Am I Depressed?

The World Health Organisation (WHO) considers depression as becoming the second most common cause of morbidity by 2020. It affects various aspects of the individuals life- social, work, the prospects to work, the carers and friends around the sufferer and thus lowers the overall quality of life. In addition, it is also linked with an unfortunate mode of death i.e. Suicide amongst other causes of suicide.

But if screened early, it can be treated early. There have been advances in the modalities of treatment of depression including pharmacological i.e. medications, psychological therapies. More recently, there are non- invasive neuromodulation treatments like Transcranial Magnetic Stimulation (TMS) to help with depression and other psychiatric & neurological disorders. This new treatment is a major step towards the use of other non-invasive techniques in the future before one needs to consider ECT (Electric Convulsive Therapy). ECT brings up all sorts of debates but as a practicing Consultant Psychiatrist, I am of the opinion that it remains an efficient treatment when considered at the right time of depression treatment.

So if we can pick it up early, the prognosis is better. Here’s a tool to help you screen for depression and seek help early.

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Gambling Myths- 2

Problem Gambling is not a problem if the individual engaged in Gambling behaviour is able to afford it.

Affordability has got no association with Problem Gambling. When the relationship to gambling takes priority over other areas of life eg spending more time in Gambling and less time with significant others to fulfil the roles such as the role of a spouse, partner, parent, employee etc. that becomes Problem Gambling.

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Motivating Yourself

If you want something, go get it ~ Will Smith

Motivation lies at the heart of activity and any health behaviour change. There may be many external motivators such as peers, work colleagues, family to name a few for anyone to consider changing. But the change happens predominantly when internal motivators weigh up more than others. So how can one tip the balance of the motivation scale towards actual positive change? As a Consultant Psychiatrist in Wales, I use Motivational Interviewing (MI) routinely and in MI, we use the concept of helping people through the MI Hill. So have a look and see where you are on this hill- imagine you want to make a positive health behaviour change by wanting to commence a fitness program (most common at this time of the year), answer the following and as you go down the numbers with your answers, you are travelling down the MI Hill. Record your answers for your own benefit-

1. What change do you desire?

2. Do you think you have the ability to make the change? Think of past successes to help you here.

3. Are there any reasons for you to make this change? Record all of them.

4. What is the need for you to change?

5. How can you demonstrate commitment towards the desired change? Remember here that wanting to change is different from willingness to do something for that want.

6. What action and steps would you take to bring about the change?

Once you have answered these, look at setting goals and remaining focussed. I will cover that in tomorrow’s post.

Let the Motivation begin!

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Drinking too much? Do’s & Don’ts

For many people Christmas is a time when alcohol consumption goes up and they can then bring the consumption back to Non- Hazardous levels. But for others it could be a time that makes them aware that there may be a problem with their drinking- difficulties in controlling, drinking more than what is considered as sensible drinking. Many may decide that they want to come off and that can happen with no ill consequences if they are not physically dependent. If they are physically dependent, medical supervision is important.

If this is the time that you have been thinking of reducing the harm caused by alcohol or want to stop, then the starting point may be to look at the quantities you are drinking in units.

Once you have calculated the units, take a self screening questionnaire- CAGE-

C- Has anyone- a friend, relative or carer ever asked you to cut down your drinking?

A- Do you ever get annoyed if someone asks you to cut down or stop drinking?

G- Have you ever felt guilty about your drinking?

E- Have you ever used alcohol as an eye opener ie used it first thing in the morning to steady your nerves or to function normally?

If you have answered YES to 2 or more questions above, you may be having a problem with the drink and it would be advisable to see your doctor or a specialist- Consultant Psychiatrist specialising in Addictions.

There are many new interventions available to tackle the problem with Alcohol- from reducing the amount of drinking to medically supervised detoxification, abstinence maintenance medications, anti- craving medications and relapse prevention strategies.

So think healthy, screen yourself and seek appropriate professional help.

And if using alcohol has become necessary to avoid withdrawals such as headaches, shaky hands, sweats, calming your nerves in the morning etc, then DON’T STOP AT ONCE as that can be dangerous. That would require a specialist assessment and a gradual reduction or a medically supervised detoxification which the specialist can help with.

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Alcohol and ‘White Collar’ Professionals

Walking through the streets of Central London today and thinking of Alcohol Awareness Week I was deliberating with my thoughts- Alcohol problems are found only in ‘blue collar’ population- is that really true? Not in my experience. I see ‘white collar’ professionals in clinical practice who develop a problematic relationship with Alcohol.

As reported in a recent BBC interview and campaigned by Alcohol Concern- Cymru, it often starts with recreational use where the reasons could be many- including coping with stress, using alcohol as a social lubricant to facilitate a subjectively improved social interaction, part of business networking world to name a few. This, when continues gradually results in gradual development of tolerance to the effects of alcohol and before long can be above ‘Hazardous Use’ giving way to ‘Harmful Use’ and ‘Dependence’.

In case stress is the underlying reason to seek shelter in Alcohol, then there are alternative and healthier ways to manage stress which I will be writing about in the next post.

But for now knowing what the considered safe limits are would be a start for Alcohol Awareness. For men, it is no more than 21 units and for women, no more than 14 units a week. These have to be spread out through the week with at least 2 days gap between drinking days. You can check your units consumption and calories on

Look out for ‘Managing Stress Healthily’ and ‘Acute Effects of Alcohol’ posts coming up shortly.

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National Addictions Conference- Cardiff 2012

It was a matter of pride for hosting the Royal College of Psychiatrists Addictions Annual Conference in Cardiff this year. It is the first time that it was hosted in Cardiff. The feedback of the conference had been very good spanning from the topics covered to the minute details of the venue, the organisation and the hospitality. Dr Tony Jewell’s opening set the Welsh flavour and that carried on throughout. It was timely for the press release regarding the minimum pricing of alcohol to be released just before the conference as well. Listening to the news today, I picked up that the national alcohol consumption is being reported as going down with more health concerns, rising taxes and increased price to buy alcohol and based on that it was being argued that ‘minimum pricing’ should not be a strategic direction.

Most importantly, it is clear that pricing does have an impact on levels of consumption and given all the evidence on price- elasticity, the ‘marketing- mix’ used by the alcohol industry, the impact of availability and licensing, in my opinion, it becomes even more important to endorse ‘minimum pricing’.

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Psychological Trauma and Brain- Part 2

Carrying on from the previous post one can argue whether PTSD or traumatic symptoms following trauma are ‘disorders of memory’ or ‘disorders of forgetting’. The virtue of understanding these concepts lies in understanding what happens in the brain when memories are laid down. So let me spend sometime on that.

What we know from knowledge of memory systems in our brain is that during exposure to the traumatic incidents, the ‘action systems’ are set in motion and settle down to adaptation as one comes through to the other side of the traumatic event. The memories of the event initially are ’emotionally charged’ and get stored in a specific part of the brain. Now as the processing is complete- a narrative quality to the memory is established and it gets stored as yet another complete memory (almost like a photograph in an old picture album). Whenever one needs to access it, it becomes almost a case of going back to the album, picking the photo and describing it as a story in the broader timeline of an individual’s life. A personal example could be demonstrative here- when I learnt to ride my bike without stabilisers, I can recollect from my life’s picture album a memory where my brother, a cousin and dad supported me from behind and I rode round and round in circles in the back garden of my cousins house in Watford and suddenly realised that on my last round I was riding on my own with two of them standing and just watching me ride whilst my dad was in the middle of the garden stopped at the spot where he had left me on my own.

A negative event, similarly, gets processed and on complete processing gets a narrative quality. One could go and access that memory as well without getting unduly distressed or even if does experience a subjective distress, it is but just a memory in the story of life. However, people suffering with sequalae of trauma are not able to process that event completely and the emotional aspects of that event get stored as the main memory with the primitive systems being in a state of ‘chronic activation’ thus restricting the processing from happening, and hence they are ‘not able to forget’ the event and life becomes pre-occupied and organised around the traumatic event. This is seen in various clinical presentations in Psychiatric practice.

So how can psychiatric treatments work? Working in my capacity of a private psychiatrist in Wales, I use both to pharmacological treatments including anti- depressants, Prazosin and others along with Eye Movement Desensititation and Reprocessing (EMDR). The idea behind EMDR is the facilitation of complete processing of the traumatic memory thus helping the establishment of the narrative quality and being able to move on in life.

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Psychological Trauma and Brain- Part 1

Bessel van der Kolk is a name that most professionals working with psychological trauma recognise. Recently attended his webinar and was re- assured to hear that the things that I have seen in my practice as a private psychiatrist and my conceptualisation of trauma and it’s consequences are similar to his.

Whilst writing about the full description is for a scientific journal, I thought it may be useful to put things in a simple way. So here is a simple explanation- there are some inherent stress action systems in human beings that make us function as a ‘whole organism’-

1. The Freeze system
2. The Flight system
3. The Fight system

These help us in situations of danger and being ‘primitive systems’ get modulated by the ‘Neocortex’ (Newer developed parts of brain), so that the person in a stressful situation such as trauma, eventually derives a ‘context’ and puts a meaning to the stressful or traumatic life event in the wider context of his/her life, the ‘primitive systems’ are reset and life moves on.

What happens in PTSD or in people suffering with consequences of trauma is that the ‘primitive systems’ remain active for a longer period of time than what is necessary for adaptation and the individuals are in a state of ‘Chronic Hyperarousal’ leading to living life in a sense of fear with constant alertness or hyper vigilance to ensure their safety and experience symptoms of anxiety.

At the same time the memories of the event are laid down in a disjointed manner. More on memory in trauma in my next post.

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EMDR for Travel Anxiety after RTA

Eye Movement Desensitisation and Reprocessing (EMDR) is a psychological treatment used for improving symptoms of post trauma sequeale. Whilst NICE recommends its treatment for PTSD, newer indications and it’s application as a treatment have increased over the years. Working as a Consultant Psychiatrist in Wales and as part of my medico-legal practice in Personal Injury, recently I have treated someone for Travel Anxiety following a RTA who had been struggling to pass a particular point on the road and had anxiety symptoms when on the road in general. The outcomes were very good as the EMDR phases were very useful and all the symptoms improved within 6 sessions. The desensitisation phase was one phase that was very useful to get past the particular point on the road for the patient and by the end of sessions, the patient had commenced driving, had gone past the struggling point, felt more relaxed on the road in general and scored 0 on all scales used in the therapy.

The crucial element was the use of ‘Eclectic’ tools to help the individual to regain control over the situation and in Neuroanatomical terms, what we now know in Trauma work is that once the ‘Chronic Hyperarousal’ is modulated and regulated, the symptoms begin to improve.

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