Mental illness at work

The news that people with mental health problems suffer at work will not come as a surprise to anyone with those problems. In my experience it isn’t down to malice on any one’s part, but clearly something isn’t right if so much talent and money is wasted. Remember that people with mental health problems include some of the most creative people around.

One major problem at work is that mental illness …

“Mental health sees 300,000 people leave their jobs each year”

And I was one.

I should immediately qualify this statement by making clear that I was in no way forced to leave. I was one of the lucky ones: I just didn’t feel strong enough to do that job properly any more, and I had many other things I wanted to do instead. Like writing this blog, and producing the best book ever on consciousness. I was tired and worn out and lucky enough to have alternatives. But if I had been mentally stronger I might have carried on for longer.

The news that people with mental health problems suffer at work will not come as a surprise to anyone with those problems. In my experience it isn’t down to malice on any one’s part, but clearly something isn’t right if so much talent and money is wasted. Remember that people with mental health problems include some of the most creative people around.

One major problem at work is that mental illness is often not considered to be a “real” illness or disability. I know of many people with problems (including myself) who have never been asked what reasonable adjustments could be made to their work environment, and indeed whose requests for relatively minor changes have been met with something between pained resignation and aggressive exasperation. This aspect of things could be improved by better training of managers.

But the power of institutions and employers is limited: institutions and businesses are made up out of people. Generally instititions in the UK at least now have very good rules, and often there’s not much more they can do apart from making sure that they implement those rules, and to help change the attitudes of their employees.

It’s that final bit that’s difficult. How do you change centuries of stigma and ignorance? On the bright side things have changed for the better very quickly, but there is still a long way to go.

We can learn by looking at three areas where there have been enormous strides over the last fifty years: women’s rights, LGBT issues, and race. Again, I am not saying that everything is now perfect – clearly it isn’t, and there are still massive changes in attitudes to be made. They have all though made progress because those discriminated against have formed strong movements and taken direct action. We lunatics are hardly among the strongest people in society, but perhaps we have a duty to stand up and say we are ill, we are disabled, we need help at work. You wouldn’t treat someone with cancer or in a wheelchair this way, so don’t treat me like it.

I’ve lost track of how many mental health support groups and societies there are; there are too many. We need to unite, and we also need to mobilise. It’s difficult when you’re too depressed to move, and difficult when you’re worried everyone is going to mock you, but if you have the strength, it’s time to come out and be counted, and not let yourself be pushed around. Sing if you’re proud to be mad.

 

 

 

Winter is coming

The autumn equinox this year was 22 September. From then on the sun peaks at midday overhead somewhere in the southern hemisphere until the spring equinox late next March. In practice, day and night are of equal length on the equinox, or would be if our earth fortunately didn’t have an atmosphere. In London, on 21 June the sun rises at 4.43 and sets at 21.21; on 21 December the corresponding times are 8.03 and 15.53. That’s nearly nine hours more light in the summer. With such a dramatic difference at this latitude, no wonder so many react to the difference.

Light plays a central role in regulating our biological clock. …

Winter is here – almost.

The autumn equinox this year was 22 September. From then on the sun peaks at midday overhead somewhere in the southern hemisphere until the spring equinox late next March. In practice, day and night are of equal length on the equinox, or would be if our earth fortunately didn’t have an atmosphere. In London, on 21 June the sun rises at 4.43 and sets at 21.21; on 21 December the corresponding times are 8.03 and 15.53. That’s nearly nine hours more light in the summer. With such a dramatic difference at this latitude, no wonder so many react to the difference.

Light plays a central role in regulating our biological clock. We live on a natural rhythm called the circadian rhythm, and our internal clock is set by the action of light on the retina of the eye, transmitted by special tracts of nerve cells to the pineal gland. The pineal gland, situated near the centre of the brain, manufactures a hormone called melatonin. Melatonin helps send us to sleep, so much so that in some counties it is available without prescription as a sleep aid, and melatonin is also used in overcoming jet lag.

Light then is essential for keeping us awake, and sleep plays an important role in maintaining our mood. Most people have heard of seasonal affect disorder (SAD). The definitive mental illness diagnostic system, the American Psychiatric association Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth edition) officially classifies seasonal effects on mood as “recurrent major depressive disorder with a seasonal pattern”. In winter people with SAD are – well, sad. Some people become depressed only in the winter months, and maybe autumn and spring too, and for some people their pre-existing depression becomes worse. Unsurprisingly, given that in winter days are shorter the further north (and south in the southern hemisphere) you go, there are substantial geographical variations in the incidence of SAD, In the USA, in Florida the figure is very low, just over 1%, and in Alaska nearly 10% of the population is affected. Pity the three hundred thousand inhabitants of Murmansk, situated north of the Arctic Circle, which does not see the sun at all between 2 December and 10 January.

I should point out that not ever researcher accepts the existence of SAD. Some studies have failed to find any correlation between mood and time of the year. As with all studies on this sort of subject, much depends on the detail of exactly how mood is measured, how many people are studied, and whether or not they are receiving any treatment.

If people’s moods are affected by the amount of sunlight available then you would expect the suicide rate to vary with the seasons. It does, but not in the simple way you might expect. In the northern hemisphere the suicide rate increases dramatically in May and to a lesser extent June, and in the southern hemisphere in November. This pattern is strange and there is no accepted account of why it happens. One explanation is that when people are very depressed they are too ill to kill themselves, and need the upsurge in energy when they are starting to feel better. I don’t find this explanation wholly satisfactory because I have always felt most suicidal when I feel most depressed; it’s then that I want the pain to end. Most people when they start to recover feel relief. Another possibility is that when people are improving there is a surge in the chemical, or neurotransmitter, serotonin in the brain, and serotonin is associated with aggression as well as mood. In depressed people aggression can be directed towards themselves, leading to self-harm and suicide.

Suicide rates also vary across regions. If you look at a map of Europe there is an increase as you go from the south and west to the north and east, and again it is not simply the case that suicide is always more common in cold, dark regions; socio-economic and cultural factors play a large role too,

I graph my own mood, as I suggest everyone with a depressive disorder does, and have noticed a slight seasonality effect, but it is much less pronounced now I that I am on fairly effective medication.

We are not completely helpless when the nights start drawing in. Those fortunate to be able to overwinter in southern California should now start thinking about packing their bags. Those a bit less fortunate should book their winter holidays, going somewhere likely to have as much sunshine as possible. For the rest of us, there are still things we can do. SAD lights, which emit very bright light (look for at least 10,000 lux) and which produce light in the shorter, bluer frequency range, are now cheaper and much more widely available than they were just a few years ago. But one of the best therapies is free: being outside in natural light as much as possible, particularly in the morning, especially if it’s sunny. Wrap up and get outside.

(The above is an expanded version of my new column in What’s hot London!)

Student depression

University terms are starting all over the country. When I was an undergraduate, the Cambridge term started late, in early October, and our terms were only eight weeks long. That first one was seven weeks six days too long for me.

I have had several responses from students to my blog on dysthymia – low-level persistent depression, or what is now called persistent depressive disorder. The people who contacted me are just the tip of the iceberg. In your class of a hundred fellow students it could be that as many as nearly twenty of them are mentally ill, to some degree, right now. That’s a lot of sick people; imagine a class where twenty people were sneezing and coughing non-stop. Who are these people? Can you tell? Are you perhaps one of them? And a couple of lecturers are probably depressed right now, too.

What’s the leading cause of death for young people aged 20-35 in the UK? Those risky boys speeding round blind bends in their sporty cars? Drugs? Falling under a bus blind drunk? Being mugged and murdered? No, by some way, it’s suicide. Suicide is also the leading cause of death for men under 50. And most people kill themselves because they can’t take the hopelessness and pain of depression any longer. And if suicide doesn’t kill you, depression is associated with a host of disorders, such as heart disease, cancer,  and dementia, which might get you later.

Depression and anxiety are closely related, and usually go together. Epidemiological studies show that anxiety and mood disorders are remarkably common: it’s estimated that one in three people will suffer in their lifetime, and between one in six and one in ten are ill now. The reporting of mental illness has increased, but whether that’s because of better understanding of the disease, better diagnosis, reduced stigmatisation of the ill, increased pressure of contemporary life, or, most likely, all of these, is unclear.

When I was young (under twenty, say), I didn’t know what depression, anxiety, and obsessive-compulsive disorder were, although in retrospect I suffered from all of them. I was aware of something my relatives talked about in rather hushed tones called “a nervous breakdown”. I’m still not entirely sure what one of these was, but I think it was a sudden mental illness requiring some kind of treatment, and even incarceration in an “asylum”. Treatments were very limited back in the 70s; remember that chlorpromazine wasn’t released to the market until 1953, the first benzodiazepine, Librium, in 1960; and the first antidepressants in 1957 (iproniazid, a MAO inhibitor) and 1958 (imipramine, a tricyclic), although these drugs have many serious side-effects. The relatively more benign Prozac (fluoxetine) wasn’t available until 1987. I don’t think I knew about these drugs until I switched as a student from Natural Sciences Physical to Psychology. Indeed when I was a teenager, I thought of treatment as shock treatment; that’s about all there was.

Attitudes started to change when Prozac became widely available; perhaps that’s generally true – diseases only begin to lose their stigma when there is some hope. When I was young “cancer” was another dirty word, sometimes just called the “c word”. Don’t ask my younger self about swearing though; when I was ten, I thought the filthiest word in English was “pub” (where my father went Sunday lunchtime).

I was the first person in my family to go to university, and I had no idea what was involved, no idea really what a degree was (although I knew students “read” for it on University Challenge), no idea how to manage money (fortunately credit cards weren’t available then), no idea how to manage my time, no idea how to study independently, no idea how to live, no idea how to make use of what was available, no idea what a girl was, and no idea of how to cope when I was a raving loony without realising it. I was extraordinarily shy, which didn’t help. I wasn’t lazy; I tried my best, but I had no idea how to organise my time. I expected university to be like school, which of course it isn’t.

I stuck out the first year, mostly because I drift through things and staying was the easiest thing to do, and I was just clever enough to get by in spite of my deficits. The turning point was joining a society where I met other people. I still can’t say that I felt at home, and at the end of the first year I got a summer job where I did. I was earning good money, I had friends of sorts, I seemed to have some purpose, I felt like I was part of a community, and I wondered why go back to Cambridge. At that point I nearly gave up.

I don’t really know why I didn’t; it was easier to stay than not. And when I went back to Cambridge I discovered psychology, and things started to look up.

If I knew then what I know now I would have got professional help. I would have started with meta learning rather than learning. I would have been bolder about asking questions. Mostly I would have realised that I was ill, I wasn’t alone, and that I should talk to people.

What is “normal” for a depressed person?

“Dysthymia, now known as persistent depressive disorder (PDD), is a mood disorder consisting of the same cognitive and physical problems as depression, with less severe but longer-lasting symptoms … dysthymia is a serious state of chronic depression”. Wikipedia.

As part of my mental maintenance, I keep a mood diary. I’ve experimented with several kinds, including apps, but now just use the very simple system of noting one number at the end of each day, on a scale of 1 (extremely, suicidally depressed) to 7 (ecstatically happy), with 4 being “average”. Here is my chart for the last 18 months or so.

moodgraph

The first point to note is that this graph is by no means representative of my life. It begins in April 2016, when I had already been in weekly therapy for well over a year and had at last found the medication that worked (to some extent) for me. I’ve shown the trend line (a guess at the average) which shows a continuing slight improvement over time, although I think this is line is affected by a prolonged and severe relapse I had in the summer of last year. To complete the statistical background, my scores do seem to follow an approximate Gaussian (“normal”) distribution, with my mean score in the middle of the range, at about 4. (Actually it’s very slightly beneath, at 3.8.)

It’s the word “normal” that causes me trouble. What is normal? How can I gauge my mood and experience against what other people feel? And is it reasonable to expect mood scores to follow a Gaussian distribution, and if so what will the mean be?

To give a concrete example, consider someone with PDD (persistent depressive disorder). Their daily mood ratings will presumably be low every day, for long periods of time. Hence compared with people without PDD you would expect their mood rating, if they were comparing themselves with the rest of the population, to be low (as they’re not severely depressed, probably in the 2 to 3 range).

But how do people give ratings of their behaviour? Maybe, completely reasonably, people compare their mood with what they think other people experience – so the moods are relative to the population rather than the individual. But how do we know what others feel?

I use a strategy between the two. And I’m not happy about treating a rating in this inconsistent if not incoherent way. I think a 7 should be “extremely, unusually happy”, although no one should expect to be ecstatic all day long. A 4 should be average for me but not too bad. When I rate a day as “average” I mean I’ve been a bit depressed that today, but no more so than average for me

If you have PDD, your normal is low. I don’t know how other people feel most of the time, but I suspect it must be better than I do. Do you wake up looking forward to the day? Does a day pass without you thinking about suicide and death? Does your day bounce along when you’d say you feel happy? Does your life have meaning? Can you sleep naturally? Do you feel like you have the energy to do everything you want to do? Does the thought of emptying the dishwasher or taking a shower fill you with despair? If so I envy you. Your 4 is not my 4.

The opposite is also presumably true: someone who isn’t depressed has no idea how those of us who are feel. So please keep your comments about “when I’m down I always find going for a good run sorts me out” to yourself.

As I have said before, being depressed steals your life.

Does a psychiatric diagnosis mean anything?

I have a new psychiatrist and a new tentative diagnosis. Or rather, a new additional diagnosis. So at the moment I have been diagnosed at some time by somebody with: severe depression, bipolar disorder, obsessive-compulsiveness disorder, obsessive thinking, anxiety disorder, social anxiety disorder, panic disorder, dissociative disorder, autistic spectrum disorder, narcissistic personality disorder, borderline personality disorder, and now adult attention deficit disorder. I have might forgotten one or two. Although I am certain I have depression and a batch of severe anxiety disorders, parts of all these diagnoses seem right, but none of them alone fits perfectly. I don’t think I’m special in feeling confused, even frustrated, about the problems in getting a clear diagnosis.

When you have a problem with your gallbladder or spleen, the diagnosis and treatment are comparatively obvious. Your just look at the spleen and you can usually see what’s wrong with it, and if that doesn’t work (I’m no spleen specialist) you run a few simple tests, like a blood test, and look at those results. But looking at the brain won’t help for mental illness. You can see a brain tumour easily enough, but you can’t see depression or anxiety. (I admit that this claim isn’t quite true, as there are some correlations between some structural changes to the brain and some mental illnesses some of the time, but the correlations are complex and not perfect predictors – yet – so I think my statement is essentially true.)

And then there is the pathologising of the extremes of normal behaviour. It is perfectly normal to grieve when a loved one dies, or to be upset when something important goes wrong. When does grief edge over into depression? It isn’t easy to say. When is a child abnormally hyperactive and not just rather boisterous? When is a person manic and bipolar rather than just lively and extraverted?

So at the moment mental illness is different from physical illness. Things might change in the future, with more sophisticated imaging and the means of visualising neural circuits and neurotransmitter system in real-time action. But even then we are left with the fact that the brain is a hugely complicated organ and the relation between what it does and its structure is also extremely complicated, and mental illness results from the interaction of developmental, situational, and genetic structures to the whole brain. Although we obviously have many working hypotheses, we don’t have any good complete models of mental illnesses and how exactly they arise, and how changes to the brain and its neurochemistry changes behaviour. I think this difficulty in seeing what is wrong contributes to the stigma of mental illness: with a physical illness, you can see, and therefore point to, your problem – look at my swollen spleen! – but people with mental illness look the same on the outside and on the inside.

Simple diagnoses make life easier for clinicians. You have a label, and then you also have a range of possible treatments: the label will determine that treatment. If you are diagnosed with depression and are given anti-depressants, and you respond to anti-depressants, then you must have had depression. Everything else, like poor concentration, tiredness, anger, lack of empathy, and inability to sit still, or whatever, must have been caused by the depression. But why should disorders of a very complex organ that we barely understand map nicely on to simple linguistic categories devised by clinicians in order to enable them to classify and treat people? I doubt if they do.

I don’t see that for mental illness we are in any better situation than physicians at the time of the Black Death who thought that the plague was caused by a miasma rising from the ground. But at least they could see the buboes. Just look at the mess the idea that depression is caused by a lack of serotonin is in.

In practice there is no point going in to see your doctor, psychologist, or psychiatrist, saying that their diagnosis is rubbish and unscientific. They have busy, difficult lives and can’t know everything. Do though make sure that every symptom that troubles you is taken seriously, and that you receive appropriate treatment for these symptoms. And if after a while things don’t get better you need more or a different sort of help. If your mood improves a lot but your concentration doesn’t, then you shouldn’t feel bad about trying to find out why. Good luck.

Loneliness

Lonely people tend to die younger. They have more health problems when they’re still alive, and tend to be more anxious than average. They tend to suffer more from high blood pressure. They have weaker imune systems. And I’m lonely.

Lonely people tend to die younger. They have more health problems when they’re still alive, and tend to be more anxious than average. They tend to suffer more from high blood pressure. They have weaker imune systems. Bummer.

Of course as with all findings about mental health, you must be careful talking about causes when all you have are correlations (feeling unwell might prevent you going to social events, for example), but it does seem likely that being lonely is bad news. The findings on the positive effect of social support – people with plenty of good friends and a strong social network tend to be happier and healthier – are after all just the other side of the coin.

We can distinguish acute loneliness (loneliness that persists for a relatively short period of time and that arises as a result of loss or transition, such as the death of a partner, change of job, or a geographical move) from chronic loneliness (loneliness that goes on and on and is part of a person’s life over some years). I’m currently reading Emily White’s book Lonely, about her chronic loneliness, and enjoying (or identifying with it perhaps) very much.

I think there is now more of a stigma attached to being lonely than there is to being mentally ill. Most people now accept that mental illness is a result of many factors, and that the ill person is not to blame. However, many people appear to believe that if you’re lonely, it’s your fault. You should just try a bit harder: join a club, do volunteering work, or take a dancing lesson. Or perhaps, they think, you’ve got no friends because you’re not a very nice person.

I admit it: I am chronically lonely – and I’m a very nice person.

Being chronically lonely (just lonely from now on) is related to many other things. White clearly thinks that being lonely and being depressed are very different; the main evidence for this claim is that many people report average levels of depression. I’m a bit sceptical that people have good insight into their mental states (we know from cognitive psychology that our insight is limited), but loneliness does seem to be related to social anxiety and personality factors independently of depression. I can feel lonely at a crazy party. In fact I sometime feel loneliest at a crazy party, where everyone else is obviously enjoying themselves, playing party games and singing songs. I have been in a packed football stadium where everyone else is singing and chanting and cheering and I just can’t join in; it feels false, wrong. I’m not looking down on the people who join in – although it must often look that way to other people – I just can’t make myself feel like other people. I’m an outsider (or as my mother used to say, “weird”, the irony being that she also is a lonely outsider).

I do wonder if people who think of themselves as very lonely mean “lonely” in the same way as others do. I think most people have acute loneliness in mind, whereas I think people like White and me are struggling for a word to capture a sense of alienation and otherness that pervades our lives even when others are present. A lot of what White talks about in Lonely makes me wonder if she just means “single”: a lack of intimacy, having somewhere there, the sound of voices and feet padding on the carpet at home, havint someone to touch, having someone with whom to share everything. But then I have felt lonely when with other people, including partners. Perhaps some of us are just destined to feel different. And for me it is entwined with depression.

But these are simple labels for complex experiences. I have no advice for others in the same party. I don’t want to go to a party or start dancing. Perhaps that’s why I enjoy the gym so much: I can be with other people, who vaguely share the same aim, but who don’t expect anything of me.

 

 

Getting the words out

I’ve been silent because I’ve been busy. I have found that writing my “great work”, The Science of Consciousness, is good for my mental health – although whether I’d be able to write at all without a certain level of mental health is a moot point. Writing gives my life direction and purpose, and structures my day. The amount of work involved makes a mockery of any notion of being “retired”; writing is fulltime job. Consciousness is the most difficult subject I’ve ever written about: to paraphrase the British psychologist Stuart Sutherland “an awful lot has been written on consciousness, mot of it rubbish”; why do I think what I’m writing isn’t rubbish too? I suppose you can only do your best and then just hope. I’m not going to fall into the trap that many psychologists fall into, of equating consciousness with attention, or even just visual attention. I recognise it’s a big, difficult topic.

I have been reflecting about why I have found this writing so enjoyable and so therapeutic. Perhaps it’s obvious, but it’s because I really want to do it. I would probably write it even if I didn’t have a publisher and a contract. The only downside of a contract is often a fairly tough deadline – but if I didn’t have a deadline I almost certainly would work more casually, so it’s an advantage as well as a curse. (And usually the deadline wouldn’t be so bad if only I had started earlier.)

In the odd spare moment that I have, I wonder if my mood would be as good without this purpose. As ever there is circularity: doing stuff makes your mood better, but you have to be well enough to be able to do any stuff in the first place.

Of course in the end I will die (unless I decide to have my head frozen, and even then I expect eventually to die regardless) and eventually my books will go out of print, and I will be forgotten. At this point I envy people with children; they will live on through their genes. As others have observed, our lives are like stones thrown into a pool, causing ripples to spread out. Eventually the ripples fade and it is, for most of us, as though our stone was never thrown into the pool.

When writing a book I try not to think about it too much. I have 150,000 words to deliver before the summer. If I think of it in that way, the task is an enormous one. So I break the task down into 1000 words a day (number of words left divided by number of days left, allowing Sunday off – or rather do those jobs that have accumulated in the week) come what may. I think deciding to miss one day is a slippery slope; of course choosing to miss one day wouldn’t make much difference, but it’s easy for that one day to become two, and before I knew it, a month would have gone, and a 1000 words a day has become 1250. And then there’s reading, researching, and checking. You have to treat it like a job, or any other job I suppose, and just get on with it. I know there’s no point putting off starting to write every day because I know that it has to be done regardless, and starting at 5 pm is much more miserable and difficult than starting at 9 am. I still procrastinate a bit first thing, but I gather many writers do. I think it was Derren Brown who said something like “all self-help books just boil down to – just do it”. If you’re writing a book, writing an essay, or just have to mow the lawn – get on with it now.

Also on the positive side, I have had three outputs this week, and nothing lifts my heart more than seeing my name somewhere.

First, the second edition of my book, Talking the talk: Language, psychology, and science has just been published by Psychology Press. See:

 

 

This book is a gentle introduction to psycholinguistics, the science of how we produce and understand language. I still think the first edition was the best thing I have ever written (so far).

Second, I had a letter in the Daily Telegraph on Tuesday about futurology, robots, AI, and the implications for the economy. I’m a pessimist about these things:

 

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Rather to my surprise, it generated a great deal of interest. There were letters in reply (none of which really addressed the problem, I thought) and offers to write about the subject elsewhere. I think the future is a pretty scary place, and although I would have loved a laptop with fast internet connection when growing up, it could be that I have lived in the best of times – a rather optimistic conclusion for someone as usually as negative as me.

And third, finally, I gave a talk at Durham University on How to be successful in academia, particularly if you’re suffering from mental illness. I’m told it was very successful.

So a good few weeks. Success and achievements lift the spirits – just as you would expect. If you can, do something. But there will be times when you are too depressed to do anything. My advice, based on my experience, is to sit it out. Things will get better eventually, because they always have in the past. I promise.