a month after that last letter was written.

I feel reassured that this time I am seeing a counsellor without an official referral from my GP, so they won’t share information about me. But I know I suggested in an earlier post that it would be useful for them to share information. The point is, I want information shared in a way that includes me. I want professionals who are collaborating in my treatment with me. If they communicate, I should be copied in. Instead, I get a choice between uncoordinated treatment from two separate professionals who don’t know what the other is doing, or coordinated treatment in which I have no voice.

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Six weeks on Citalopram.

It’s six weeks since I started taking Citalopram. As I’ve mentioned, I track my mood on Mappiness. The graph below shows how happy, relaxed and awake I’ve felt between the end of November and mid January. Overall, I think there’s been a slight improvement, although it’s not particularly clear.

Mappiness 2012-13

A comparison to the same period last year provides even less clarity (there’s more data here, as I was tracking twice a day): I had a more pronounced upward trajectory this time last year, when I wasn’t on medication.

Mappiness 11-12

I saw the GP for a second follow-up on Thursday and mentioned that although I felt a bit better, I had noticed a similar pattern last year so wasn’t confident the change was due to medication. He didn’t really accept that explanation:

GP: I mean it can be a combination of things. Normally around the winter months, there’s less sunshine of-course, it affects people’s moods. And if you are pre-disposed to developing low moods anyway, probably it can make it a bit, exaggerate its effect. Now, ah, the other thing about the tablets is that ah, sometimes you don’t see the effect because it’s so gradual and what tends to happen is the only time that people realise it’s working is when they come off, and then they realise that it was working. So I think, you know, they’re actually working.

It’s winter now and I was telling him that I’m feeling a bit better, so his explanation made me feel that he wasn’t listening. From our previous conversations, I feel like he is very confident in the efficacy of SSRIs and that it would be very difficult to change that belief.

I’ve also felt in my two follow-up appointments that he’s not really interested in psychological treatments, and has only offered it as a complementary treatment because I wanted it. This time, I don’t think he would have even checked in about the counselling he’d referred me for, except that I brought it up.

GP: You still feel bad about yourself, self esteem?

Me: Yeah, that’s, yeah that’s still there. I’m gonna start counselling with Mind, but that’s not for a few weeks.

GP: Okay, okay. You managed to get hold of them.

Me: Yeah, yeah. So I had my assessment but I’ve just got to wait for them to allocate me a counsellor.

GP: Right. Great. Concentration?

He didn’t change my Citalopram dose, but gave me a repeat prescription and told me to come back in 3 months. I left my third appointment feeling frustrated. In my own line of work (a different health field), we talk constantly of “partnership-working”. In my first appointment, the GP gave me the phone number for Mind, but he drastically under-estimated how long I’d really have to wait to access counselling, didn’t know they offered evening appointments nor the actual cost, and he couldn’t tell me what type of counselling they offered. Now, he knows I’ve accessed the service but he’s not interested in knowing anything more.

It strikes me that once I start counselling, my counsellor will probably have the best insight into how my mood is changing. But there will be no discussions between my counsellor, my GP and I about these changes and my medication. This leaves me stuck in the middle, responsible for coordinating my treatment, and trying to communicate with a GP who believes that antidepressants are the best answer.

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A counselling assessment.

I had my counselling assessment on 7th January. Here’s what I posted on twitter straight afterwards.

Twitter 7Jan2013

I’d been referred to my local Mind, but I had a flat bike tyre and it took me 40 minutes to get there. It was an area I’d never been to, in a bleak housing estate. I was buzzed into a courtyard where a group of older men were smoking; I had to ask them for directions to reception. As I walked in, the receptionist signalled for me to wait while she finished a counting task. She finally asked my name, rang up for the counselling coordinator and asked me to wait. I sat down on the one seat available, squashed between a cupboard and a second chair which was taken up with a huge carton of sugar. Several more people came in. The tiny space got crowded and everyone else was standing, so it felt like they were all on top of me. The door was open; the room freezing. I took some notes as I waited:

This feels like a place for people who are sicker than me. It feels like all the places I walk into through my work. I want to walk out now, go to work, find myself a private therapist and ask P to help me pay for it. This doesn’t feel like a place for people who work, it’s a place to go during the day if you have nowhere to be. I feel claustrophobic and like I want to cry.

I’m aware these feelings seem judgemental. What they reflect is my anxiety about being displaced from the position of ‘professional’, with the status that comes with it, into the vulnerable position of ‘service user’. This was part of the reason it took so long for me to seek help, and sitting in that reception, I felt out of control and wanted to run.

Perhaps the receptionist picked up on my discomfort, because she sent everyone else outside to wait and asked if I was cold and needed the door closed.

Eventually Liz* came down to collect me. She looked younger than she sounded on the phone, and seemed friendlier. She took me upstairs to a small but comfortable room. I noted that she positioned herself closest the door. I know that she does that is so she will have an easy escape if I turn violent. Liz told me that the only reason any of my notes would be shared would be if they were subpoenaed, which was a relief given concerns I’ve had about information being on my medical record. She asked detailed, difficult questions, but was gentle and empathic and I trusted her. I disclosed pretty much everything, and I cried a lot.

She asked if I’d been diagnosed in the past and I told her about the Borderline Personality Disorder. She later asked whether I’d been angry at that time. I said yes, and that I suspect that’s why I got the diagnosis: women aren’t supposed to be angry. She laughed and nodded, which I liked, and said, “We don’t do diagnosing here.” She clarified that their counsellors work from an integrative approach, which means they draw on a range of theories in their practice. I’d been worried they would offer cognitive behavioural therapy, which I’ve found unhelpful, so was glad she agreed that CBT wouldn’t be appropriate. As she said, I don’t know why I’m feeling the way I am, so I need therapy that allows me to explore where my feelings are coming from.

The assessment took 35 minutes and Liz offered me 12 sessions of counselling. I need a female counsellor in the evenings or on the weekend; she thought she would be able to allocate me an someone next week, but would call to confirm. I left wishing that Liz could be my counsellor, but feeling hopeful that her approach is reflective of the ethos of the service. She called back this week, but unfortunately can’t offer me a counsellor for another five weeks. I’m going on holiday then, so I won’t start counselling until the first week of March: three months after my first GP appointment.

*not her real name

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Self help.

It’s been just over a month since my first GP appointment and today is the day of my counselling assessment with Mind. The new year was a reflection point and helped me to think of 2013 as the start of a journey towards recovery. I would have liked to access counselling quicker, but in the meantime, 1st January provided an opportunity to set some self-help resolutions aimed at taking responsibility for my own recovery.

I use Mappiness and because I’ve been using it for a while, I have good statistics in there about what activities are associated with me feeling happier. I used this to devise these strategies and I’m recording my progress with them using Evernote. My iPhone is a great tool to keep track of my mood and what works in stabilising it.

1. The Good List: record one good thing that has happened to me every day. It doesn’t need to be big, just a reminder that my life is full of good things. This was inspired by Facebook’s Year in Review, which reminded me that although last year was tough emotionally, it was full of incredible experiences.

2. Listen to music for half an hour a day: music has always been an important part of my life, but when I’m down I often forget to use it as the positive soundtrack that it can be.

3. Read a book every day, even if it’s only for 10 minutes: when I’m feeling low, I can spend hours reading ‘stuff’ on the internet that often makes me feel worse. Putting the screen away and reading a book creates a different space in my life and I feel like it stimulates my creativity. And it doesn’t have to be ‘happy’ reading (I’ve just finished The Bell Jar).

4. Only 1 hour of TV per day: I can get sucked down the hole of endless hours of crap TV, which helps switch my mind off but encourages my feelings of emptiness.

5. Cook 1 new meal from recipe per fortnight: I love cooking for pleasure, I hate cooking when I have to. This is designed to bring back some of the pleasure of cooking into my life and I’m looking forward to exploring Hugh Fearnley-Whittingstall’s Veg.

6. Four days off alcohol per week: I often end up drinking frequently, generally tied to social activities, but I know that alcohol really impacts on my mood. I need to learn to go to the pub and order a soft drink or juice.

7. Get to the pool or gym three times per week: Exercise does help me sometimes, but when I get into it I can get a bit obsessive. A goal of 3 times a week is also about keeping it moderate. I’m training for a 7km run in a few weeks, so the fear of embarrassing failure should help motivate me (still not quite sure if this resolution is a positive coping strategy?).

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Booking an assessment with Mind.

The day after my first GP appointment, I called Mind to arrange counselling. I made the call sitting outside in the cold on my lunch break, trying to find a place where no one would hear me. I was anxious. The first time I saw a GP about my mental health, in 2003, I was also given a number for counselling. Back then, I was similarly sitting on a park bench making the call from my mobile. The receptionist who took my call insisted that I do an assessment over the phone, including the question: “Do you have any suicide plans?” I did. It threw me to be asked it so blatantly. I now know to be prepared for that, but back then it was my first ever contact with mental health services. I didn’t want to discuss my suicide plans over the phone, in a public place, and I was living in a house with 7 other people so there was nowhere I could go to make a private call. I asked her whether I had to answer, she said yes, and I hung up. She hadn’t taken my contact details and I didn’t seek help again for 6 months.

This time, the Mind receptionist put me straight through to the counselling coordinator, but I got her voicemail and left  a message. I was nervous about that because it meant I then couldn’t control when I took the call, but I didn’t want to put it off. Ten days later, I hadn’t been called back so I tried again. Again, it went to voicemail, I left my details again and waited for a callback.

This time, the coordinator responded the following day. Apparently she couldn’t make out my number in the first voicemail, so she was glad I called back. This seems likely: my phone is on its last legs and I’m hanging out for an upgrade. She took some basic contact details and said they can offer out-of-hours appointments if I can “make the time” to come in for an assessment during working hours. Because of the Christmas break, the next available appointment wouldn’t be for three weeks.

So my assessment is booked for 7th January and I received a confirmation letter to my home address, with a leaflet explaining Mind’s counselling services. It will be £15 per session as I’m working full time (significantly cheaper than if I went private), but there’s a limit of 8-12 sessions. I’m hopeful that will be enough, but if it’s not, I’m concerned that I will have built rapport with this counsellor and then have to stop and find someone else. They offer group therapy after individual counselling is finished, but group therapy sounds like my worst nightmare. My other concern about Mind is not being able to choose my counsellor. If I was going private, I would research counsellors beforehand, but here I have to go with what I’m given.

It’s a week now until my assessment. I still don’t know what to expect; the leaflet says it’s to “assess your needs appropriately”, but who knows what that means? I would have liked more specific information, such as what sort of questions I will be asked. The coordinator was also vague about how long I’ll have to wait to see a counsellor, as it depends on how “flexible” I am. I suppose that means I choosing between a short waiting time and seeing a female counsellor in the evening (my minimum requirement).

But I appreciated that the coordinator was kind, and at least she didn’t ask me to be assessed over the phone.

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My first GP appointment, transcribed.

Two weeks ago, I went to see the GP about my mental health for the first time in 7 years and I decided to audio record the interview. I was conscious that my memory of what happened would be influenced by my experience of it, so I wanted a more objective record of exactly how it went. And I wanted to be able to share it here, to give a better account of how it happened. This is my experience, not necessarily a representation of the service anyone else would get from a doctor in their local NHS practice, but it’s one example.

—————————————————————————————————————————

GP: Hi, come in.

Me: Hi.

GP: Hi, take a seat. [inaudible].

Me: Um. [pause]. I’ve had low mood for about 18 months now and I’m just a bit tired so [laughs], I thought I’d come to the GP and talk about it and see if there’s anything I can do.

GP: Okay. So what’s been going on?

Me: Um [sighs]. I don’t know if there’s anything in particular that’s been going on, it’s just, um [pause], yeah, I dunno, it’s just kind of [pause] continuous, so I don’t know [laughs].

GP: Right.

Me: It kind of goes up and down and it’s not as bad as it has been, but…

GP: Hmm.

Me: Um, I think, last time I came to the GP it was a while ago…

GP: Yep.

Me: I was going to talk about it then but I didn’t feel able to…

GP: Right.

Me: So it’s taken me a while to come back.

GP: Okay, right.

Me: Um. [pause] I’ve had depression in the past but that was quite a while ago.

GP: Okay. Were you on medication?

Me: Yeah. I was on Zoloft, and then on Citalopram.

GP: Okay. And how long was the treatment for?

Me: Um, it was probably, I think I was on it for a couple of years.

GP: Right, okay. And then did you finish the last treatment?

Me: Um, it was 2005.

GP: 2005?

Me: Yeah, a long time ago.

GP: So you’ve been okay since then?

Me: Yeah, ah, yeah, I’ve been okay, yeah. I was fine for a long time and so, yeah.

GP: Okay. So when did this current low mood start?

Me: Um, about 18 months ago.

GP: And ah, are you able to sleep okay?

Me: Um, it, it comes and goes. It’s not so bad at the moment, but it, sometimes it, I’ll wake up in the night. Like I’m fine falling asleep, but it’s just that I wake up quite early.

GP: Right, okay. So how many hours of sleep would you say you get?

Me: Um. At the moment it’s okay, I’m getting about 7 hours of sleep at the moment…

GP: Right, okay.

Me: But other times it will be 4 or 5.

GP: Right, okay. And your appetite?

Me: Appetite is fine.

GP: [inaudible]

Me: Ah, I have lost a bit of weight, but I think that’s just because I’ve been exercising.

GP: Okay, okay. Right. And any thoughts of self harm?

Me: Ah [pause]. I think about it but it’s not something I’m doing.

GP: Right. How often do you think about it?

Me: [pause] Um. Quite a lot, like it’s always sort of there, but I.

GP: Okay, right. But you haven’t got, haven’t got any kind of plans or anything? No? Okay. But have you self harmed, cut yourself or…?

Me: I have in the past, but not this time.

GP: Not now, okay. Are you in a relationship currently?

Me: Yes.

GP: And does he support you?

Me: Yeah. I’ve spoken to my partner about it, but only recently.

GP: [inaudible] right. Now, how are your energy levels?

Me: Not great [laughs]

GP: Right.

Me: I’ve just got that feeling of being kind of heavy, all the time.

GP: Right, yeah, okay. Are you enjoying things you normally enjoy, like going out with friends and things?

Me: Not really. Like, yeah [pause]. Not as much as, everything’s just more of an effort.

GP: Right, okay, okay.

Me: [inaudible]

GP: And alcohol?

Me: Um, I’ve been managing it, it’s not too, yeah. I probably should drink less.

GP: Ah okay, right. Drugs…?

Me: No.

GP: Smoking?

Me: Oh smoking, yeah.

GP: Right, okay. Now, um, the other thing is that obviously, you know, with a history of depression and the way you are feeling as well, I think you would know [inaudible]. Now compared to the last time you started on medication…

Me: Yeah?

GP: Do you think you are feeling the same or getting towards feeling, you know, the same again?

Me: Um [pause], yeah, it’s pretty similar.

GP: Okay. Did you have any counselling or…?

Me: Yeah.

GP: You did? Okay, right. Did you find it helpful?

Me: Um [pause]. Not [pause] hmm. I, well, I had counselling and then I was referred to a psychiatrist as well…

GP: Right.

Me: It [pause]. Yeah. I think I would like counselling again, but I didn’t have a very good relationship with my psychiatrist.

GP: Right, okay. Yes. Now, with the counselling, we can refer you to our psychologist.

Me: Mmm.

GP: And the waiting period is normally a couple of months or something.

Me: Okay.

GP: But then there’s a, a place called Mind.

Me: Yeah, I know Mind.

GP: Then they can give you, you know [inaudible]. And they charge, I think it’s £5 a session.

Me: Okay, so it’s not expensive.

GP:  So I can actually give you their number, and then if you would like I could [inaudible] probably you can do…

Me: Right, okay. I might give Mind a go.

GP: Yes, you’ll get in quicker.

Me: What sort of counselling is it?

GP: Ah, I think it’s one-on-one, yeah [inaudible] they decide the number of sessions you need to do, and then in combination with that kind of treatment I think maybe we’ll start you on some antidepressants as well.

Me: Okay.

GP: Because the last time we saw you was May last year, and if at the time you were having these issues and you couldn’t talk about it and it’s still the same now, then I think we should start you on some Citalopram maybe?

Me: Okay.

GP: But it depends on you, if you want to give the counselling a go first or whether…

Me: Yeah.

GP: …or do you want to, it depends on how you feel, you know?

Me: Yeah.

GP: The thing is, I think that you are probably moderately depressed.

Me: Mmm.

GP: And drug treatment may be beneficial.

Me: Yeah. I suppose I’m not quite sure about antidepressants, I’m sort of [pause]. Yeah. Are they really effective or not, you know?

GP: Yeah they are, they are. Because for somebody who’s had depression in the past, sometimes there could be a physiological reason, or an underlying cause for it.

Me: Yeah.

GP: And it’s due to the seratonin production. Sometimes, for some reason it does not produce enough, and if it does not produce enough, there’s nothing you can do. You can try everything to lift up your mood, but it still doesn’t [inaudible]. Your body for some reason doesn’t produce enough serotonin, so therefore when you do take the medication it stops the breakdown of seratonin and therefore you take that and it elevates the mood. So it will help. The thing is, ah, [pause] you know that people, some people think, oh well it’s…

Me: It’s not a happy pill!

GP: Yeah. But we find, it depends [inaudible] initially it takes about two weeks for it to kick in and then it starts to accumulate and then the way that people realise that, you know, its effect, is when they stop.

Me: Yeah.

GP: Sometimes they’ve been taking it for a while and they’re feeling alright and then they stop and when they start getting depressed again they know, that’s when they realise it was working.

Me: Yeah.

GP: So it’s a slow, you know, kind of treatment. It takes time to build it up. But it depends if you want to give Mind a go first, or whether you want to start, you know, on the antidepressants.

Me: Um. And Mind, they usually don’t have a waiting time, is that?

GP: Ah, I think, Mind’s probably shorter than our psychologist. A week or two.

Me: Ah, okay.

GP: So if you like, you can wait and see them, that would be fine.

Me: And do they have, do you know, do they have appointments only in office hours, or..?

GP: I think probably. I think it’s probably that, 9 to 5. I mean you’ll find all the psychologists will be in office hours.

Me: Yeah. It’s a bit hard for me.

GP: Yeah.

Me: I don’t like, telling people at work that…

GP: Yeah. So that’s what it is. Now ah, it’s entirely, I think you know maybe the antidepressants are [inaudible]. Because you’ve got a strong history, a past history of depression, I think you know you may benefit from, ah, [inaudible].

Me: Mmm. [pause] Can I take a prescription and then…

GP: Yeah, I can give you a prescription now, start you out on the lowest dose, and then I’d like to see you in a couple of weeks time.

Me: Okay.

GP: And see how you’re getting on [inaudible].

Me: Yeah, okay. Thank you.

[GP typing]

GP: Are you on the pill?

Me: No. I’ve got the coil.

GP: Ah, okay. And how are your periods?

Me: Yeah, they’re fine.

GP: Not heavy at all?

Me: No, they are. But it’s been like that since I got the coil.

GP: Mmm, riiight. Because you look a bit pale to me, you know, you may have anaemia or…

[checks my eyes]

GP: Are you feeling more tired than usual?

Me: Yeah.

GP: I think we’ll just get a blood test done to check your iron levels.

Me: Okay.

GP: Because sometimes a combination of factors, you know, can actually affect your mood. You know, being tired already from iron deficiency, and that can also make your mood a bit lower.

Me: Mmm, okay.

[GP writing]

GP: And how’s your self esteem? Your confidence?

Me: Mmm, could be better [laughs]

[GP typing]

GP: Do you know which antidepressants you were on in the past?

Me: Yeah, I was on Zoloft to start with, then I changed to Citalopram.

GP: Right, okay.

[GP printing prescription]

GP: Now the Citalopram is one a day. If you take it during the day and you feel, you know, a bit tired, then take it in the evening.

Me: Okay.

GP: And then let me get you the number for Mind.

[pause]

GP: [inaudible]

Me: Okay

GP: That’s the Citalopram, 10mg is the lowest dose, and I will see you in a couple of weeks.

Me: Okay, alright, thank you.

GP: Okay

[inaudible short conversation as I’m getting up to leave]

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