Terry Maguire enters the rabbit hole of mental health research
Alice descends
It started with Fergal Keane and an ‘in-depth’ article on the BBC website on a Sunday morning. It was the entrance to a rabbit hole, I knew that if I entered, I would certainly fall down and be there for some considerable time. In Fergal’s excellent piece, he opened up about his mental health challenges — a problem with alcohol, PTSD, and periods of deep depression that had him in and out of hospital over his busy and successful career.
He has now achieved an accommodation with his mind following the insight that happiness is ethereal, fleeting, and hard-won. There is a need to work hard for it, he tells us. He has been doing the hard work
of real happiness for some time now and is achieving it. It’s a journey, not a destination. Really loving and caring for others, appreciating the beauty of nature, and being kind to yourself is all that is needed. So why is it so difficult, asks Fergal.
He now writes a gratitude list every morning, reads more poetry, goes for long nature walks, and has started to meditate. He goes to the movies, enjoys cleaning, washing, cooking, and paying the bills — small quotidian pleasures. He has returned to a simpler life, one that is more likely to offer the happiness he seeks. Not pleasure, but happiness. Happiness is completely different to pleasure.
Take 5 campaign
What Fergal is doing is fully engaging with the ‘Take 5’ campaign messages currently being promoted by the Public Health Agency in the most recent Living Well Pharmacy campaign in Northern Ireland. Pharmacies are paid to participate actively in these campaigns. Take 5 tells us that to improve mental health we need to: Connect, exercise, give, take notice, and keep learning. The benefits in these five activities can transform your life and yet what seems so simple is, as Fergal Keane says, difficult, requiring hard work over time, and most of us just don’t want to be bothered.
Hi Phillipa
In a side tunnel in this rabbit warren I meet psychotherapist Philippa Perry, wife of British artist Grayson Perry. She was interviewed in The Times of London, which I moved on to this Sunday morning from the BBC website. Philippa candidly suggested that many of her clients just needed to wise up and stop being so self-centered, negative, and selfish. She is convinced that people are more focused on their own catastrophic thoughts without any reference to facts. They allow terrifying thoughts to occupy their minds, so it’s not surprising they suffer from poor mental health. We need to know which thoughts are unhelpful and toxic and we need to let them go, she insists. This is something that GPs neither have time or training to address when meeting patients who are seeking help. It’s unlikely too that the Living Well Pharmacy Campaign being run for two months will achieve very much.
Interestingly, The Times‘ journalist tells us that the day following this interview, and before it was published, Philippa contacted them, asking if this comment could be deleted as she feared a ‘woke’ backlash. It wasn’t deleted and she didn’t get the backlash, and the article is much the better for it.
In the same edition of The Times, there was an article reporting that 80 per cent of UK GPs in a survey believe that everyday stresses and strains are too readily identified as mental illness. Most patients prescribed antidepressants probably didn’t need them; instead, they needed to change to be more caring and connected in their lives. However, GPs seem powerless to integrate this into patient advice.
Meet the new authors
The books section of The Times that Sunday morning featured a number of mental health self-help books and I suppose this is not unusual, given society’s need for magic bullets to improve our mental health and make our lives better.
One of the books by a young author TJ Power, a bestseller called The Dose Effect, was too tempting to ignore and I was off into another tunnel. The book, aimed at millennials and younger adults, makes the case that we need to learn to live our lives so that our brain neurotransmitters are in optimal balance. Dopamine, oxytocin, serotonin and endorphins (DOSE) are the neurotransmitters discussed and while offering a useful explanation, this book is much too simplistic. I went down this rabbit hole for the following week and didn’t get much in return.
A much better book covering the role brain neurotransmitters play in mental health is The Molecule of More by Daniel Lieberman and Michael Long; which, of course, is about dopamine. Where dopamine focuses on maximising motivation for more of the things we like and for designing our futures, oxytocin, serotonin and endorphins are grouped together as the ‘Here and Now’ neurotransmitters (H&Ns). The H&Ns are the neurotransmitters that when active, make us appreciate the here and now.
Together with dopamine they create happiness. And the widely-promoted practice of mindfulness gets us to the present, where we can enjoy things. This is also where Fergal Keane had arrived with his hard work, maximising his H&N chemicals to counter and calm the wondrous, dangerous dopamine which is the core of his talent and insatiable ambition. Raging dopamine has over his life suppressed the H&N neurotransmitters, allowing him to succeed, yes, but also exhausting and depressing him and giving him a difficult relationship with alcohol and ultimately, chronic PTSD.
Fancying meeting you, RFK Jr
In the final tunnels of my Sunday rabbit hole odyssey, I came across an article on The Conversation website about Senator Robert F Kennedy Jnr (RFK Jr). RFK Jr is against the wide use of antidepressants. The article addressed a recent comment he made that it is easier to come off heroin than it is to come off antidepressants.
Weaning off the most commonly used antidepressants, the SSRIs, can be difficult, causing SSRI discontinuation syndrome. The main symptoms — dizziness, nausea, headache, and fatigue — are viewed by many as the return of depression, and so they continue with the SSRIs.
Evidence suggests that SSRIs with short half-lives are more likely to cause SSRI discontinuation syndrome. These drugs include paroxetine and fluvoxamine, which cause discontinuation syndrome in about 7 per cent of people. Antidepressants with a long half-life — such as sertraline and fluoxetine — only cause the syndrome in about 2 per cent of people. But some studies suggest that discontinuation syndrome may be as high as 40 per cent when people stop taking SSRIs abruptly.
We fail mainly because current culture demands a diagnose- and-treat approach
The situation is further complicated in that some SSRIs, when broken down by the body, have active metabolites. These metabolites can have similar effects to the SSRI and effectively prolong the half-life of the drug. So, fluoxetine, which has quite a long half- life and an active metabolite, rarely triggers discontinuation syndrome. On the other hand, paroxetine, with a short half-life and no active metabolite, is the SSRI most likely to cause withdrawal effects, accounting for about 65 per cent of cases.
To minimise SSRI withdrawal syndrome, taper-off the dose over several weeks or months before coming off completely. Switch from a short- acting SSRI to one with a long half-life like fluoxetine, and then taper off.
More users of heroin experience withdrawal compared to users of SSRIs. Some 85 per cent who inject the drug experience severe withdrawal symptoms when stopping. As with SSRIs, opioid withdrawal syndrome severity depends on how long they have been used for and the half-life of the specific opioid. We use methadone and buprenorphine for recovery, as they have a longer half-life.
The half-life of heroin is very short, giving severe withdrawal symptoms. However, heroin produces two active metabolites when it is broken down in the body, 6-MAM and morphine, which, like heroin, activate mu opioid receptors.
But these metabolites do not activate the mu opioid receptor to the same extent as heroin. So in most cases of heroin withdrawal, significant symptoms occur, leading to severe effects.
RFK Jr is wrong. Coming off SSRIs can be very difficult but, for most people, it is not as difficult as coming off heroin. But his core point is that we prescribe SSRIs for too many people when they can naturally enhance their mental health by doing a few simple things.
Alice emerges
I knew it would be a long journey when I entered that rabbit hole and when I finally emerged about three weeks later, rubbing my eyes and feeling like Alice, I had a much better appreciation of the mistakes we are making in mental health policy and treatment. We fail mainly because current culture demands a diagnose-and-treat approach. This is not what is required and is likely making things worse. It is difficult to live our lives differently given the Western capitalist culture we are embedded in, but to embrace happiness we really need to support greater harmony with our key neurotransmitters, just as Fergal Keane eventually learned to do.
Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.
