crackedmirrors and angelpie

I woke and heard the news about the death of Robin Williams with a sinking heart. For me, and I am sure many other manic depressives, it was doubly distressing. Distressing not only on the individual level – the loss of an extremely talented man, the loss of a husband and father – but also the personal distress that manic depression had claimed another life. Irrational though it is, there is a feeling that if the illness can rear its head and take the life of someone like Robin Williams then it can also take the life of an ordinary person. I know that to be true, as within the last 12 months manic depression has taken the life of an acquaintance of mine, a dynamic successful GP in his fifties who on the face of it had everything to live for. Petre was no ordinary person, famous in his own circles, but ordinary in comparison to Robin Williams.

Many column inches (and probably much air time) have been devoted to Williams’ life and death, and I have chosen not to read most of it. However I was struck by two article that appeared in the Guardian the day that Williams’ death was announced; one by Russell Brand, and one by Mark Lawson. The two could not have been more different and it was Brand (of whom I am definitely not a fan) who wrote as though he knew what he was talking about, and had some understanding of manic depression. Lawson on the other hand was superficial in his writing, and I found this comment “The fact that all three actors had suffered serious addictions and depression must be worrying for the industry and suggests that fame lessons and psychological counselling should perhaps be added to the curriculum of drama schools” unbelievably crass. Lawson seems unaware that manic depressives often have addiction disorders, whether drugs, alcohol, or (lack of) eating. These are secondary to their primary mental illness although they may certainly contribute to mood instability. Lawson glibly suggests that ‘fame lessons’ and ‘psychological counselling’ be added to the curriculum of drama schools as though these actions would prevent those with manic depression from becoming unstable. Speaking as one who has had virtually ten years in therapy (at a frequency of 1-3  times a week) I can say that therapy certainly helps one come to terms with chronic illness, and helps one understand one’s self much better; it may also help improve compliance with medication, but it cannot offer a safeguard against major, and potentially suicidal, shifts in mood.

A feature of manic depression for some, though by no means all, sufferers, is that the illness is infinitely appealing in some of its aspects. Kay Jamison, herself a manic depressive as well as a highly respected Professor of Psychiatry and authority on the illness, writes:

Who would not want an illness that has among its symptoms elevated and expansive mood, inflated self-esteem, abundance of energy, less need for sleep, intensified sexuality, and- most germane to our argument here-“sharpened and unusually creative thinking” and “increased productivity”?

This is something that is very difficult for friends and families of manic depressives to understand. Why would you want to have, and then under-treat, an illness that carried a high rate of suicide? Stephen Fry, in his well publicised documentary The Secret Life of the Manic Depressive memorably asks various sufferers whether, if it was possible, they would push a button to stop them being manic depressives. I totally identified with the man who had survived a serious suicide attempt, yet said no, he would not choose to be rid of his illness.

The key to living well with manic depression (which we are supposed to call ‘bipolar’ – presumably considered a more user friendly name) is to have access to high quality medical care. I have been incredibly fortunate (more by luck than judgement or planning) to have exactly that. The front page of the Guardian the day after Williams’ death carried an article that showed all too clearly how enormously lucky and privileged I am. An interview with the President of the Royal College of Psychiatrists, Professor Simon Wessley, reveals that about 70% of people in the UK have no access at all to mental health services. As he rightly says, if this statistic applied to cancer there would be massive public outcry (and probably the fall of the government), yet when mental health is concerned there is a black hole. One might consider this curious since about 20% of the population suffer with mental ill health at any time, but of course mental illness is still highly stigmatised in our society, so the majority of sufferers try not to reveal their illness. Danny Baker recently wrote an article titled ‘Seven reasons why the mental health stigma is a killer‘. His number one reason is that stigma stops people from seeking help. I believe this to be very true, but if a person is persuaded to seek help, Professor Wessley’s statistics show that help is very unlikely to be available. A friend of mine, an articulate professional woman, finally picked up courage to see her GP (after much prevarication). She was given a prescription for some antidepressants and told that she would benefit from a short course of CBT. Two years later she has heard nothing about the CBT and is still taking the antidepressants.

I know from my own experience, both personal and professional, that it can take a long time for a doctor to get to know their patient, particularly if the issues involved are complex or intimate. One of the most important things for stability of mental health is a stable and trusting doctor patient relationship. My own life has been saved on two occasions over the last 16 years because I trusted my psychiatrist implicitly. This trust has been built on monthly half hour consultations, which have increased in both length and frequency when I have been ill. Needless to say I have paid for this care. The NHS, in which I trained to practice, and in which I fervently believe, was unable to offer me even rudimentary specialist care when I first became ill, and my then GP told me that although he respected my views about private practice, he strongly advised me to accept private mental health care. His view was that there was effectively no specialist mental health care available. (In fact, had the few months of NHS mental health care that I had received as a student many years earlier been good enough to make a correct diagnosis, it is possible that I would not have presented to my GP 16y ago with acute hypomania).

All this happened 16y ago, and I know that the situation in my part of the country remains largely unchanged. Professor Wessley’s comments suggest that the problem is not restricted to the south coast. With regular outpatient consultations and a handful of hospital admissions I have remained mostly very well. I have had to stop the job that I loved, but have been lucky in finding an alternative career that is absorbing, and more forgiving in its demands. Of course I have spent thousands of pounds over the years – more than I care to add up. Again I am very lucky in having a highly supportive husband, and a good pension from my previous career.

Only a tiny minority are as lucky as I am. The harsh reality is that most people with mental illness will not get any specialist medical help at all. Those who do will usually get very substandard care. They are unlikely to see a psychiatrist on any regular basis, and certainly unlikely to be able to form a meaningful therapeutic relationship with him/ her. Most secondary care treatment occurs via the community mental health team, where the reality (as opposed to the laudable theory of pooled expertise) is that you are most likely to be seen by a psychiatric nurse or occupational therapist a few times and then returned to the care of your GP. The NHS cannot currently afford high quality specialist mental health care, in fact the reality is that it cannot provide even the minimal level of care to all who need it.

As Robin Williams has shown, money and access to good mental health care cannot insure against death from mental illnesses that carry a high mortality. However, high quality care can offer access to a high quality of life, and may help to reduce mortality. Current NHS lack of care surely contributes to unemployment, socioeconomic deprivation, stigma and probably over-medication. This is a scandal that remains unrecognised and under-reported.