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Simon

Age at interview: 31
Brief Outline: Simon has experienced repeated depressive bouts since he was a teenager. He tried several different antidepressants before he found one that worked best for him. He was initially a bit erratic about taking them, and felt ambivalent about whether or not they were useful, but more recently has begun to take them regularly. He feels that they keep his mood stable and help him cope more easily with life.
Background: Simon is married and has two young children. He is a GP who specialises in mental health issues, and also works as an academic and clinical teacher/researcher. Ethnic background: White British.

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Simon is a GP who has a special interest in mental health issues, which has partly been driven by his own experience. He himself first experienced depression as a teenager, but did not go to seek help until he was at university, training to become a doctor, when he was finding it difficult to cope.
 
‘I went to the doctor feeling I was depressed… explained that to him and yes I think that, I was aware that that [medication] was the only real option at that time’.
 
The GP prescribed citalopram but Simon only took it for a short while mainly because he experienced initial side effects which he found troubling.
 
’ I don’t think the first time I was prescribed them I really took them long enough for the side effects to settle… the first time I don’t think I took it regularly enough for it to really get into my system’
 
After this first time, Simon had several short periods when he took an antidepressant - he tried both citalopram and venlafaxine but didn’t feel comfortable with the side effects he experienced. Now, with hindsight he knows now that they are likely to subside if you give the antidepressants a chance to ‘kick in’. About four years ago, after looking for information on the internet, Simon decided to try sertraline because it was reputed to be more easily tolerated and to give a ‘balance between working quickly and working well’. He now takes sertraline on an ongoing basis, as a preventative measure.
 
Initially Simon felt reluctant to rely on medication because he felt it was a ‘lazy’ option and that people should deal with their problems and not expect a tablet to do the job for them. The first time he was prescribed antidepressants no other treatments or therapies were offered. However when he began to take antidepressants more regularly Simon was also referred to see a psychologist, although there was a long waiting list. In the meantime, he enrolled privately for a course of Cognitive Behaviour Therapy (CBT), and has also benefitted from seeing a life coach who has a psychological background.
 
Over the years, having qualified as a GP and has specialised in mental health issues – Simon now knows a lot more about antidepressants, as well as other ways to improve and maintain mental wellbeing. He has now made the decision to continue to take an antidepressant for the foreseeable future as he has recurring bouts of depression. Simon feels that antidepressants can help people to maintain a sense of equilibrium, although it can be difficult to really know to what extent they help.
 
‘It’s always hard to know with depression because different things make your mood go up and down anyway and there are so many other factors going on, changes in life, changes in kind of level of workload, things I’m coping with kind of relationships with people, I don’t know to what extent it’s down to the medication and to what extent it’s down to other things’.
 
One of the things that he felt has been a mistake has been constantly wanting to come off them and trying to work out when or whether he was ‘ready’.
 
I was making things worse for myself by always thinking is now the right time to come off it should I, you know, should I stop, you know, is this doing me more, inconveniencing more than I’m benefitting and actually by taking those questions out of the equation by saying right no I’ve committed to go on this medication and stay on this medication… I’m going to deliberately not use that as a strategy of something I’m going to turn on and off’
 
Simon finds now as a practicing GP that his own personal experience of depression helps him to empathise with, and understand his patients needs more fully. As a GP he says he would usually try to explore other avenues of help for patients’ experiencing mild to moderate depression, but that antidepressants may also be helpful. If a GP is prescribing an antidepressant, he/she should always explain to the patient that they may take a while to begin to take effect, and that there are a range of different antidepressants, and people may need to try a few before they find one that suits them best.
 
 ‘It will make you feel rubbish for at least about two weeks possibly up to a month, it will get better is something that I always tell people. I always say … if you have any side effects think to yourself is this something you can put up with for a few weeks? If it is, put up with it because it will get better. If it’s something that you feel you can’t put up with come back and we’ll change it’.
 

The first time Simon was prescribed citalopram he experienced...

The first time Simon was prescribed citalopram he experienced...

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Yes the first time I was prescribed citalopram.
 
So when you first started taking it can you remember that first time how it made you feel?
 
I remember having a lot of side effects feeling very sick some diarrhoea some clenching of the jaw, tightness in my face it was quite unpleasant. I remember, you know, being in between lectures and feeling quite uncomfortable at home as well so I had a lot of side effects there. I don’t think the first time I was prescribed them I didn’t really take them long enough for the side effects to settle.
 
How long a period was that first time?
 
I reckon I took them for about three weeks regularly, I may have had prescriptions after that but I didn’t, I didn’t take them regularly.
 
So if you weren’t taking them regularly then do you know what the effect of that was on you, were you feeling different on days when you didn’t take it?
 
I’m trying to recall if the first time I took it I really took it, the first time I don’t think I took it regularly enough for it to really get into my system.
 

As a GP Simon gives his patients an idea of what to expect...

As a GP Simon gives his patients an idea of what to expect...

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Certainly, some especially the ones that are pretty much inevitable so it’s pretty much inevitable that people will feel sick when they first take it especially if they take it on an empty stomach, it’s pretty much inevitable they they’ll have some degree of change in bowel habit, some diarrhoea and often feel anxious just when they first take them and the amount of people who stop taking it within a month is huge. And I think the best way of minimising that is warning people it will make you feel rubbish for at least about two weeks possibly up to a month, it will get better is something that I always tell people. I always say look if you have any side effects think to yourself is this something you can put up with for a few weeks, if it is put up with it because it will get better. If it’s something that you feel you can’t put up with come back to me and we’ll change it, so I always warn people about those.
 

When Simon was first prescribed an antidepressant he...

When Simon was first prescribed an antidepressant he...

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I reckon I took them for about three weeks regularly, I may have had prescriptions after that but I didn’t, I didn’t take them regularly.
 
So if you weren’t taking them regularly then do you know what the effect of that was on you, were you feeling different on days when you didn’t take it?
 
I’m trying to recall if the first time I took it I really took it, the first time I don’t think I took it regularly enough for it to really get into my system to the point of view of having withdrawal symptoms which I now know.
 
What the reason for not taking them regularly, were you, what were you, was it because of the side effects or what?
 
I think partly that, partly just being forgetful which has never changed since partly I was very ambivalent to taking them, until well until the last two or three years I’ve always been very ambivalent thinking, you know, is this the right things it’s been something that I’ve not wanted to do but have done begrudgingly so I think I was ambivalent about taking it.
 
And what’s, and what’s that ambivalence about?
 
Yes there’s not liking the side effects on medication which get a lot better but they didn’t completely go away especially with the first antidepressants I was on a reluctance to being on medication I, you know, I didn’t want to be on medication for a long period of time as I the more I understood about depression the feeling that I should be relying on psychological approaches to managing the depression as well and feeling like relying on the medication instead of these other things that I’d been doing was, was in some ways it felt lazy yes.
 
So are you saying that you didn’t see the medication as being the answer to solve whatever the problem was behind your depression?
 
No, no I certainly didn’t.
 
You said earlier that you weren’t really sort of good about taking things regularly at one point, are you more vigilant now about making sure you take it every day?
 
I’m still pretty hopeless.
 
Are you?
 
I’m still really hopeless.
 
A bit erratic?
 
Yes and quite often I will have two or three days and it’s only when the withdrawal symptoms are beginning to kick in that I then think ah I’ve not taken my medication and I feel awful and then I’m taking it.
 
So you do notice after a while?
 
Oh yes, yes.
 
What are the withdrawal symptoms?
 
Anxiety, tingling in my skin especially on my face sickness that sort of feeling like you’ve not eaten that kind of hypoglycaemic feeling.
 
A bit light headed?
 
Yes, yes they’re the main things.
 
So that would prompt you then to remember to take it. And then when you start again how does it?
 
Then I often get some of the increased kind of feeling sick again for a few more days and that gets better after I’ve remembered to take it for a little bit of time.
 

When Simon first started taking an antidepressant he didn’t...

When Simon first started taking an antidepressant he didn’t...

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Yes the first time I was prescribed citalopram.
 
So when you first started taking it can you remember that first time how it made you feel?
 
I remember having a lot of side effects feeling very sick some diarrhoea some clenching of the jaw, tightness in my face it was quite unpleasant. I remember, you know, being in between lectures and feeling quite uncomfortable at home as well so I had a lot of side effects there. I don’t think the first time I was prescribed them I didn’t really take them long enough for the side effects to settle.
 
How long a period was that first time?
 
I reckon I took them for about three weeks regularly, I may have had prescriptions after that but I didn’t, I didn’t take them regularly.
 
So if you weren’t taking them regularly then do you know what the effect of that was on you, were you feeling different on days when you didn’t take it?
 
I’m trying to recall if the first time I took it I really took it, the first time I don’t think I took it regularly enough for it to really get into my system to the point of view of having withdrawal symptoms which I now know.
 
What the reason for not taking them regularly, were you, what were you, was it because of the side effects or what?
 
I think partly that, partly just being forgetful which has never changed since partly I was very ambivalent to taking them, until well until the last two or three years I’ve always been very ambivalent thinking, you know, is this the right things it’s been something that I’ve not wanted to do but have done begrudgingly so I think I was ambivalent about taking it.
 
And what’s, and what’s that ambivalence about?
 
Yes there’s not liking the side effects on medication which get a lot better but they didn’t completely go away especially with the first antidepressants I was on a reluctance to being on medication I, you know, I didn’t want to be on medication for a long period of time as I the more I understood about depression the feeling that I should be relying on psychological approaches to managing the depression as well and feeling like relying on the medication instead of these other things that I’d been doing was, was in some ways it felt lazy yes.
 
So are you saying that you didn’t see the medication as being the answer to solve whatever the problem was behind your depression?
 
No, no I certainly didn’t.
 
So when you, you went on and off them a couple of times then were that each time a different antidepressant?
 
No the first time I was prescribed citalopram and then I stopped them and then I went back and had a conversation with the GP when I had a relapse with the depression and he asked how I felt towards the citalopram and I said the side effects that I’ve had with it and he then put me on venlafaxine.
 

Simon reflected ‘I was making things worse for myself by always...

Simon reflected ‘I was making things worse for myself by always...

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I’ve had several bouts of depression which have relapsed and I think I’ve got some degree of chronic Dysthymia in the sense that my symptoms don’t completely resolve in between bouts of depression as well and so from the point of view of the guidance I’m the sort of candidate who would, would be suited to stay on it indefinitely.
 
And is the, is the effect of that yes preventative rather than?
 
...the other thing is that I recognise that I was making things worse for myself by always thinking is now the right time to come off it should I, you know, should I stop, you know, is this doing me more, inconveniencing more than I’m benefitting and actually by taking those questions out of the equation by saying right no I’ve committed to go on this medication and stay on this medication I’m going to deliberately not use that as a strategy of something I’m going to turn on and off, does that make sense.
 
So is it, is it what some people would all a maintenance dose that keeps you on a certain level?
 
Yes, yes. I think an analogy would be like getting married okay. Before, in my experience and this is partly just, just me because emotionally I don’t feel I have kind of strong, you know, connections. I remember before I got married I always had these thoughts you know is this the right thing, is this the right person, should we be together, should we not be together... from the point of which I made a commitment I’ve not had any of those thoughts because for me being married is something that will be there forever more, I’m not allowing myself to have an out, you know, it’s through thick and thin, you know, I’ve made a decision and that’s very, very comforting, you know, because it’s down to me to make it work I haven’t got the option of divorce I haven’t got the option of breaking off the relationship because those options are put out of my mind which means making it work is, is down to other things. It’s the same with my depression by always thinking should I go off it, should I stay on it and resenting the fact that I’m on an antidepressant it makes you think about it more. By actually accepting the fact okay no, I’m choosing to stay on this, I’m choosing not to have the choice to come off it, and it means the choices that I make with regards to my mental health are often a lot easier.
 
And so in term of that however long you might be on it do you have any concerns about it, because some people talk to me about worries about dependency and relying too much on something that’s chemical?
 
Yes, yes and I’ve had conversations with colleagues you know particularly about the recovery model and dependents, we’re all dependent on different thing, dependence isn’t a bad thing, you know, we’re dependent on our partners, our spouses, on our families all sort of things that give us a sense of purpose and well-being. Dependent on a morning cup of coffee on eating food three times a day, on drinking water, there are lots of things that we need to do to carry on. Dependence isn’t a problem it’s when that dependence is interfering with other aspects of my life so yes I’m dependent on the medication but I’m also dependent on my wife and children and all of these other things so that’s not a problem to me anymore. And actually it was more of a problem resenting the fact that I was taking medication than accepting it.
 

Simon is a GP and has depression. He encourages his patients...

Simon is a GP and has depression. He encourages his patients...

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When it comes to mental health problems I’m very psychologically minded okay I think the research suggests psychological therapy is much more effective than antidepressants and lasts a lot longer so the mainstay of my treatment is going to be psychological. And I consider mental health to be like physical health, you know, in physical health we’re not divided into sick people and healthy people we can all be fitter, you know, we could all it’s a spectrum and the same is true for mental health, you know, even if you’ve never had a mental illness you may not be living a mentally very healthy lifestyle. So there’s, there’s lots of things that we can do to improve our mental fitness and so a lot of my conversation with patients is along that line. So when it comes to certainly mild to moderate depression as distinct from people who have got mental distress or stress in their life. I think there isn’t a lot of evidence to say that antidepressants are effective at all, I’m very concerned that that we haven’t got clear data on antidepressants and some of them we have problems with publications bias that only the positive studies are being published I think the effects aren’t clear so I am hesitant to prescribe antidepressants to those people and would much prefer to try psychological therapies as a first choice.
 

Simon said ‘I don’t know to what extent it’s down to the...

Simon said ‘I don’t know to what extent it’s down to the...

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It’s always hard to know with depression because different things make your mood go up and down anyway and there are so many other factors going on, changes in life, changes in kind of level of workload, things I’m coping with kind of relationships with people, I don’t know to what extent.
 
I remained quite ambivalent when I was on it I think it worked well again I was doing other things as well. I went over to [city] once a week for to see a life coach for a period of eight weeks I was referred to see a psychiatrist who did an assessment but nothing, nothing really found out I was on a waiting list for psychological therapy as well so lots of other things were going on as well.
 

Simon is a GP and has specialised in mental health. His own...

Simon is a GP and has specialised in mental health. His own...

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You’ve gone into the mental health side of the profession yourself is that a deliberate choice because of your experience?
 
Yes I think having, having an experience of mental illness myself I think I’ve got a greater degree of empathy, I’ve got, I have a greater degree of understanding of mental health problems and yes I think it’s definitely to do with that. I often say to colleagues you don’t often see an optician who doesn’t wear glasses or contact lenses, I think it’s very natural to try to learn about conditions which you’ve got an acquaintance with either yourself or relatives and family members and I’ve got both.
 

Simon says that keeping a mood diary can help promote positive thinking.

Simon says that keeping a mood diary can help promote positive thinking.

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A couple of strategies that I put into practice, one was having a well- being diary, so one of the things that people who are depressed including myself often do is go to bed thinking about everything that went wrong during the day and all of the things they have to do tomorrow and worrying about how I’m going to make my life better. So it’s making a deliberate effort to say okay what went right today, why did it go right, you know, and especially looking for reasons within yourself when things go right.
 
Writing down when you have a tendency towards pessimism which, which I do and I think most people who suffer depression often do. When something good happens it happened just that once and it was because of somebody else and it will probably never happen again. When something bad happens it was because of you and it happens all the time in every area of your life, okay. so the using the gratitude diary is actually saying okay this has happened and it happened for a reason and that reason was something to do with me, even if that was just, you know, I was walking home and there was a really beautiful, you know, autumn trees there and I noticed them and it was great and the sun, you know, and I noticed that because I wasn’t looking down at my feet worrying about tomorrow I was looking up and I was paying attention to the world around me and that was something that I’d chosen to do okay. So looking for the positive aspects of the day and recording them and writing them down. and doing other things such as writing a thank you letter to somebody that you’ve never properly thanked for something as well, yes it has a big impact on them but it also has a big impact on you and one that lasts. So they’re what I mean by the kind of gratitude interventions.
 

Simon, a GP, says pharmacists have specialised knowledge...

Simon, a GP, says pharmacists have specialised knowledge...

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I think pharmacists are a totally underused resource I’d much prefer people went to their pharmacist and asked about, you know, both about review prescriptions or their regular prescriptions, you know, both coughs and colds and skin rashes which they’re very, very good with but also any concerns they have about side effects because they…
 
Especially side effects because I think often a lot of people say they didn’t want to bother the doctor and but haven’t thought of asking a pharmacist.
 
No and the pharmacists know more about that than we GP’s do, you know, what, if someone comes concerned about a side effect to a doctor unless it’s a particularly common side effect we’re likely to look it up pharmacists often know because that’s what they specialise in interactions between drugs, how drugs work and, and the side effects so absolutely, I think it’s well worth talking to pharmacists about that.
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