The black dog

The Black Dog is costing us. High rates of those claiming a sickness benefit cite mental illness as the chief reason. Over half of patients seeing their GP are presenting with some level of psychological distress. Nearly one and a half million prescriptions a year are being filled for antidepressants. The DHB is funnelling resources into assisting those classed as severe; the greater number of mild and moderate cases are seen by GPs, or are not seeking help at all.

Life is fast paced, busy and full. For many it’s just too much. Throw in any number of relationship, employment, financial (and other) pressures and the Black Dog can turn feral.

The meaning of life, our search for gratification, our sense of curiosity, are all elements of what we term the human condition. It’s in all of us, in different forms and concentrations. It’s the thing that brings us wonder, creativity, joie de vivre.

There’s a dark side too to the human condition, especially when difficult life circumstances, genetic makeup, traumatic experiences and chemistry come in to play. People sometimes struggle to cope with the day-to-day. Some turn to medication, others self-medicate, some people find a way to ask for help, a few don’t make it out the other side.

In its Annual Plan, the Hawke’s Bay District Health Board (DHB) outlines its overarching approach to health. Key strategies include “better, sooner, more convenient” care, enhancing the capacity and capability of primary and community-based providers, and increasing focus on wellness and supported self-care. This approach is applied to all health, whether it’s mental or physical.

“As we move progressively towards the more minor mental health problems … the emphasis has to be on equipping primary care, communities and families to support those who need help,” says DHB clinical director of mental health Dr Simon Shaw.

The DHB does put resource into mental health; in 2011-12 it budgeted around $37 million for mental health (about 8.6% of its total budget). But the DHB focuses its activities on those ‘severely affected’ and, to an increased extent, is clumping mental illness and addiction services together. For those presenting with mild or moderate mental illness, sometimes seen as depression and anxiety, the DHB relies on Primary Health Organisations to coordinate support through primary health providers, like GPs.

GPs the point of entry

Dr David Doig has been in general practice in Havelock North for ten years.

“We’re the 50 cent psychiatrist, to put it bluntly,” says Doig. “The barriers are that you need to be tremendously unwell to attract the services of the hospital.”

Barriers are also raised by the need to fund support once a suitable avenue for help is found. Although patients can occasionally access up to six free sessions, counsellors and psychologists don’t come cheap, with $150 a session the average.

“Being psychologically unwell is quite challenging financially,” says Doig, who estimates one out of every four patients he sees would be primarily dealing with a psychological illness.

“And in two or three out of every four there is an element of psychological distress,” he says.

Although the numbers are high, he sees 110 patients every week (alongside the 140 some of his colleagues may see), Doig believes it is only the tip of the iceberg. “The levels of hidden mental illness are pretty enormous. People are very good at hiding things from family and friends.”

Around 15% of New Zealanders (WHO figures) suffer from mild or moderate anxiety, and often it is left untreated. Only the US figures are higher (27%). The last mental health survey carried out nationally in New Zealand – Te Rau Hinengargo, 2006 – found that a large proportion of people developing mental health problems, even severe ones, never sought or obtained healthcare at any level.

For most, the process of seeking help – if they do – starts by visiting their GP.

“Everyone is quite different and they approach us in different ways. Some people come in with what they think are physical problems – lungs, heart, brain – some are dragged in by someone else. It’s very individual.”

GPs then have a range of resources to help people, of which one is antidepressant medication. Counselling, psychotherapy and sessions with Weleda’s nurses are other options.

The government-funded Primary Mental Health Initiative is designed to assist people experiencing their first episode of psychological illness in the mild-to-moderate category. After a screening test GPs can refer patients for four fully-funded counselling sessions. But the initiative is capped. For the 11 doctors and 10,000 patients at Doig’s practice there are only 11 places on the initiative every quarter.

“The mental health service is stretched very thin. They are under pressure to see people with the highest need. There’s a high turnover of staff. It’s a high-pressure area of medicine. They should get the best conditions but they tend to be the poorest.”

Gender differences

Doig cites comedian Mike King and sportsman John Kirwan as real heroes in terms of mental health advocacy. Few people are willing to talk openly about their own mental health.

“John Kirwan’s impact has been quite extraordinary, especially in terms of New Zealand men coming in.”

OECD figures mark depression as the leading cause of disability in high-income countries. Although overall the prevalence of mental disorders is about the same among men and women, depression is more common among women, with men more likely to experience substance-abuse disorders.

A recent study by Dr Kate Scott and Associate Professor Sunny Collings of University of Otago has found men with anxiety or depression have more difficulty functioning on a social level than women.

“Women are more likely than men to experience mood and anxiety disorders. What is new is our finding that among men and women with those disorders, it is actually men who experience greater difficulties in role, social and cognitive functioning,” says Scott, who suggests the findings should be taken on board by health providers, clinicians and policy makers.

Dr David Doig believes the pathway towards becoming well again is very specific to each individual.

“It’s the patient’s journey and they have to be ready for it. Just coming to us, discussing things, identifying solutions, that may be enough for some people.

We will see some people who simply want chemicals to fix the problem, and there is a place for antidepressants. Probably as many as 60% benefit, there’s a percentage who are made worse, and a percentage where there is no effect at all.”

Medications have pros and cons

Journalist Lindy Andrews has first-hand knowledge of the mental health ‘journey’ and antidepressant medication.

“You have to sort out depression from sadness. Depression is a very different animal. It’s called the Black Dog, and it really is a blackness that dogs you.”

After years struggling with her own health, Andrews has become an advocate for a raised awareness around what antidepressant medication can do.

In 1993 a number of significant stressors – at work, in her relationship and with family – meant Andrews began experiencing panic attacks, she couldn’t sleep and she had trouble compartmentalising. Her GP suggested Arapax, one of the first selective serotonin reuptake inhibitors (SSRIs) brought into New Zealand.

“At first the medication gave me energy, it flattened me emotionally, it made me impervious to stressors.” But within a month Andrews was also experiencing physical problems. “I developed a movement disorder, I was beginning to lose clear speech and I had to stop work.”

Andrews spent 16 years on antidepressants and it took until 2009 to discover her increasing disability was an adverse reaction to antidepressants, specifically SSRIs.

“Over time I progressed from Arapax to Prozac to Cipramil. I was prescribed them for anxiety, but they could be prescribed for depression, anxiety, pain relief. Until the early 2000s it was believed they had no side effects.”

There is certainly more information available today, with most drugs having been used for five or six years overseas before coming to New Zealand. Drug side effects, while now clearly stated, are still staggering. One such drug, Efexor-XR (advertising in the Listener, 25 Aug 2012), lists “common side effects” that “include stomach, bowel, urinary tract problems, headache, difficulty sleeping, drowsiness, dizziness, nervousness, confusion, agitation, muscle tremor or weakness, fast heart beat, menstrual problems, weight loss, sweating, hot flushes, hair loss, bleeding or bruising more easily than normal, changes in your eye sight, sexual function problems.”

“For a great number of people these medications do work,” says Andrews. “Although I had a severe adverse reaction, I wouldn’t recommend anyone suddenly stop taking their meds. It’s vital people talk to their GP or psychiatrist first.”
However, Andrews is clear that if she had her time again she would think carefully before taking antidepressants. Over the last twenty years she has found other things that help tremendously with her anxiety and depression.

“At the time I took medication I was under extreme stress. In retrospect there were several things I could have done differently. I could have learned to relax, I could have taken more exercise, improved my diet, had some counselling. But, like many people who live in this truly fast-paced world of ours, when I was offered a quick fix, I took it.”

Verona Nicholson is a counsellor who practices psychotherapy. She has been in private practice for over thirty years and in Hawke’s Bay for eleven.

Her experience is that medication used to get through the day can also help facilitate personal work with a counsellor.

“For some people meds can give them a foot up so they can address things. It can give them some stability so they can go to a counsellor when they might otherwise not even be able to get out of bed,” says Nicholson.

PERSONAL STORIES

One in four suffers from mental health issues, but what does that look like on a day-to-day level? In the personal stories told here, names have been changed to protect the anonymity of those interviewed. Although it is discrimination, insurers, employers, landlords, even some friends and family, make judgements on people with a mental health diagnosis. The people whose stories are told here are living in Hawke’s Bay, and have recent experience with mental health and its service providers.

Rae is 38 and has cared for her step-daughter Emma, now 17, since she was a toddler. Rae is married and has three younger children.

“When Emma came to us she had lots of issues. She had no rules, no routine. I took her to specialists and they’d always say it was a social issue.

“At school, the counsellor saw her every day from when she was 5 to 12. She was brilliant and she helped us a lot. During that time Emma went to Australia for four weeks to see her mother. After she came home we got a letter saying we were being done for sexual abuse of Emma. Her mother had signed an affidavit saying Emma had told her these things. I ended up taping phone calls and in one Emma’s mother let it slip that it was lies. Eventually we were cleared. In the meantime Emma went through hell.

“Then Emma’s mother cut her off. No presents, no letters, no phone calls, no nothing. We didn’t hear from her for five years. And as she got older things got more and more complicated.

“I ended up going to Directions Youth to get help for her – I knew she wasn’t right – but it didn’t really help her and they couldn’t tell me what was wrong because of confidentiality. She’d go through moments of serenity and calmness, then for a month we didn’t know what might happen, she’d really go off the rails.

“When she was 15 her mother rang out of the blue. Within 48hrs she’d gotten into my meds and taken a lot of them. She tried to knock herself off.

“I took Emma to my GP and he prescribed an antidepressant and referred her to the DHB. A psychiatrist there talked to her for a few hours. He felt she had long-term depression. We went to the psychiatrist for eight sessions and then she was supposed to be miraculously cured.

“She was on antidepressants for a whole year. They were good for her but she didn’t like taking them.

“She was physically violent. She’d spend a lot of time alone in her room. She went from rages to sombre moods to being fine. When she gets backed into a corner her first thing is to lie and manipulate. That’s what she’s figured out works for her.

“When Emma turned 17, she was drinking and she wasn’t doing so well at school, then her half-brother turned up – she hadn’t seen him since she was little. A month later she hit rock bottom, it was April this year.

“I took her back to the GP, he said she needed to go back on antidepressants. She refused. Then a few weeks ago she threatened to kill herself. I didn’t believe her, but I rang the hospital. They told me to make sure sharp objects and pills were kept away from her! That was their advice. A few days later a social worker met with us. After a one-hour conversation he wrote a report on her. It was a very slanted view. It didn’t show the depression, stress or anxiety we see at home. What she needs is a no-nonsense psychiatrist who can get into her head.

“Because she’s over 16 I can’t make her see a counsellor but because she’s under 18 I have to have her living in my house. I know she needs help and I’ve found her that help since she was five, but now no one can do anything to help her until she signs a bit of paper, and she won’t do that.

“Until she turns 18 we walk on egg shells waiting for the next big thing, it’s like watching a tornado coming towards you. I don’t have a problem with sex, drugs and rock ‘n’ roll – you know the demons you are playing with. Mental health is like fighting a ghost.”

Kim is 41. Divorced with two pre-teen children, she is a professional working in the health industry.

“My personal experience was that I’ve had shit years for as long as I can remember and the only thing that changed was to see it reoccurring in my children.

“I’d always had the perception that life was hard, that it wasn’t fair and that what happens in your life is of your own making – you can’t really turn around and complain. When things went wrong I felt it was my fault and therefore I didn’t deserve any help.

“Eighteen months ago I crashed with my past and I couldn’t hold it back. I had a breakdown to such an extent as I couldn’t look after my children anymore. One day I got up, I dropped the kids at school like normal, I said goodbye to them at the gate, I got in the car and I drove for hours. I just wanted to disappear. I had no plan except to get away.

“My personal experience is not that I wanted to die. What is true is you get to a point where you can’t keep going. It’s like walking through treacle. You can see the door but physical exhaustion means you can’t get across the room.
“I went into my GP and said I wanted antidepressants. I said I needed to take care of my children and he had to help me. The GP made me see a counsellor, initially for six sessions. He wouldn’t give me drugs until I agreed to that. I was very defensive and it’s true to say I only did counselling so I could get the drugs. I was very clear I had no intention of lying on the couch for years and years – I wanted tools.

“The most cathartic thing was just telling my story. Getting it out of my head. You can’t answer all the questions all at once – you peel off the issues and leave them sitting there to unpack later. I left tons of weight in that room. I felt lighter but also the drugs would have kicked in by then.

“The medication I take is almost ritualistic now. I don’t question it. My GP told me I have to take it for two years and so that’s given me two years to begin to sort things. Then I’ll reassess.

“When it comes to medication, there was no minute when I suddenly said ‘wow I feel great’. It made no discernable difference until maybe six months down the track – it just smoothed things out. The highs weren’t so high, the lows weren’t so low. It hasn’t made life happier and it doesn’t answer any questions.

“I was in my mid-twenties when my father took his own life. It’s obvious that genetics is part of my picture and it’s stupid of me to think I would escape some kind of mental health issue – it was the package I came with.

“Depression for me was when I became overwhelmed with choices, emotions, decisions and exhaustion – it’s so overwhelming you can’t think, and your brain and your body just stop. I physically couldn’t get up in the morning. I couldn’t do normal things. I was immobilised by it.

“I feel so lucky to have had that breakdown, without it I would have gone on as if nothing was wrong with no room for transformation. I feel very hopeful about the future. I’m not there yet – and that’s exciting – but don’t get me wrong, it’s terrifying too.”

Happy pills

It has been twenty years since Prozac and what’s known as the new generation of antidepressants became available in New Zealand. Every year use of the drugs climbs steeply. Prescribing has nearly quadrupled since 1993. Pharmac estimates 400,000 New Zealanders are on antidepressants.

Each year about 1.4 million prescriptions for antidepressants are filled. This is up 36.6% from 1 million in 2006. There are 18 antidepressants on the New Zealand market, with three added in the last few years.

Hawke’s Bay is on the lower end of the figures with about 12,000 scripts filled each year.

Dr Peter Moodie, medical director of Pharmac, says the peak of spending on antidepressants was ten years ago. In 2003, we spent about $30 million. Now, $20 million each year is spent on the drugs. “Although the numbers have gone up, the prices have gone down,” Moodie notes.

At the mild-to-moderate end of the mental health spectrum, the question is whether to treat at all, says University of Otago’s head of primary health care and general practice, Professor Tony Dowell. With the average length of time for depression being around three months and often linked to a traumatic event, such as a job loss or marriage break-up, should we even treat mild-to-moderate depression?

Another expert in the field of antidepressant medication, Professor David Healy from the University of Cardiff has received press here in New Zealand and internationally for claiming drugs may be more of a hindrance than a help in cases of depression. He believes only one out of every ten prescribed so-called ‘happy pills’ is helped by them. He also feels pharmaceutical companies hide evidence about the effectiveness and risks associated with psychiatric drugs.

Distressed youth

For many, teenage years can be when mental health issues first show themselves. Diagnostically it may be referred to as ‘adjustment disorder’. Some young people have a shaky time and get through; for others, what manifests in adolescence stays put long after.

Fiona Rainbow has been a counsellor at Directions Youth Health in Hastings for nearly seven years. She works with 10-24 year olds.

“Thirteen to sixteen is a particularly difficult period and people often need more support than just their parents. Schools have counsellors and there is help at the Napier Family Centre and Family Works, but some want anonymity. We have a free service for youth and that encourages young people to take control of their own health,” Rainbow explains.

In the years she’s been at Directions, only two or three clients have been prescribed antidepressants, although a number of others have come to see her while already on medication.

“If there is a struggle that’s persistent, that’s affecting life, we talk about medication as a support while we’re doing therapeutic work.”

Adolescence can be a trial for some but there are often other things at work when mental illness presents itself.
Fiona Rainbow: “There are hormonal changes and changes in the limbic system, and if you add time, drugs, alcohol, predisposition, the impact of friends who have perhaps committed suicide, vulnerability – there’s a lot of things at work.”

Societal changes mean young people are perhaps not as prepared for the ups and downs of life than they may have been in the past.

“In our two-minute-noodle society we are less trained and less familiar with strategies to live through hard times as humans. There’s a lack of richness and depth of understanding that life is a mixture of hard and good,” says Rainbow.

A major drive is currently taking place focused on the mental health of youth. Over the next four years the Government will spend $62 million overhauling mental health resources to ensure they are “youth-friendly and technologically up-to-date” (John Key, April 2012). This will include investigation of technology, such as Facebook, smartphone apps and online pop-ups, and $2.7 million in funding for computer administered “e-therapy” tailored for young people that can be carried out at home.

While many people, once they have come through it, talk about their mental health experiences in the past tense, Fiona Rainbow is in the thick of it. The immediacy of her work makes it a vital link in the mental health equation.

“Working with young people is very ‘live’. It’s happening now. While it’s happening you can hear them, honour them, give them strategies. There are things you can do to really help before it becomes ‘for life’.”

“Gone After A Long Illness. At Peace Now.”

For the legions of people accessing some form of mental health help, there are one or two who don’t make it through. Suicide is not something we talk about openly in our society. Most people know someone affected, but in obituaries and eulogies we use euphemisms to protect ourselves from painful questions: could I have done something more to help?

GP Dr David Doig: “In the first five years of practice I was very nervous about what might happen if I got it wrong. Now it’s more a recognition that even if you do everything right there are some who will not be saved, and I think in the approaching decade we may see more.”

Data published in April 2012 by the Ministry of Health showed 111 suicides in Hawke’s Bay from 2005-2009. Every year there are 500 across New Zealand with 2,500 intentional self-harm hospitalisations. Men are three times more likely to suicide. The highest risk ages are 15-29 and 45-54.

Sometimes suicide comes out of the blue, but often people have been seen at some stage by a health professional.

DHB’s clinical director of Mental Health Dr Simon Shaw: “Very sadly we do see suicides occurring from time to time in people in contact with mental health services. This is partly due to the fact that, just like severe heart disease or severe lung disease, severe mental illness does sometimes result in a fatal outcome despite everyone’s best efforts. It is an enduring myth that every single suicide is preventable. If a person is determined to carry out a suicidal act and doesn’t tell anyone of their intentions then prevention is very hard.”

Verona Nicholson feels that seeking support can itself often come after a long journey, “A real hurdle is that it’s hard to ask for help. There’s a culture of ‘you should be able to manage’. There has been some shame attached to it, creating an attitude that if you sought help you were mentally ill, as opposed to being a person who was suffering and didn’t know what to do about it. And further that you couldn’t seek help unless you were feeling extremely mentally unwell. But the more mentally unwell you are, the more disenfranchised you become, and the harder it is to get help.”

“Sometimes people don’t know where to start. In many ways you have to hit bottom before you can begin to climb out,” says Nicholson.

Lindy Andrews certainly hit rock bottom, two fold, the mark left on her by SSRIs overshadows that left by the anxiety she began feeling twenty years ago.

“There are tremendous pressures placed on women anyway: raising children, holding down a job, staying fit and healthy, doing the majority of domestic chores at home. Add some stressors, then it’s basic laws of physics: for every action there’s an opposite and equal reaction. But we don’t want to put a halt on our lives long enough to get better.”

Lindy’s advice for anyone first identifying the need to talk to a GP about mental health is this: “Don’t expect a GP to do it in ten minutes, so make a double appointment, make a list of things that are bothering you so you can be clear about your needs, ask if there are options other than antidepressants.”

Dr David Doig agrees: “First, be honest with someone close to you who can support you. Secondly, understand that GPs have enormous experience with mental health and the best thing to do is not be shy or embarrassed, and to bring up the big issues right at the beginning of the appointment.”

“Many people come to us with something physical, a sore elbow for example, and it’s only after a lot of talking that we get the real reason they made the appointment,” says Doig.

“It’s much better for them if they are upfront and honest right at the start. Then we can really help.”