Overshadowed

A couple of years ago I did some work around inequalities in healthcare; the fact that people with mental health problems or learning disabilities tend to get significantly poorer access to and outcomes from health services. This was a reaction both to the many examples I’d come across through working with advocacy organisations and the BMA report that showed that diagnostic overshadowing (i.e.  ascribing physical health complaints to issues relating to mental health or disability) contributes to a shortening of life expectancy of between 10 – 15 years.

Sometimes these issues are framed in terms of a shortfall in the person; that the person can’t speak up or articulate their problems well. Or that there is an intrinsic interlinking of mental health and physical health pathology. I’d like to offer an alternative narrative, but to do so I have to give some additional context.

There was a time when I was able to keep personal and professional stuff completely separate. Some of you will know that this kind of ended when I was open about my experiences with depression. In one post I talked of trying to view my depression as a state from which I was recovering rather than a one-off incident like a car crash. The comparison wasn’t arbitrary. I’d recently been in car accident and was sure that the road to recovery would be swift. Now, almost two years later, I am still dealing with spinal pain. Though I am a fan of irony it is little compensation for the pain and the impact that has on my life.

So what does this have to do with anything? Well, a little while ago after the physio had said I had a clear and consistent problem relating to a couple of my vertebrae I was sent for an MRI scan. When I phoned my GP surgery to find out the outcome, the doctor that I spoke to said that the results were unclear as the image not good enough for diagnosis. No problem there, such things happen. The next thing they said surprised me, though it really shouldn’t have. In short it was along these lines (paraphrased for brevity) :

GP:         I see from your notes that there are references to depression. Are you sure that the pain isn’t just an expression of that?

Me:        I’m pretty sure. I think it’s more to do with being in a stationary car that was hit from behind by a car going over 30 mph. The pain started about an hour after the incident. It hasn’t changed for 2 years. I’m pretty sure that’s the more likely cause.

GP:         But you might not know how depression can affect the way you perceive pain. Are you sure it’s not about that?

Me:        No, I’m pretty sure it was the car accident. I know a bit about depression, this isn’t part of it. By the way, how did you jump from “the image isn’t clear enough for diagnosis” to “are you sure it’s not in your head?”

GP:         Erm…

There’s a wonderful idea in logic called Ockham’s (or Occam’s) razor. It basically means that  if there are a competing ways of explaining something, you should choose the explanation that relies on the fewest assumptions. The GP assumed that it was more likely that I would experience back pain as an expression of depression. I assumed that it was more likely to be down to being rear ended by a car.

The GP assumed that an unclear MRI scan was down to my depression. (No, I don’t get it either). I assume it’s more likely to be down to having to lie on my back for a scan on an injury that is exacerbated by any pressure being put on my back. I would say that I’d leave it to you decide which was the more likely explanation, but we’d both know I was lying.

I was able to talk this through with the GP, we got to a reasonable endpoint. But I absolutely felt as if a health problem with a definably physical cause (it even had a registration plate for goodness sake) was being put down to my past mental health. It takes a pretty big assumption to overshadow a car.

So I’m offering this up as an example. Whether we call it diagnostic overshadowing or the credibility gap, the problem can’t be located solely in the person who is disadvantaged in healthcare. It’s not just about being able to speak up; I can do that. It’s not about a lack of articulacy; I hope I’ve shown I can manage to string a few words together. It’s not even about mysterious causes. Cars have not been mysterious since the early 1900s. The problem is caused by the fact that, regardless of how  much it strains Ockham’s razor, too many people think that mental health problems somehow preclude physical ill health.

Getting From A to B

The Distance From Should To is…. It’s an idea that fascinated me for a long time. Usually it's a way of comparing policy, theory and announcements to reality. This time it’s about me.

It’s been a while since my last post, and some might think that this gap is a little curious given the recent select committee report on the Draft Social Care Bill. I’ll write about the draft bill shortly but first I’ll talk about the gap.

I’ve just returned  to work following sick leave. Late last year I reluctantly accepted that:

a)   I was suffering from depression

b)   It was stopping me working properly

It took me a long time to get from a to b.

I don’t intend to speculate on the reasons for depression or to spell out the effects. There are other bloggers out there that can do that far better than I. But other people’s openness about their own mental health issues is something I’ve always admired. It was really useful to me when I was finding my own way through. It seems only fair to add my own small contribution.

I also want to publicly acknowledge that there was a problem, particularly for anyone who may have been wondering why I’ve been so bad at communicating with them recently. It wasn’t you, it was me….

...so, back to me.

I should have taken time off earlier. One of the things that stopped me was the belief that I would be able to turn things round. Even when I accepted that I had depression I didn’t accept that it meant that I would be affected by it. Other people? Yes. Me? No.  

I should have been able to sort things out. I was able to seem ok to most people, surely that meant I was almost ok. I was convinced of this, so I piled more and more pressure on myself.

I always felt that I just needed to sort out one more thing. I’d take some time off in a bit, but not just now. The problem was that I was dealing with what should be, not with what was really happening. As a result I worked longer hours, achieved less, and got worse.

If I had broken my leg I wouldn’t have expected myself to keep running. However, despite a lifetime working in and around mental health, I couldn’t accept that depression would reduce my ability to get things done, so I kept going. In retrospect, this was a special kind of idiocy.  It was harder to sort things out, many things didn’t get sorted. I got worse.

Recently I’ve been asking myself why I was so reluctant to accept the impact of my depression. I've came to the uncomfortable realisation that despite many years trying to reduce the stigma and prejudice that people with mental health problems face, despite being a fan of the Time To Change campaign and the Black Dog Tribe, when it came to me I was somehow ashamed. Other people would be affected by mental health problems. Somehow I thought that shouldn’t apply to me.

Well, it did apply to me.

Taking time off was one of the scariest things I’ve ever done. It was probably one of the best things I’ve ever done. As the eagle eyed amongst you may have noticed from my profile, although I’ve returned to Action for Advocacy, I’m not coming back as Chief Executive. I need to make sure I’m able to put some things into that wonderful pile marked “someone else’s problem”, but believe me, I have enough to get my teeth into.  So let me finish by saying a few things both you and I should already know.

Depression is as real as physical illnesses. It has as great an impact as physical illnesses or injuries. I expect that our society should treat mental and physical health problems with a parity of respect and understanding. Mental health problems no more define a person than does a fractured rib. I have spent years of my life challenging fears, assumptions and prejudice about mental health. It’s strange to realise that one of the most ingrained problems was sitting in my own head.