This is a story about overcoming depression and also about coming to terms with loss. The two are closely related to each other. I know about this not just from my personal experience, but because I am a psychiatrist. I have specialised in treating those who suffer from the same problems which have afflicted me throughout my adult life. I’ve survived and come through it, and I know others can too.
So opens a new book by Dr. Linda Gask, a British psychiatrist. This Week’s Reading: an exclusive excerpt from The Other Side of Silence: A Psychiatrist’s Memoir of Depression, which was just published by Summersdale Publishers Ltd.
This Reading is the third part in a three-part series on depression.
Two weeks ago: a look at better psychopharmacological management.
Last week: consideration of better treatment in the primary care setting.
This Week: a look at the burden of illness on the patient and the psychiatrist.
(And this isn’t Mad Men Season 4. Miss a week and you aren’t lost.)
Dr. Gask has had a remarkable career. Beyond clinical work, she’s had a sparkling academic career, with a focus on mental-health policy and practice. She’s published papers and book chapters; she’s trained residents; she’s lectured all over the world. She was a Harkness Fellow at the Group Health Research Institute in Seattle, Washington. And she has also worked as a consultant for the World Health Organization and with the World Psychiatric Association.
I remember first discovering her work back in my residency. During an outpatient rotation, I was struck by how different supervisors gave different advice on writing a consultation note to the family doctor. One supervisor encouraged long “impressions,” touching on the analytic literature as a way for family docs to better understand the patient; another supervisor felt that the priority should be a focused list of specific recommendations, enabling the primary care team to work with the patient better; another supervisor suggested great detail, documenting symptoms that may not have been flushed out in the bustle of a family medicine clinic. I wondered: had anyone published in the area? During a quick trip to the library (alas, I’m dating myself), I found a short paper Dr. Gask had written for the British Journal of Psychiatry considering one-off psychiatric consultations, inquiring if the recommendations were followed; they were for just 6 out of 30 patients – the paper closed with practical suggestions for both psychiatrists and family physicians. I found the paper very thoughtful.
When I heard that Dr. Gask had written a memoir, I was intrigued if cautious. Memoirs have a tendency to white-wash life events – to simplify complex issues into black-and-white disputes, to minimize life struggles, to emphasize successes and gloss over failures. While I knew of her struggles with depression, I wondered how frank her book would actually be. Would she actually discuss her depression?
This book is frank. She talks about the reality of her illness – the suicidal thoughts, drug side effects, losses – and emphasizes her own experiences. She glosses over nothing. Her book discloses her sexual fantasies about her psychotherapist, her stormy relationship with her emotionally absent mother, and the affair that busted up her first marriage. Making the book even more interesting: she pairs her personal stories with those of her patients. So, in the chapter where she describes plunging to the depths of depression just weeks before her final medical school exams, she describes the problems of Sandra, her patient, who is depressed and suicidal. The effect is the narrowing of the seemingly large divide between provider and patient.
Dr. Gask enjoys her triumphs: one of her former patients, for example, recovers and goes on to exhibit her work at an art gallery. And there are defeats, including the suicide of an inpatient.
This book is raw and emotional. It’s also honest.
Reading over her memoir, a few thoughts:
1. It’s remarkable how much our field has progressed. Dr. Gask’s life is made so much better with a paroxetine trial. She had tried older antidepressants, but couldn’t tolerate the side effects. Of course, new is not necessarily better in psychopharmacology (think lithium and clozapine) but we have many more options available to our patients now, and patient care is the better for it.
2. The more things change, the more things stay the same. At a critical point in her life two decades ago, deep in depression, she is offered an inpatient admission. She notes that, at the time, it was the only way to quickly access psychotherapy. For too many Canadians today, decades later alas, evidence-based therapies like CBT are still inaccessible.
3. Stigma is lifting and people are growing more and more comfortable in discussing their mental-health issues. We are lucky that people like Dr. Gask are willing to come forward and write honestly and openly about their experience with this illness. It’s important.
Interested in reading more? Dr. Gask’s book isn’t widely available in North America, but you can order it though Caversham Booksellers.
Please note: this excerpt has been re-printed with permission of the author and the publisher.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.
Excerpt: The Other Side of Silence
I was in a bleak new consulting room at Wythenshawe Hospital in South Manchester, in the Laureate unit, a modern building where every ward is incongruously named after a writer or poet. Outpatient clinics take place in bare, impersonal offices where doctors camp for one or two ‘sessions’ every week. There wasn’t even a filing cabinet in the room, which I could illicitly try to open and explore. Although it wasn’t quite new enough then that I started to get high from inhaling the solvent in the carpet adhesive, I could still detect a faint whiff of Evo-Stik in the air. The only distraction was the previous month’s dog-eared hospital newsletter on the corner of the desk. I read about fun runs for breast cancer to distract myself while I waited for my new doctor, who had rushed back to reception to collect my notes from the desk. I felt alone once more and more than a little afraid.
Of course it wasn’t my first time in the psychiatrist’s chair as a patient. But it was a strange occasion because the person sitting opposite me, whom I shall call Dr V, was a colleague I had known for several years, who had agreed to see me and take over my care. She was polite and business-like, and looked at me in the way I know I look at people sometimes – over her glasses, which I have been told can be intimidating – but I could see that she wasn’t entirely at ease with the situation either. She fiddled with her pen while I spoke. And it was almost as though I could read her thoughts, because this process of finding out about the patient’s problem was so very familiar to me. My palms were sweating in anticipation and my heart jumped a beat. My tongue seemed inexplicably glued to the roof of my mouth and I had to take a deep breath to reassure my mind that I was still in control of my body. I knew these were physical symptoms of anxiety, but I worried: what would she make of me? How much should I tell her? When you are on the receiving end of a psychiatrist’s questions, you find yourself subtly judging how much to give and what to leave out.
‘On a scale of one to ten, where ten is as good as you have ever felt, where would you put yourself at the moment?’ She paused, waiting for my reply.
‘About six or seven.’
This is a very hard question to answer. I tell people not to think about it and instead answer instinctively, but did I really feel like a ‘seven’ or did I simply want to justify taking up this time, this ‘slot’ that someone else could have used? I had most of the answers prepared, rehearsed even, in my head, because I knew exactly what was coming.
‘I know quite a lot already, from the letter,’ she continued, indicating the notes that she had received from my previous consultant. ‘But can you tell me more about your past? When did this all begin?’
‘When I was a teenager, I used to get very anxious, especially before exams,’ I explained, omitting to add that I still had nightmares in which the main fear was not yet having passed my finals.
‘There was something about the death of…’ she began, rustling through the letter.
‘Yes,’ I replied. I didn’t feel ready to talk about it; I didn’t know her well enough yet. I wasn’t sure whether I wanted to begin again, getting to know another doctor – or rather, allowing them to get to know me – because allowing that bond of trust to be forged makes it much harder when they disappear.
Unaware of my doubts, Dr V carried on with her questioning: ‘You had difficulty getting over it?’
I have often asked the same thing to others. But is a death something you really ‘get over’? I wonder how you can ever know the answer but I simply replied ‘yes’ because that seemed to be the right answer. I also know that it was many years before I really began to grieve, and successive losses, such as the retirement of my doctor, could resurrect the ghosts of the past once more.
‘And what treatment are you on at present?’
‘I’m taking sixty milligrams a day of duloxetine and two hundred micrograms of thyroxine,’ I replied, considering how many different tablets I had tried.
I had to stop a combination of lithium, which is a ‘mood stabiliser’, and venlafaxine, an antidepressant, because my electrocardiograph was abnormal (I had a ‘prolonged QT interval’, which increased the risk of my heart just forgetting to beat one day). I wasn’t sad to see the end of the lithium, as taking this had resulted in my thyroid gland becoming underactive. And then, as now, if I don’t take the thyroxine tablets, I get tired and put on weight, which makes me feel even worse.
‘… And I’ve tried psychotherapy, too; it was helpful, at least some of the time,’ I added.
‘What type of therapy?’
‘Psychodynamic… I’ve never had CBT.’ That was true at the time although I did try it later on…
‘And when was your last episode?’ came the next question.
‘A couple of years ago I had to have time off because of problems at work… six months… but I am OK now.’
Wasn’t it always work? Or at least this was what I found most stressful. It was never the patients who kept me awake at night but my interactions with the system. My skin was too thin; I was too easily affected by what people said and did around me.
‘… But I do seem to get a bit lower in the winter months too.’
We continued talking for about three quarters of an hour and then came to an agreement about what should be done next and when to meet again.
As I got up to leave, Dr V said, ‘You don’t have to wait out there next time you come; we can find somewhere quieter…’ I knew she was trying to spare me the embarrassment of being recognised by colleagues, but this was something I spent hours telling my patients not to be ashamed about.
‘That’s OK, I’m fine out there.’
I was quite happy to watch daytime television with the sound turned down, along with everyone else in the waiting room.