Intended for healthcare professionals

Rapid response to:

Practice A Patient’s Journey

Psychotic depression

BMJ 2012; 345 doi: (Published 24 October 2012) Cite this as: BMJ 2012;345:e6994

Rapid Response:

Re: Psychotic depression

I too applaud Rebecca for writing this account. I hope that her objective of changing colleagues’ attitudes to mental illness is altered by it. However I am uncertain because I think that many of us are comfortable with a sharp divide between doctors and patients- the barrier between doctors and patients is more than just knowledge and a white coat; it is my belief that some of us self select medicine in order to deal with our worst fears by helping those who present with what would be to us, intolerable illnesses, but by working on them in our patients we master some hidden angst. I say this as a practising consultant psychiatrist and as a sufferer for over 30 years from Bipolar 1. Therefore whilst I find resonances with many aspects of Rebecca’s history I must admit to never before this having had the courage to declare myself as such ie both a user and provider of psychiatric services. Some reasons for personal secrecy are to do with the enormous personal struggle I had to accept having this condition (even though I recognised the onset-episode whilst denying it was a severe post-partum-psychosis in discussion with the obstetrician on Day 4 after the birth of our eldest son) and I only started to think a little about it on my own by reading an undergraduate text book in our attic 18 months later, when the first cycle was resolving.

I had no treatment for this first episode (other than being threatened with being sectioned ) and subsequently had 15 years living in an emotional desert – scared to feel happy – through 3 subsequent pregnancies, early family life with some degree of marital misunderstanding. Finally I commenced psychiatry as a career in my mid-30s, and in Higher Training under the pressures of a demanding professor (!) and unresolved grief, I became very depressed and sought assistance via the Royal College of Psychiatrist’s helpline (worked brilliantly). My mental health has vastly improved since (medications lithium+ others ) but with further mixed affective episodes with psychotic features at times of specific stress, due in no small part to the hard work of my psychiatrist – a busy NHS consultant and academic, to whom I have open email access and have had continuity of care. This I think, must be a perk of being a doctor, but I needed, and got, the best of personal committed, genuine care after the years of isolation with my fears. However in contrast to Rebecca I have not found that knowledge of my condition has been helpful in work situations, indeed rather the reverse. I recall a medical manager attempting to offer therapeutic advice, but more disconcerting was simply the feeling of being observed, monitored or evaluated when the going got tough in one consultant post. I do feel my personal experience has been of value in clinical practise. I think I have been patient and able to listen and try to understand the experiences of the other person (the patient) – really at times it doesn’t matter what the words say when people are extremely distressed, it is the emotional tone (or to my mind the music) that must be understood, which is done empathetically. In doing so I have been aware at times that I was crying out inside myself for someone to have been able to hear my terror, hold my hand and lead me out of that state of fear during the abyss of that first episode patient experience I had had.

I have now taken early-age retirement from the NHS and continue to practise independently. I feel satisfied with my NHS career – the later decisions triggering retirement were to do with organisational issues, and am able to reflect on this part of my life. I found my intellectual drive in my mid-30s was satisfied, the routine of professional practise invigorating and I did well in exams and presentations and had a rapid rise through the training grades that surprised me, but as important as that was for my self-esteem, the best happened when I commenced lithium as by then our sons were teenagers and I can look back on those days with them knowing I was a happier, less irritable mother than previously.

Given my life over again ideally I would never have been ill, or if so I would have retained insight at the beginning of an episode – I never have done, apart from some minor depressive bouts related really to trying to get off long term antidepressants. The mixed affective states are exhausting, scary and at times I have acted or said some very ‘eccentric’ things during them that are later very embarrassing. I have lost many friends through this and have been quite guarded in personal relations since as a consequence. I still struggle with laughing and feeling happy…..but am getting better at it. My inner most thoughts when my mood changes are never expressed, and certainly not written down, but I have learned to soothe myself with music and a little painting. I expect to need good medical care from a psychiatrist with excellent communication and medical skills ie as at present someone who can assess my mental state without asking a series of semi-structured interview questions (aren’t they a give away?) until I don’t know when (I am glad to say).

Hope this has helped some people. Not sure there is a point to it other than the chance to join in this conversation, and in writing it I am very conscious of the most recent tragedy that has affected a family in Wales via post natal depression. This then takes me back to Rebecca’s reasons for writing her erudite piece – I must therefore second her call to speak out, and add to it: What about the Royal College of Psychiatrists taking a lead on this?

Competing interests: No competing interests

31 October 2012
Eleanor E Kerr
Consultant Psychiatrist