On depression and V-Tech

You're going to have to forgive me for reposting from my facebook notes, but I just really want this story shared:


Remembering V-Tech
On April 16, 2007 a guy called Seung-Hui Cho killed 32 people at Virginia Polytechnic Institute and State University. None of this is news, the media called it “the V-Tech massacre” and compared it to the “Columbine shootings”. Why does this interest me? Because Seung-Hui Cho interests me. Many people hate him; others tag him with as many psychiatric diagnoses as possible in order to fathom him as a human being. I think it’s also important to have a listen to how he thought of himself, or what he thought, in general. Here are some non-contiguous excerpts of things he said prior to the massacre/suicide: 

“You had everything you wanted. Your Mercedes wasn't enough, you brats? Your golden necklaces weren't enough, you snobs? Your trust funds wasn't enough? Your vodka and cognac weren’t enough? All your debaucheries weren't enough? Those weren't enough to fulfil your hedonistic needs? You had everything.” 

“Do you know what it feels to be spit on your face and to have trash shoved down your throat? Do you know what it feels like to dig your own grave? Do you know what it feels like to have your throat slashed from ear to ear? Do you know what it feels like to be torched alive? Do you know what it feels like to be humiliated and be impaled on a cross and left to bleed to death for your amusement?
You have never felt a single ounce of pain your whole life. Did you want to inject as much misery in our lives as you can just because you can?”
“You have vandalized my heart, raped my soul and torched my conscience. You thought it was one pathetic boy's life you were extinguishing. Thanks to you, I die like Jesus Christ, to inspire generations of the weak and the defenceless people.”
“I didn't have to do this. I could have left. I could have fled. But no, I will no longer run. If not for me, for my children; for my brothers and sisters that you fucked. I did it for them.”
“When the time came I did it. I had to. “

Now everyone points out the obvious things about these words: 1) He resented those that were wealthier or better off than him, 2) He had something like a grandiose delusion comparing himself to Jesus Christ, 3) He denies responsibility to his actions by saying he “had to” do what he did. And those things may be true, but there’s something else about him that interests me. What if he really was just a normal human being reacting like how any other human being would react in the same situation? There’s this segment in the Bible where someone asks why all the “bad” people seem to get everything that they want and he who tried to live a noble and decent life, didn’t seem to get the same benefits, the same riches. What I’m saying is that the feeling of injustice or unfairness is not a new thing, the Bible is thousands of years old. But beyond a common feeling of experiencing frustration, disappointment, resentment, sadness, or anger at injustice, is something else that then enables or empowers you to act. Could this be mental illness? Could these be the immature coping mechanisms they talk about? Maybe. I’m not an expert. I know about something, though, and some people call it depression. 

What I know about depression is that it’s not the same thing as sadness. Sadness is what you feel when you experience loss or disappointment. Everyone has known sadness. Depression is like when there is nothing left to be sad about. There’s just nothing. No companions, no love, no words that could bring comfort. It’s like having this dark being by your side—always—that follows you around and fills your space. It’s what gives you the courage to fear nothing because nothing outside of it exists. Sadness is almost beauty, a romantic ideal you wish you could at least aspire to. In depression there is no love, no beauty—no sadness, even. It’s a void; a dark space with nothing inside and no walls you could even break through. Therein lies the frustration, and when you have no battles left to fight, you cry. Everyone cries, and most people cry at the moment they realize their defeat. 

You know when you have those dreams that you’re falling into a black hole, but then you wake up and you’re still in your bed? Imagine this, but you keep falling for hours, days, months – and you can’t get used to it. There’s no sense of direction or orientation; nothing you can grasp at and no sensible motion, so although you’re moving and falling, you can’t even feel it. You don’t feel a thing. Nothing. Pretty soon you realize you can’t leave, you can’t scream, you can’t see or experience anything other than complete overwhelment at the nothingness that is your life. You can’t feel and so you stop wanting to. That’s the worst part: when desire finally leaves your soul. Nothing hurts and nothing feels pleasurable; nothing you could care about exists. There is you and outside of you there is only darkness and the void. You can’t touch or be touched. You can’t feel or want to feel. There is nothing to be sad about and you’re not. You’re not sad—you’re dead already. You’re not content or satisfied; those things describe nothing known to you—but you’re not sad, either. To be sad one has to be alive, to long for something. When you’re depressed, you’re no longer alive or wanting. Depressed people don’t commit suicide; they commit euthanasia by physiologically killing what on the inside is already dead. 

That’s one side of the story of why someone could react the way Seung-Hui Cho did (and I am using him only as an example). That argument could explain suicide, but what could possibly explain homicide on such a large scale? I believe it’s not such a large leap. When nothing matters, when you realize you have nothing to lose because the future has already being decided and there are no consequences to fear because you won’t be living with them, then you are the most powerful being around. In this line of thought, it’s quite easy to believe you are a God, with the ability to do as you want, to decide who lives and who dies, to act with ultimate freedom. The knowledge of your power is what allows you to explore all your options, things you may never have even considered before, things like actually hurting random strangers “just because you can”. 

I’m not trying to justify Seung-Hui Cho’s behaviour at the end of his life. But I do believe it’s important to remember “the V-Tech massacre” if only for the reason of trying to understand. George Santayana said “those who cannot remember the past are condemned to repeat it”. So lest we forget. 

—11/04/2009

On the military and PTSD

There’s something I have wanted to discuss for a little while now but didn’t feel quite ‘qualified’ to. In fact the other reason I hesitated was because I was unsure of my future career direction/choices. It is a comment about the military, or more specifically I should say it is about post-traumatic stress disorder in ex-military persons.

What do I know about the military? Actually, having always been a civilian and having no family members with military or political pursuits, you could say I know nothing about it. Even growing up during the course of a civil war of the kind South and Central America was famous for in the 1980s, my own family was always politically neutral and non-participant. But I admit I do have a very privileged position in my job where people often share with me their stories – and don’t we all have our own war stories to tell!

Now, I won’t violate the trust gifted to me by the men / patients who have told me their stories, but I don’t even need to because the themes of their stories are all so similar. At some point in their journey they have come across me for very simple reasons, for something so banal as to re-prescribe them a certain medication. Usually they will tell me that they have been on some medication for years and just need to continue it, they are content with it, and they need it. And the types of medications they are on are pills for insomnia, for anxiety, to help deal with substance dependency, for depression, for psychosis – essentially medications to help them deal with negative thoughts and noxious mental states. I have previously discussed how men in particular are rarely keen to take psychotropic medications because of some concept of misplaced pride, and yet here I encounter men who are almost desperate to continue on these medications. Do you know what the difference often is? These are men who have seen hell, it lives in their thoughts and memories – they are the men who have been in military combat. These are not weak or desperate men, on the contrary; these are the men every country calls their “heroes”!

Post-Traumatic Stress Disorder (PTSD) is not a new concept nor is it specifically related to military service. Basically it describes a negative mental state that occurs after a person has suffered any traumatic experience. They will often re-experience the negative emotions experienced at the time of the event; often accompanied with vivid recollections of the event itself also. They will feel fear, panic, pain, hypervigilance, etc., exactly as they once did, and often this will be unaffected by the time that has elapsed since the initial event. The initial event can be any traumatic experience, and it is different for each individual with PTSD. Having said that, there are few things in life quite akin to active military service life. And you know what kind of people go into the military? All kinds.

The men I’ve met who tell me their stories almost invariably say ‘I wish I had known’. They wish that someone had told them about the nightmares every night, the hypervigilance and anxiety that denies them enjoying even simple things like just walking down the street without feeling on edge as they once did fearing they would be shot, etc. They wish that someone had told them that joining the military wouldn’t just be a way to secure employment training, to learn self-discipline, to defend and serve one’s country, to procure excitement, or the other variety of reasons a person may join military service. The disenchantment comes when the brave men taking life-and-death risks consider that they were deceived by a sin of omission. And more than disenchantment is the reality that few tasks in this life are as psychologically-endangering as the tasks encountered in warfare.

Of course, the military is possibly the best institution at training personnel in a variety of tasks, and their personnel learn how to “do their jobs” effortlessly. However, how many other jobs are there where you are personally in charge in deciding whether the person standing in front of your weapon will live or die, or that the chances of you killing someone are about the same as those of getting yourself killed, or seeing other human beings (adults, children, civilian, enemies, comrades) been purposely injured with weapons / things that were specifically designed with the intent to harm others? My job is not that stressful; I’d dare say very few other people’s are too. There's no way of estimating which types of events will be psychologically-traumatic to a person - but you can almost be sure that the kind of tasks encountered in military service are quite unique and should at least come with a forewarning.

And that is what these men wish they had been told; that’s why a lot of them become disenfranchised with the whole institution. A lot of these men feel that they have been treated not as men, not as humans, but as “things”, as these commodities that shoot the guns, as if they were merely an extension of the firearms themselves and not human beings with thoughts and emotions and brains that capture moments and memories for years to come. They wish they had known that. It’s a shame we do this to our “heroes”. It’s a shame we feel the need to go to war at all or that those few in charge of making national decisions send others to “represent” them; but if we must fight, I dare to propose that we are at least kind enough to those on our side.

On poor us

I’ll start by acknowledging that I’ve recently finished reading the book ‘Affluenza’ by Clive Hamilton and Richard Denniss and so I’m not even trying to pass off any of these ideas as things I’ve discovered myself. One aspect of the book I found particularly interesting is not so much the “outing” of our obsession with ourselves and with money, but rather the way we see ourselves as deprived.

I wasn’t raised in a wealthy family (or in a rich country, for that matter). When my family moved to Australia (and my mum still describes it this way), it was like entering paradise. There was no immediate threat of death from warfare, no real struggle to put food on the table or pay the rent, nothing but encouragement to pursue our education, and besides readjusting to a new culture, a new language, and missing friends and relatives, there basically was nothing to complain about. My family was one of the very lucky ones where a large proportion of our family immigrated to Australia also, so in fact after the first year or so there were few of us to miss. We soon learnt the language (we were actively taught it!) and we made new friends. To describe some aspects of our lives in Australia to people back in El Salvador for them is incomprehensible. Things like, for example, free (and high-standard) basic healthcare, housing assistance, and government co-payments for students, disabled persons, the unemployed, single parents, etc. We are fortunate amongst our family and amongst other peoples born in third world countries; and not just my family, but Australians amongst the world’s citizens are so extremely fortunate.

What’s my point? Well, the truth is that if you ask most people in affluent countries like Australia if they are content with their financial situation, the things they have, their jobs, their houses -their lives- they’ll say no!.... But wait, aren’t we so wealthy and well-off and living in ‘the lucky country’? Yes, but that’s other people, not us. We have bills we struggle to pay, things we wish we could own but can’t afford, thankless jobs that consume all our time and energy, and family and friends we have lost touch with. Collectively we are the lucky people in the lucky country, but as individuals we feel deprived. Feeling deprived and being deprived are two different things, though. The reality of it is that if you look at the pure facts, the numbers, the truth of it is the vast majority of Australians are not homeless, are not going without food, are employed, are managing to pay their bills, and most households own at least one car. You can look around you and immediately you know this is not a third world country. That is the reality of it!

What is it that we are deprived of then? We are deprived of satisfaction! And you know what the most intriguing reason of why we are so dissatisfied is? Because if we weren’t dissatisfied, then why would we keep working jobs we don’t like, for the long hours that hurt us in so many ways, just to buy the things we don’t really need? The question then becomes, well, then who is it that is keeping us dissatisfied, who makes us believe we are struggling, that we are a deprived people? In short, industry and government.

The advertising industry , the entertainment industry, the manufacturing industry, the pharmaceutical industry, etc, are all trying to sell us things. To sell us any product, you first have to convince the consumer that they are better off with it than without it. Even if there is nothing wrong with you, you could still be better off. Never mind you already having a functional car, a comfortable house, and practical clothes; no, that’s not good enough. They want us to believe that what we should have is a bigger more luxurious house, a luxury car, and the newest clothes of this season. Why? “Because you’re worth it.” There’s another thing that has been marketed heavily by industry: our deity. We deserve everything, just like the celebrities have. When you see yourself as being unable to afford the newest and most expensive of everything, of course you’ll feel deprived! And that’s good news for industry because then you’ll keep slaving away at your job to buy more and more of these things, which only keep getting more and more and newer and newer. Of course, if it all gets too much, then it’s time to make the poor pharmaceutical industry some money and invest in their pills that cure the human soul.

A people who are deprived is a woeful thing; thank God for politicians who can make it all better for us! That’s right, the other group of people interested in perpetuating the myth that we are all struggling are our governments. The benefit to them is that if we believe ourselves to be struggling and they promise to provide for ‘the battlers’, then they can secure our votes. I can’t recall a politician stating as his election plea that he will ensure that wealthy people can afford to buy a newer luxury car. He would be scorned! Instead we would rather vote for the guy who wants to help poor folks like us (who are “poor” only in the sense that our lives aren’t like those on those fictional films or because we don’t own the things that celebrities seem to).

We are sold the idea of deprivation from various levels and multiple interested parties. They sell it so well that we are unwilling then to recognize what is so clearly around us. I wish there were interested parties who thrived instead in helping us see truth, building up our self-worth and self-esteem, someone that would remind us that we are poor only when we rely on material things to define ourselves. I once read about a different sort of dissatisfaction, one I would like now to share:

On prescribing choice... and the hypocrite's spiel

There are many people who will tell you that pharmaceutical companies are the devil. I say the devil is the devil, but I also say the pharmaceutical companies are no angels. Let me first disclose something to you: I eat the lunches brought in by the pharmaceutical sales representatives (almost everyday at my work!), I give my patient’s their drug samples, I enjoy their “educational” dinners at expensive restaurants, I am grateful at their supply of products ‘directly related to my clinical practice’, and I miss the days of the free drug-stamped stationery and random gifts. I do not claim to be immune to their marketing tactics simply because I am aware of them; both they and I know that I am human and the tactics exist because they do work. There are those who directly embrace the drug companies with the attitude of ‘hey, if they want to give money away, they may as well give it to me and I will do what they want me to do’. And there are those that completely shun them, who demonize them, who accuse them of being a… a business. Aren’t we all in business? Those who claim they aren’t, aren't in business very long.

Just this past week I recognized a tactic by the sales reps I hadn’t noticed before: bullying. Now, what I mean to say is not that they wanted to humiliate or hurt me, but they sure as hell wanted to make me feel guilt. Now if I remember correctly from my industrial psychology and marketing readings, creating negative emotions in targets is one of the least effective methods to inspire change of behaviour (in this case, prescribing more of the drug they’re promoting); however, least effective doesn’t mean ineffective. The rep was telling me of some new medication; was I using it, she wanted to know? I said no, I studied a little pharmacology too and I felt more comfortable with another medication. She was horrified! Did I not know that it was the most popularly prescribed medication in its class, prescribed by the greater majority of my peers?! My mind was thinking ‘yes, and?’, but I said, ‘Oh, ok. I’ll keep that in mind. Anyways, thanks for the lunch.’ I went away thinking, wow, really, everyone but me uses it, was she implying that I am doing the wrong thing by prescribing something other than “the most popular”? Is it the most popular because it’s the most effective, because it the newest (and newest we are told is better), because they are better doctors than me and if I want to be good then I must be like them. As I walked towards my consulting room from the lunch room where I had the food brought in by the friendly drug rep, I realised it had worked. I was here second-guessing my clinical management not based on clinical data or evidence, but based on simple human emotion: everyone likes to be liked and to be like the rest. I then laughed at myself.

A few weeks ago another drug sales rep was speaking of a medication for erectile dysfunction. Of course it was about the drug, but they alway tells everyone “it’s about the patient”, thinking of what’s best for them. There’s no news or controversy in saying this; no matter what industry you work in, at the end of the day everyone must eat (and you need money to buy food, right?). Every drug rep walks in to that lunch room and comes with 1) our daily bread (or gourmet lunch), and 2) the “educational material” to impart to us that just so happens to show that the drug their company sells is better for our patients for some or another important reason. But this drug rep wanted not to tell me about why their erectile dysfunction drug was better than the other two, but wanted to know what I based my choice on. I’ll tell you what I answered but first I just want to consider another point on prescribing choice.

Now, you could have five different drug reps talk to you about five different drugs from the same class, both targeting the same “disease” (I’ll explain later why a disease is worthy of my quotation marks here), and they can all show you with ‘real clinical evidence’ and ‘scientific studies’ that their company’s drug is the best. The first rep will say their antihypertensive is the best because it, say, doesn’t have this bad side effect. The second one says theirs is better because it reduces blood pressure quicker than the others. The third one says theirs is better because the effects on reducing blood pressure last longer. The fourth one says it their drug tastes better and is in a smaller pill and that this is very important to patient compliance, therefore in fact being the best drug because patients will actually take it. The fifth one will say theirs is the newest and is so many times better than a placebo. Who wants to be associated with the old and outdated, right? Ah, the stories…

What I answered my friendly drug rep is actually not anything new to them. Why do I prescribe a certain erectile dysfunction drug versus another? Honestly, I confessed, my choice was based on whatever sample pack was in stock in our drug samples cupboard. They know this, that’s why they like to stock our cupboard, not because they like to give away “free samples”, but because it works at securing consumers. I have to clarify a little, though, I use this rather non-clinical method to guide my prescription choice only in certain conditions that in my experience the medications are only slight variations on each other with similar clinical effects, for example as in erectile dysfunction. The second reason to why I do this is because these medications are very expensive and I want my patient to try it first before he goes and spends his hard-earned money on something that may or may not be right for him. Most doctors do this, too. You give the patient the sample pack and a script to purchase the medication if they are satisfied with the effect or tolerant of its side-effects. In cases like this, I prescribe what is in the drug cupboard because I know the brand name will make little difference to the clinical effect I am trying to achieve in a patient. For some reason my honesty seemed to surprise the rep and I think it is because there must be some secret pact that we, both the pharmaceutical companies and doctors, must deny that our interactions are in fact business transactions and we should pretend they are purely “educational” and clinical.

As a medical student I did a placement at a clinic that strictly forbade pharmaceutical reps from visiting to promote their products (or should I say, educate us). It was a clinic were most of the clinicians also held academic posts at the university and they were thoroughly involved in evidence-based medicine. I remember one doctor specifically telling me about how he always prescribed the generic version of a particular drug because it was the cheapest and therefore it meant less money spent on government subsidies paid to the drug companies, and subsequently more money left in the health budget for other essential matters. It made sense to me.  Some years later I worked at another clinic where another very noble and more senior doctor advised me that I should prescribed the brand-specific version of a medication for depression that was now off patent. The reasoning was that the company that made this brand of antidepressant was highly involved in drug research and development and also at producing patient education and support materials, but they obviously can’t afford to do that unless they are making money also. It made sense. Yes, besides I also knew that once you allow for the generic version of a medication to be dispensed by the pharmacist, he incidentally happens to supply the patient by the generic version of a medication which is made by his pharmacy chain. Oh, everybody is a businessman. So my choice is then, who do I feed? The pharmaceutical company making the brand-label stuff or the pharmacy chain making the exact same but generic-labelled stuff (which in most cases cost no different to the brand-label medication). Ah, such decisions… Oh yeah, that’s right, this was mean to be about the patient!

Another thing that the pharmaceutical companies are accused of is not only of making healthcare a business (which I don’t believe they are solely responsible for), but of also creating disease. What do I mean ‘creating’? This is mostly in reference to the medicalization, the labelling, of certain human existential states as disease. Some years ago I read a story about how bad it apparently is that we have made things like pregnancy and ageing disease-states. In a similar vein, drug companies have been accused of doing either a good or bad thing, depending on your point of view. One could say that thanks to the educational and public awareness campaigns directed by our blessed pharmaceutical industry, so many people can be diagnosed and directed towards the treatment of many ails such as depression, anxiety, mood swings, hyperactivity, etc. etc. Another group of people report that the drug companies directed these campaigns as a diversion to their real campaign: increase uptake of certain medications (mostly psychotropic medications). They convinced people that their sadness, that their agitation and worry, that their child’s childish behaviour, are abnormal and required treatment – by using the drug that their company so happened to manufacture. Oh, so many coincidences…

And what have I achieved in telling you of these few tales? That I am a hypocrite? Maybe. But hopefully I have also reminded us all that we live in a capitalist society and that denying that there is a devil at our table won’t make that devil any more of a saint. Worse than being the devil’s pawn is not knowing that you are. As doctors, as human beings entrusted with the care of others weakened by disease, we must ensure that that truly is the worst thing: that we sell our own souls, and not that we trade in those of our patients for a piece of the devil’s share.

On pride and prejudice... (not the book)

I have previously discussed aspects of the discrimination against people with mental illness. Specifically, I have spoken about it in the context of romantic relationships, how remaining together “in sickness and in health” means in health and in most other illnesses expect psychiatric ones. And of course, intimate relationships are not the only context this occurs in. Even in the health industry there is a deep-seated contempt of those coming into hospital medical departments with wounds that are related to a psychiatric disturbance. But what I find even more bizarre is how people can discriminate against themselves, often denying themselves a better existence, because of a connotation to mental illness!

In my job I meet a lot of people, people who we as medical professional often create. Almost every health professional can tell you a story about “some junkie”, a person with a substance addiction that they met along the way. But there’s a particular sort of person that we at times encounter and we don’t immediately think of as “a junkie” but we know that they’re addicted to prescription medication. In my experience, it’s usually the benzodiazepines class of drugs, the Valium-type medications. There’s a few main reasons why benzos are particularly good to get yourself hooked on: 1) they work, 2) gives you immediate ‘results’, and 3) doctors have fewer qualms about prescribing it than other dependence-forming drugs.

A scenario I see very often, and which I admit frustrates me to my core every time, is the young man coming in to see me for his repeat valium (diazepam) prescription. I ask why he’s on it. He says anxiety. I ask how long he’s been on it. He says years. I ask why. He says for anxiety; it’s really “good” at “treating” it. I ask how much he takes. He takes it “only” 2-3 times a day. I do the sums – he is taking huge amounts of it! I ask why he never had his “anxiety” treated, why he didn’t get proper treatment, why he never had counselling, why he isn’t on more appropriate medication. He says it’s because he doesn’t get “anxiety” that often or that it is not very severe; he only uses the tablets every 5 or 6 of the 7 days in a week, 2-3 times a day.

Usually at this stage my heart sinks because the next part of the conversation is also very predictable. I ask does he know it is very addictive. Yes, he knows, but he only takes it when he needs it, those 2-3 times a day on those 5-6 days a week. Again I ask why he takes it (yes, I always pray the patient will have an epiphany – and no, they never do). He takes it for anxiety, of course. I tell him that it must be pretty devastating to be feeling anxious to the point of needing external relief 2-3 times a day almost everyday; surely that would be very uncomfortable. Yes, he tells me, it is pretty unfortunate – but luckily the drugs are so good at “treating” it that as soon as he takes one, within minutes he feels better. I offer a friendly suggestion: wouldn’t it be better to be able to function without having to feel so anxious almost all the time, wouldn’t it be great to be free of the anxiety? Yes, he concedes. Good, I am relieved he agrees! I say ‘ok, let’s get rid of the anxiety then’ (usually I’ll have figured out by this stage that this guy has no time or patience for psychotherapy, he prefers a pill, even a bandaid if that would do it). I suggest this tablet, you take it only once a day, it’s safe, not addictive, and it has a longer time of action so you need only take it once and you won’t have those flare ups of anxiety at random times during the day or week. He doesn’t believe that’s possible. I assure him, it is; in fact if he takes it everyday he won’t even need the valium for those random daily attacks of anxiety because he just won’t be having them anymore!

He has a question for me now: is the medication I am talking about also called an antidepressant? I say, well, it is an SSRI medication which are classed as such, but has a mode of action that will relieve him of his symptoms. At this point he says No!.. But, but, why? He tells me the story again about his anxiety not being that bad, he doesn’t get the symptoms that often (only 3 times a day, 6 days a week), he’s not depressed, he doesn’t need an antidepressant tablet, he’s not crazy, why change what is working, etc., etc. I explain in vain that what he is taking currently, the valium, isn’t working because if it was he wouldn’t need it everyday, multiple times a day. He assures me it does work, because he takes it and he feels better… and eventually I realize that no-one has ever made a person addicted to a substance rationalise about their dependency. It’s the very nature of addiction, there are no great epiphanies – at least not about why ‘feeling good’ is bad. And it breaks my heart that this person would rather take a tablet with much less stigma amongst prescription pills, almost with the status that alcohol has compared to illegal substances, than take the one he really needs. And he makes his choice because of the association this other medication has to “bad things”: a mental illness such as depression. Apparently it’s a matter of shame to have ANY association to mental illness.

Let me now tell you of another class of patient. He also doesn’t want to be thought of as mentally ill. Luckily for him, he isn’t! He has this condition, a complex pain syndrome, a condition that is very difficult to treat. I met a man once who had been diagnosed as having fibromyalgia. The poor guy, was such a shame to see him; he was in discomfort and pain all the time. He had seen a lot of GPs, a few specialists, spent hundreds on natural remedies and iridologists, spoke to anyone that might be interested and asked for help. Eventually one medical specialist got him started on a medication he hadn’t tried before. He didn’t get his hopes up because he had tried many many medications with no relief. But, amazingly, this one worked! He was free from pain; it’d been months, maybe years since he felt so ‘normal’. And then one day he picked up his tablets from the pharmacy and started to read the consumer information page in the pack. And then he read in there that this drug was a TCA – and that the A in that means antidepressant! He was furious, disgusted, so angry at the doctor that told him to take it. It didn’t matter that the tablet alleviated his symptoms; what was intolerable about it was its name, its association. He stopped taking it immediately and attended his doctor to express his disgust.

I spoke to him a few months afterwards, his face was all cringed and he seemed in a lot of pain. He told me the story of what had happened and about how disgusted he was that the doctor had offended him by giving him an antidepressant for his fibromyalgia. He imagined that the doctor thought he was “crazy”, that he was only pretending to be in pain, etc. I let him speak and then I asked it the medication had worked, though. Yes, he said it had – but that was not the point. My heart again sank a little and I explained to him (gently, not trying to tell him what to do), that the TCA type of drugs are commonly used for some types of pain, and that they are very effective. I said they are called tricyclic antidepressants because their original purpose was to be used as an antidepressant but this new use for them had been found and it was great for pain of that particular sort. Yep, good story, Vanessa; he believed me because he knew I have a medical degree, but pride isn’t always about having rational or accurate information. Poor guy, I still see him in so much pain.

Now I’m going to deflect a little to tell you about something I initially thought about when I was at university. There was a ‘gay rights’ rally and in response to someone’s judgement that homosexuality is a disease and a social evil etc., someone had made a banner saying “homophobia is a disease”. It was like the perfect comeback. Only I’m a nerd who probably overthinks things and I was at the time studying medical microbiology and infectious diseases, so I immediately thought: cancer is a disease too. The point is no-one chooses to suddenly grow a cancer because they want to endanger their life or a limb or organ, or because they like to suffer. Most of us can at least empathize on seeing a person sick with cancer, ravaged either by disease or chemotherapy. I have never met anyone who would discriminate negatively against someone with cancer, someone with a disease they did not ask for, a disease that is beyond their control. Mental illnesses are a disease also, something no-one asks for or can internally control. Why should we accept that it is OK to discriminate against those suffering an illness? It’s sad that almost any reference to mental illness, whether people, disease processes, and even the medications used to treat it, still attract such great discrimination. Maybe the time for a new human rights movement is arriving.