If we are serious about suicide prevention… what about this conversation?

I find myself constantly despairing about the missed opportunities to change our ways of thinking in order to prevent mental illness and suicide.

I’m worried we are taking a less than optimally effective approach to suicide prevention.

I was reading about Australia’s  “you can talk about suicide” launch.

I found no reference to shame in the document and that concerns me, as shame, I think, isn’t far from self-loathing if it’s not talked about, shared and normalised.

What about “How to have conversations which disclose and normalise the experience of shame, and self shaming internal dialogue?”

I don’t believe we can have an effective conversation about suicide until we are skilled up in having this conversation. 

I think it’s not that hard, but the principles of the conversation are counter-cultural.. let’s start on that project ASAP rather than conversations which assume that depression or anxiety have an internal locus (diagnostic model) with a biochemical basis, on top of causal genetics and experiences and therefore respond to fortification or medication.

The diagnostic model is struggling to achieve great results in primary prevention. It’s had an OK effect on secondary prevention but I strongly believe that looking at the social construction of mental illness might be more fruitful. 

Let’s start the conversation with the question “We all suffer from shame in some form or another. What would I need to do differently so that you and I/we all can talk about our shame and work together against its effects?”

What do you think?

“Mental Illness” and medical students with Anxiety/Depression

So today I heard on the radio that 3 point something percent of medical students are suffering from a severe form or mental illness, which was described as anxiety or depression. A brave young doctor spoke out about her own experience. You can find the information here .

What I want to say about this is simple, and I believe vital.

That we regard “anxiety/depression” as “mental illness” is part of the problem.

Continue reading “Mental Illness” and medical students with Anxiety/Depression

Do you do an emotional workout?

It’s 11am and I’ve already (unintentionally) done my emotional workout for the day. It started with a phone call where I learned about a senior doctor (supported by two colleagues) bullying medical students. (not in my town fortunately!)  They berated the students, accusing them of arrogance, stupidity and weakness. The students were told “Know your place!” all because the students asked to be excused from an activity so they could study for their upcoming exams. Haven’t these doctors been reading the news?

ANGER– Which I have re-narrated as “passion for justice”. When will we turn our medical culture around? I felt ashamed of and angry with some members of my profession.

Then I read about the outpouring of generosity for the homeless student who wants to be a criminologist and is living in a tent under a bridge (It must be SOOO cold!) I shed a tear or two.

THANKFULNESS TO OTHERS for being so compassionate. I felt good to be a human.

Then I remembered all the work I had to do today! I had a little panic.

FEAR- I had a little chat with fear, thanking it for reminding me not to waste the whole day, and re-examined my expectations. I wouldn’t try to do so much. The panic was a little less overwhelming

Then I decided to head down to the local coffee shop for coffee and a croissant (yes I know it’s pro-inflammatory! and yes it might have been avoidance!) The new Florence and the Machine album was playing, the sun was streaming in, and some kind patrons were rescuing a terrified wandering little dog outside. I read a funny clip in the Herald Sun from a lavatory in Japan

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LAUGHTER AND JOY

That’s it. Workout over. On with the working day!

Must get a physical workout in later!

Appreciation

My friends are all heading overseas, or are already there. Well, not all, but many. I’m envious, but have decided to turn this into a positive. What if….. I was a tourist here, in Geelong? What would I notice? How would I experience life differently. I was pondering this, when I saw this…

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What a beautiful eucalypt! Subtle sunset colours in its upper branches at the end of a wonderful crisp wintry day. I was biking home from work. What a privilege to live as an unpersecuted person in Australia. Tomorrow I hope to catch up with some friends who are still here. I’m not envious any more, and I’ll do some more of the “What if…..?” technique, as today it seems to have put me in touch with the simple things I might have missed.

Rethinking medicine- the microbiome, diet and disease

Ok. This is my third post and it’s really the first one that has anything to do with the URL “unorthodocs” which I derived from being a doctor and finding my ideas really on the “fringe”. This has been the case for most, if not all, of my career. As a GP I found myself admiring people with so called “borderline personality disorder” when my peers were in a different frame of mind. I became interested in narrative therapy as a very respectful way of dealing with suffering rather than the diagnostic model which believed in chemical deficiencies, ideas of “normal” and “abnormal” and pharmaceutical supplementation. (I’m not dead against this, obviously, but against the overuse of this model, especially when it doesn’t help). In the 1990s I became interested in what we thought then was “food sensitivity” despite much scoffing by some of my peers.

Anyhow, times have changed. The stuff that was scorned is suddenly OK again. Colonic enemas, once quackery, are being reappraised as we contemplate faecal transplants for some conditions now that we have a new of understanding  of disease.

The new model is complex. It can’t really be simplified. But here goes (forgive any oversimplification- but it’s not possible to do this simplistically- we really stuffed up previously with oversimplifying eg: “Saturated fat is bad for you”, “cholesterol causes hardening of the arteries” etc.)

We all come with a genetic makeup. Some genes protect us from disease. Some predispose us- there’s a lot of luck here, but diversity is important for survival, so we are not made as clones. This is not new thinking- I’ll get to the new stuff soon.

We also come with a microbiome: that’s bugs in us and on us. (In fact they are mainly “on us” as the gut is technically part of the exterior world, and that’s where the most bacteriae reside).

Our microbiome is unique to each of us. It depends on our early exposure (Caesarean section anyone? Would you like a five-fold increased risk of food allergy with that?). If you are born by vaginal delivery you get a microbiome very much based on your mother’s gut microbiome rather than her skin microbiome. That’s probably good.

Our microbiome is then modified by our lifestyle- predominantly our diet, but also by exercise, antibiotic exposure and other medications that we previously didn’t realise also kill some bugs and favour others.

Our microbiome directly or indirectly alters our metabolism, our desires, food preferences and cravings. (Google “neuropods” if you are interested!). We westerners eat an excess of food. It can also create inflammation in the body, directly starting off processes that underly much of our troublesome diseases.

A healthy diet for you may not be so for me. We have different genes, and they might even be because we are descended from different cultures or geographical areas. We’ve adapted differently. Then add in what might be our uniquely healthy microbiome. Our optimal internal bacterial community will differ depending on whether we are descended from populations whose staple is maize, wheat, rice, millet or others. And it will move and change dynamically with our diet.

The microbiome and disease.

There is lots being written about the microbiome. A lot of it is not new, but a lot is. Rather than write a huge essay, here is a start-

There are some bacteria that are appearing as culprits in the generation of dementia, depression, diabetes, infertility, inflammatory bowel disease. These diseases may be more related than we think. They all involve inflammation. Firmicutes species (some types only) Proteobacteriae and Clostridium difficile seem to appear in the police lineup with suspicious regularity. Currently we have a few suspects, and a lot of crimes. Matching them up will require supercomputing, not conventional research trials.

Anyway, it’s not just the microbiome that’s new on the block in our understanding of disease. There’s a few people around challenging the orthodoxy in our understandings. And their ideas are looking plausible. Some are greatly more plausible than what we doctors thought was fact:

Diabetes and insulin

What if we are wrong about diabetes? What if insulin is as much the problem as it is the solution? What if diabetes is an adaptation to overnutrition? (ie- get so sick you have to stop overeating, and spill glucose into the urine to avoid it being driven into overloaded and inflamed fat cells) If overloaded reserves are the cause of organ damage, treating with insulin may be harmful. Maybe we should be advising increased fat intake and reduced carbohydrate intake (a reliable way of reducing total calories) thereby reducing the need for insulin (see the Ted talk by Peter Attia, or the work of David Lustig, Jimmy Moore’s podcasts, or David Gillespie’s books here, and read them all discerningly- no commentator is perfect.)

Cravings

Still on diet here… what if cravings are mediated by the bacteria, and it’s not just as simple as willpower? What if we are blaming people for a neuropsychoimmunological response that is beyond their control, just like we blamed people for TB before we understood it was caused by a bacteria? (I read an article making this connection, but I can’t find it to make the attribution here)

At medical school we were told about dopamine and cravings. We were told what parts of the brain were involved. We were told about addiction, but we didn’t know about the microbiome and how it might be calling the shots here. We were told that the vagus nerve (brain to gut) was a superhighway with 2/3 of its traffic going from gut to brain, but not why.. no-one really knew.

But back to medicine. We have a number of epidemics currently. Two of the most serious are metabolic syndrome (“diabesity”, “fatflammation”, “carbohydrate-storage-disease” call it what you will) and the second is abuse including domestic violence and sexual abuse. Both have solutions but require paradigm shift. I’ll talk about abuse in another blog.

Suggestion – Change our food guidelines.

I think we should abandon our reductionist dietary guidelines that confuse us by dissecting food down in some semblance of  a scientific experiment. We could stop doing trials that distract us from the obvious, and stop trying to control variables that can’t be factored out and ultimately leave studies wide open to criticism. Instead we could adopt sensible National Food Guidelines like Brazil’s. Or just to keep is simple, we could avoid any “food” that doesn’t rot or wasn’t in existence before the industrial revolution- they are most likely not a real food.. more likely a  “food like substance”. We should, as Katz found when he compared all diets, eat food, as close to nature as possible with a predominance of fruit, nuts, vegetables and fibre. We should eat just enough to satisfy hunger.

Meat is problematic. Apart from the ethical issues, it’s pretty hard to find meat that isn’t based on grain-fed animals or fish. Grain isn’t great for animals or many humans, but grass fed meat is expensive, less available, and we can’t make enough to feed the world.

I think we should ignore consensus derived guidelines and stick to evidence based recommendations, or if there are none, regress to traditional pre-1900 diets appropriate to our genetics.

Warning- if you are diabetic, don’t experiment with diet without sound medical support.

I advise finding an up-to-date doctor (Try the word “microbiome”. If your doctor looks puzzled, move on, or suggest tactfully they update their education). If you have cravings and are not diabetic, do the painful withdrawal from sugar and processed carbohydrates (yes, even whole-grain bread) and use fats, nuts and fermented products to assist by reducing the number and power of the bad carb-dependent bacteriae that feed the cravings. If you are diabetic, carb withdrawal should be supervised as your natural insulin will likely start working again and you will need medication reduction, so see a doctor who is up to date.

There’s a lot of exciting research being performed and new strategies are emerging to prevent or treat diseases when previously we could only despair our therapeutic impotence. The drug companies are also excited. See this article in Nature. I prefer to be excited about lifestyle and dietary change without popping pills, but each to his/her own. The microbiome will be big, and people aren’t even talking yet about the virome (your average spinach leaf is teeming with viruses which can kill bacteria called phages, and it seems they attack the bacteria that cause us harm). It will take decades to nail the virome and make it into pills, so in the meantime, lets just stick to green leafy vegetables like grandpa and grandma said.

 

Airport ponderings re: friendship

I’m sitting in an airport with an hour or so to kill. (How fortunate and environmentally irresponsible are we in Australia that jet travel is available to the masses- $38 to travel 900km!)

Nevertheless, putting aside my greenie guilt factor, I’m contemplating friendship, and the dynamic exchange of values. Rather like a tide washing back and forth. There’s a bit of intercontinental drift too.. Some of my friendships have just drifted away, without any active encouragement or discouragement- “that’s just the way it is”. Others are consolidating and as this happens it helps me to contemplate love. There’s much to love. I don’t understand it, but I’m enjoying learning more about it and myself.

So I’ve just had a few days with a dear friend whom I love. He’s a pretty chilled out guy. Quite different to me, so I learn a lot from him. And we have our differences which we exchange. Somehow I feel that if we were partners we’d get to a base level disagreement that would deconstruct or self-destruct our friendship, but the luxury of friendship is that you can actively make decisions to ignore, or tolerate, or learn from the differences. Why is this so much harder in our chosen relationships (which are often formalised by marriage, defacto agreement, whatever)?

Coincidentally, while spending time with my friend, I received a belated invitation from an another (“old”) friend to an event. He’s very like my current friend in a way, but it’s complicated. We spent a lot of time together in our formative years and we have so many of these experiences to reminisce about, but I feel I failed in my part of the friendship. There were some differences that I wanted to explore, and his “model” of friendship meant NOT exploring these. “You just tolerate these things quietly in friendships” (Not his exact words: I can’t remember them, but that the message was explicit). I miss this friend and I grieve not knowing what is going on in his life, but I haven’t made the steps to bridge the gap of time, and it’s widening. I haven’t had a meaningful conversation with him for many years now, so what to do?

Expediently I could say “We’ve just drifted apart”, but what is that? I’m a very social person, and I’ve “moved on”- I hate that expression.. look at the offence Julie Bishop has caused with invoking the good old “let’s look forward” after the execution of Andrew Chan and Myuran Sukumaran, and I totally see why. Its reminiscent of John Howard not getting why an apology to our indigenous population was needed- when you are “moving on” you lose an opportunity to reflect and learn from the past.

So what have I learnt? Not sure, but I know I value my friendships deeply, and I feel that I’m too fickle- I love my friends, but I know that some of the “special” friendships have changed. Making someone special has huge spiritual benefits, but can also generate expectations and raise the risk of letting them down. (My greatest fear!) Then there’s the complex ingredient of their life choices of friends and partners- what to do with all the factors there? Loyalty, politeness, tolerance, jealousy, anger, bemusement, amazement and shock and awe are some of the experiences I’ve had watching my loved ones in their relationships. One thing I know about committed friendship is that the commitment process is wonderful self learning.. if painful. Makes me humbly ponder, and often overthink (more about overthinking soon). I wish I could just package it as “That’s just the way it is”. I’d be much more “chilled”.