Non-compliant

There’s a funny thing that you see over and over and over in healthcare: people who ignore their doctor’s advice, be it their GP or specialist, then come to the emergency department for help when they reach crisis. I guess there’s something human in us all that makes us think we’re above taking advice, even when the person giving advice has a level of expertise that we don’t. But when a complaining patient is only in ED through their own actions it can be hard to feel terrible for them. They still get the appropriate treatment, don’t get me wrong there, but when you’re done and dusted dealing with them you might share a roll of the eyes with their nurse or doctor over their behaviour.

You didn’t pay any attention to your doctor before when you were told how best to manage your condition, so why would you listen to us now? More to the point, are you going to listen now? Or maybe you will listen right now because you’ve scared yourself with how sick you’ve gotten, but how about next week, or next month? Will it be back to old habits? You got yourself into this, and now you think we would help you, because…? Of course, ethically we have to help you, even if we think you’re a dodo who has made their own bed and should possibly have to lie in it, but we spend a lot of time shaking our heads. There are a lot of sincerely needy patients: fractures, cancer patients, appendicitis, infections, many patients who have illnesses out of their own control. And when those patient’s beds are full of patients who could have avoided being there…well it grates on a few nerves is all. But we’re all only human, so we try to understand you, and anyway we’re health professionals so it’s our job to give you our best assistance regardless of our personal opinion. A professor at uni once gave this quotable quote:

“professionalism is a cloak for our personal problems”.

Compliance is the word of choice adopted by health professionals to discuss, at least in pharmacy terms, how well a patient manages to comply with the regimen of medications given to them. Do they take the medications prescribed, do they take them at the time/s prescribed, with or without food as prescribed, separate in time to other medications as prescribed, for the duration prescribed and so on? If so then they are described as compliant, if not then they are said to be non-compliant. There’s a bit of political correctness around which word you use because of the effect it might have on the patient if you “label” them. Adherence is another option, concurrence is almost never used and there’s one that I can’t think of that’s been ruled out. It applies in medicine terms as well as in other fields.

So a patient arrives at the emergency department. The presenting problem, that one main issue that has caused them to come to us right now? They have severe pain, 8/10 on the usual pain scale. And why? Well they have a chronic pain condition, whatever that is, and we know that they can relapse from time to time, but actually the reason for this relapse is that the patient stopped their pain meds. Okay, so you’ve come to the  emergency department for help: what exactly do you think we’re doing to do, other than restart your pain meds? Surely you could have worked that one out. I get that pain meds have a lot of side effects that can be hard to deal with. But wouldn’t it have been better to sit down with a doctor and work out a management plan instead of just stopping something yourself? Now, instead, you’re in worse shape than ever and we have to pour MORE pain meds into you just to get you back to where you were, not to mention the time that will take, time that you’re writhing in agony. It doesn’t make sense to me. If anyone knows how tedious and frustrating the side effects of medications are, I do. Seriously. I put on 20kg, was sedated for 4 years, couldn’t work for 2 and I sweat all. the. time!! And that’s just 1/3 of the list. But you don’t just stop your meds because you don’t like them. You go back to your doctor, talk about the problems, work with them to adjust your meds and try again. That’s my experience. And when people come to us having not been bothered to put in that work and short cutting the process, then screaming that they’re in pain which is the obvious outcome, it just doesn’t make sense. They have a lifelong pain problem, surely taking the effort of one doctor’s appointment isn’t too big an investment to make? This especially bugs me for people on insurance and worker’s compensation because those establishments will do anything to help get people back on their feet (and back to work, of course) including paying for doctor’s visits, therapy like physiotherapy, and medications. You just have to be willing to work with them. People do “get over” their condition and the ramifications of it, I get that; so do I! But you’re kind of stuck with it so sometimes you have to dig in and just work through it. Going off course just isn’t going to make it any better.

Another common presentation is asthma attack. That’s not so shocking, except when its because you didn’t bother to take your asthma preventer inhaler for the last 3 months; you “thought you didn’t need it”. What are you thinking now? Are you going to go home and take it now? Did you ever think that maybe you never had an asthma attack BECAUSE you were taking your asthma preventer, rather than that you didn’t have asthma and didn’t need it? Did you ask your GP to review your asthma and maybe check your respiratory function tests again before making changes? No, you thought you knew better. And if you start giving me that big pharma conspiracy rubbish about how GPs diagnose people with asthma and prescribe them asthma preventers to get kickbacks from some drug company, I’ll scream. They did it to save your life; asthma kills! Have you heard of the tragic thunderstorm asthma event of 2011? And that’s just what people hear about. People die all the time of asthma. It’s not just some kids disease, or a disease that doesn’t really matter, or one that can be treated every time it flares up if its been under poor control. That cough you get walking up the stairs? That’s your asthma. That tightness in your chest on a cold morning? That’s your asthma. You don’t have to have an audible wheeze to have symptoms of asthma. Take your preventer, get reviewed regularly by a doctor and you can control your disease. But take it seriously please. And FYI, when the label says take TWICE daily, that means two times, as in morning and night, not once a day. If you use your preventer once a day, it will only be in effect for 12 hours; the other half you are on your own. And if you use your Ventolin/Asmol inhaler more than twice/three times each week? Your asthma is NOT under control!

One of the worst examples of non-compliance is patients saying pure and simply “I didn’t take them”, especially antibiotics. Why did you bother to see a doctor if you then went ahead and ignored their advice? It’s kind of rude. And self-jeopardising. And for those patients who DO go ahead and take the antibiotics, did you know that almost no one actually takes their antibiotics as prescribed? If its prescribed three times a day they take less. If its prescribed for 7 days they take less. And YET, every time antibiotics are dispensed, patients are told how to take their antibiotics, and for how long, and to complete the course. It really is just up to them to take them. There are apps (e.g. NPS Medicine Wise) where you can enter your dose, and duration of antibiotic, and the app will send you a reminder each time you are due for a dose. You can use the alarm clock on your phone to remind you when your dose are due. You can have your pharmacy add the antibiotics to your Webster pack, or you can add them to your dosette box. Really there are a lot of different strategies you can use. But know that when you come into hospital, your pharmacist, and probably your doctor, and maybe the triage nurse will note the date you were prescribed your antibiotics, COUNT how many antibiotics you have left and do the math; it’s what we went to uni for! And non-compliant will be written on your chart. Just take them. Why go from a slight upper respiratory tract infection or small wound, to a full blown lower chest infection and disgusting weeping sore when you could have prevented it? Sometimes conditions progress anyway, but do your part at least. Plus incompletely taking a course of antibiotics, not killing off the bug fully, leads to it learning resistance to that antibiotic so that next time you take that antibiotic it won’t work as well as it should. If you spread that bug that has resistance to someone else, you’re spreading resistance. You really don’t want to be that person. Take them, take them as prescribed, and take all of your antibiotics.

Or there’s that person who hasn’t been bothering to take their cholesterol lowering tablet and is admitted with a myocardial infarction (heart attack) and has to have 3 main vessels in their heart unclogged! All because they thought their cholesterol level was “fine” and they didn’t need it. Did you ask your doctor about that before you committed to that course of action, triple bypass guy?

Or hasn’t been bothering with their blood pressure medication and their systolic blood pressure at the bedside is over 190 when it should be at least under 140 and ideally around 120. They insist that they have white coat hypertension which is where patient’s get nervous before their blood pressure is taken, or around doctors, and it causes their blood pressure to rise. Except it doesn’t ever cause it to rise that much, in-denial lady. Take your blood pressure tablets unless your blood pressure falls below 120, and even then keep taking it unless your doctor advises you not to. Yes your own blood pressure machine might tell you ONCE A DAY that your blood pressure is okay when you’re sitting around relaxed at home. But why did your doctor diagnose you and prescribe you tablets in the first place? So many people are so reluctant to take blood pressure tablets and I don’t know why. In most cases its one tablet once a day and the side effects are usually mild, it’s really not a big deal. And again, its not a big pharma conspiracy to get you to take tablets, it’s a lifesaving prevention strategy to stop you having a heart attack, killing your kidneys or bleeding your brain out…why not take your tablet??

Just take it, or talk to your doctor. Those are the main concepts here. Confusing?

Edit: I’m not perfect. No one is perfectly compliant with their medications. I know that. I miss doses of my tablets, in fact I missed last night’s meds cos I broke my routine. But one thing I don’t do is miss them on purpose. All I’m asking if for people to try to carry out their doctor’s directions, for their own good. I read a quote yesterday,

“No one is perfect. But if we aim for perfect, we might reach wonderful.”

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Accidents happen: Part Two

Did I say “accidents happen” the other day??

What was I thinking?!

It’s like saying its q___t at work; never say the Q word!! It invites chaos and busyness and problem scripts one after another. But I said accidents happen, and so they did! Fate heard me, even though I don’t really believe in fate…oops, is that another invitation to the world to punish me?? Well punish is a bit dramatic, but you know what I mean.

So I’ve been recovering from accidents and errors ever since I wrote about accidents!! It wasn’t enough that I had my first ever minor car accident last Friday. On Wednesday, I had to go and fall down the stairs!! Like a really idiot!

I think it was sleep stupor, but to be honest I don’t really know. It was morning so sleep stupor could cover it; not much of a morning person, me. I took one step down leading with my right foot, another step down now with my left foot, another with my right and then I just slipped off the far edge of the next step with my left foot and I was gone. Our stairs go halfway straight down, turn 180 degrees then the other halfway straight down. Pretty standard. I slipped on almost the last stair before the turn. It might have to do with the stairs being shaped as wedges for the turn and I hit the tiny point of the wedge. I don’t really know how but somehow my left heel hit close to the edge of the stair and just slipped right out from under me and slipped over stair after stair after stair with no grip on any of them. My left leg was a useless slippery pointy thing sticking out in front of me causing nothing but trouble!!!

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Brain kicking into overdrive trying to figure out what to do, hoping to hit the wall at the bottom of the first half of the steps, grabbing the railing by instinct rather than thought, left leg useless sticking straight out front and can’t get a foot hold anywhere, getting half a grip on one stair after another but slipping over each and every one, poor right leg tucked underneath getting banged and scraped stair after stair after stair!!

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Luckily, and there is always an aspect of luck with me somehow, I was trailing my hand down the banister and managed to grab it! And even though my grasp slipped down the banister, it got caught on the post halfway down at the corner and I managed somehow to haul myself to a stop. I’ve seriously wrenched my neck and back and arm because of stopping myself but at least I didn’t go head over heels or something worse. And at least my hand was in contact with the banister when I fell; usually I don’t hold on at all! So it could have been much worse. Apparently its a workplace OH&S recommendation to have 3 points of contact with stairs at all times: 2 feet and 1 hand, or 1 foot and 2 hands if you are that person who just has to push the envelope! So maybe I need to put up some OH&S posters in my stairwell!

Panic as several steps went by and I missed the wall at the end, turning instead to start going down the next flight! Finally gripping the railing at the post as I slid to it and holding on for grim death!! Or is it life? Either way, I managed to stop on that poor banged up left hip with my useless left leg still sticking out in front, and the even more useless right leg underneath and my arm twisted backwards at some weird angle. So by the time my hand found a hold on the midway post, I was through the corner and heading down the next straight with my right leg tucked well under me getting cheese grated on each and every step where the carpet is bare and the strings are coming through. Basically I got a combination of carpet burn and grating right down my shin and a good few bumps on my left hip, which is swelling up nicely. I was feeling pretty shabby!!

So I was pretty stoked to have come to a stop, even if it was at the cost of the whole left side of my torso and arm. But how to get up?? I’m not a little thing, as most of you probably know. And unable to engage to use of either leg and one arm and side made getting up some kind of origami exercise! I actually can’t tell you how I got up, but there were a couple of bad moments where I started to slide again. But here I am to tell the tale!

So I grabbed on for dear life and managed to stop my fall. There was a moment of real horror thinking that the post might let go; I definitely felt it give. But when I went back afterwards it was as solid as ever. But as it turns out 120kg dangling by one arm is not only a threat to the wooden stair railing but to the muscles and soft tissue behind my shoulder blade. OUCH! Before too long I couldn’t turn my head to the left more than 20 degrees, behind my shoulder blade was singing and I was rapidly becoming frozen stiff. So a trip to the physio to get ironed out.

To look at you can’t even tell I’ve had an accident. Well not until I covered the grazes along my shin with white dressings that is, they kind of stand out on my tan! Not intentional but there you go. It saves me feeling like an attention seeker telling people about my accident; the bandages seek your attention on my behalf!! Is that the same thing?

Its amazing the pain and irritation such superficial scrapes create. Bed sheets, leggings, any clothing just rubs so I headed down to the pharmacy for some dressings so I can at least be a bit more comfortable. Now at least the stinging doesn’t keep getting set off again. But stretching the skin by moving it any way including walking is still aggravating. So here we are, another accident. What to make of this one? I really don’t know what went wrong so that I can avoid it again. Just one of those things? Or I should take more care?

So that was my fall. I thought that was enough, how about you?

But no. I get to work and start my usual Thursday; you know, all the packs and stuff that I wrote about recently. Then my boss brings one of the packs to me and says it has been brought back to the pharmacy over an error! That shoots straight through the heart. Especially right on the heels of having experienced a dispensing error and making (possibly) a big deal about it. As it turns out I hadn’t seen that there were 2 loratadine (you know, Claratyne the anti-histamine) tablets instead of one in Tuesday morning. It’s a robot error, but my job is to pick up that type of error, and I didn’t.

I could justify my omission by saying that its not that serious an error; in all likeliness there would be no side effects as loratadine generally has no more side effects than placebo (sugar pill). But the point is that I missed the error.

I could justify it by saying that the patient hadn’t taken it yet so it wasn’t so bad.

I could also justify the error with the conversations I’ve regularly had with other pharmacists checking packs discussing how extra tablets in packs is the hardest error to pick up, compared to other errors: broken tablets, missing tablets, wrong tablets. But I still missed the error. Not good. But it has made me further reconsider my response to the dispensing error that happened to me.

But wait, there’s more!! Unfortunately.

This, I suppose, is what happens when you only work twice a week. Short of them texting you about issues on your days off (it happens!) they save them up for next time you come in!

So, it seems that I dispensed a patient’s 500mg Epilim (valproate) correctly, then attached the labels to 200mg tablets. THIS is a problem. This is a big problem. I don’t know why the patient was taking Epilim but irrespective, taking this error over weeks to months WOULD have resulted in a relapse had the patient taken it: a relapse of epilepsy resulting in seizures, a relapse of bipolar resulting in depression, mania or suicide or worse. As someone who takes Epilim and dreads the probably inevitable day that I relapse, I can totally empathise with the patient in this scenario, as well as my position as pharmacist!!

I could justify this error by…nope, nothing!! I should have scanned the medication against the dispensing; this would have shown the error. I should have compared the original script to the box of tablets to reconcile the strength; this would have shown the error. I could have reviewed the history, but that’s an extra step. All I needed to do was the 2 steps mentioned; that would’ve prevented the error. Luckily the patient identified the error, brought the medication back and no harm, no foul.

Sound familiar?? My high horse is sinking through quicksand and I’m about to go down with it, unless I jump off and acknowledge that I just made an error as significant as that other pharmacist, and how do I want to be treated over this? What lessons do I need to learn? How would I feel about being reported to the pharmacy board? My boss knows, so that aspect can’t get worse, but he was very good about it actually.

Can I console myself with the errors that I did pick up today? 5 missing doses of magnesium in one pack, 2 missing dose of metformin (for diabetes) in another, a broken Panadol tablet making an underdose, a broken clonazepam tablet (for seizures or spasms) underdose, double the Efexor (antidepressant) dose in one slot, a random thyroxine (for underactive thyroid) tablet found in a pack where the patient doesn’t take that medication, and more. Does it make up for letting a more severe error pass through to the keeper? In short, no.

But it does make you think. Here I am, on a squared playing field, accepting that human error exists but there are systems to obey to minimise it, and ignoring the systems is just not on!

Don’t panic!

On Sunday I had a bad day.

I woke up feeling bad, kept feeling bad and managed to go to bed feeling only marginally less bad. Thankfully I woke up better on Monday and I’m trying to forget about it and put it behind me. But it was an unwanted reminder that sometime, somewhere, somehow there is going to be a relapse. It’s just a fact. But I really don’t want it!!

So what is a bad day?

I just felt bad!

I know; not terribly articulate. But that’s about all I had on the day.

To my husband’s frustration. It’s hard to be the one on the sideline asking what’s wrong and getting “I don’t know”, over and over. Like, surely you know something about what’s wrong; you must know a bit about what’s happening. But I didn’t; I still don’t. And of course there’s nothing to show for it that would give either of us a hint.

It’s also hard to be the one trying to figure out an answer to the question “what’s wrong?”. I just couldn’t explain it. Between being the one on the sidelines, and the one in the thick of it, there aren’t any winners!

In hindsight I can break it down, a bit. It’s like having a bad taste in your mouth, except its in your mind and its a lot harder to shake than by chewing gum or brushing your teeth, mainly cos you can’t get at it as easily. The bad taste makes you feel icky, yucky, unsettled, nervous, uncomfortable, sad, upset, despairing, weird, a bit spacey like you’re on the outside looking in, a bit in pain and a lot confused.

And why? Why did I have a bad day? I don’t know why. Probably there is no reason why. Or maybe there is and I’m just totally missing it. I don’t know why it happened, or why it happened today, and I probably never will. But it had gone for now, so let’s be happy about that and just leave it be. Obsessing about it won’t do any do, I’ve proved that amply by now.

So what to do about it?

Sleep.

Go back into oblivion where your brain shuts down enough of your thought processes to give you some peace. I woke up at about 9am in a sorry state, went back to bed just after 10am til 11.45pm, and went out for some lunch with hubby and family, more to avoid explaining why I wasn’t up for it as compared with actually feeling like going. Then back to bed just after 1pm til 4pm, a few hours up, then back to bed as soon as possible. It’s not living, but it’s surviving and on a day like this, that is all that counts; surviving.

So I survived, and the next day was better. Who knows how it all works. Just another story in the life of. Thanks for reading.

She didn’t want to bother anyone

Last week a patient on my ward was discharged home and I went up to the ward to go through the medicines with her. She was going back to the care of her dedicated daughter who was there to hear all about the medications changes. The patient, despite being in her late 80s, was still sharp and with it and until only a year earlier had looked after all her medications herself, which is very impressive.

I admire patient’s who take the initiative and really get to know their medications and take charge of their own health. It just adds another layer of checking to the medication system which can be vital.

So I sat down with the daughter to educate her about the current medication regimen, with the patient listening in and nodding.

And although I was there to teach, I learnt a whole lot!!

First medication. The dose of prazosin has been reduced to once a day rather than twice a day as it was when she came into hospital, I say. Why has it been reduced when she’s had high blood pressure while she’s been in here? she asked. Well, I was taking over from another pharmacist and didn’t know the answer. Did she know what the blood pressure had been, had she seen the chart? I ask, stalling. No but she just knew that it had been. So I get the obs chart which shows an occasional reading of high blood pressure, maybe one in 5 or 6 so I explain that treating those one off higher blood pressure readings to bring them down to normal would put her mother at high risk of low blood pressure the majority of the time, which explains why they dropped the dose. But the kidney specialist put her on that dose, she says. I understand that, I say, but blood pressure changes and so the dose has to be changed to adapt; I’m more than happy for her specialist or GP to change the dose at the next appointment if that’s appropriate. Oh well, it was probably just high while she was in hospital, they’ve treated her horribly, I’m told!

This is always a big disappointment to hear, because I’ve gotten to know a lot of the nurses on this ward and I’ve seen how they care for their patients, even the difficult and hard patients. This patient was easy and lovely so I find this hard to swallow. I’m not saying that awful patients are treated worse, but I’m saying if the nurses can do their best for stressful patients, I’m sure they would have given outstanding care to this sweetie.

Really? I ask, surprised. Oh yes, she nods, and her mother, the patient, nods. We’ve had the most terrible time while she’s been in hospital! Well I’m very sorry to hear that, I respond. Oh it’s not your fault dear, I shouldn’t have mentioned it.

Second medication. This is the anti-fungal cream that we’ve been applying three times a day to your mother’s groin (sorry people, TMI) to treat the rash, I start. Oh yes, do you know that those nurses left her in a wet nappy overnight, for 8 hours?? How terrible is that, she asks me, starting to wind up the tone and intensity? Really? I ask again, because I just find it very hard to believe. The patient nods, yes that’s what happened. Well I’m very sorry about that, I say, that shouldn’t have happened. I wonder out loud to the patient, did you tell the nurse about it? No, she shakes her head. The daughter chimes in, she doesn’t like to bother anyone.

For serious???

You are complaining, and I find out later that there’s an official complaint, or rather several official complaints, about wrongdoing by the nurses but you just sit there and let it all happen when you have a mouth that you are fully capable of using, and a hand to press the buzzer, and surely a desire to not sit in urine for 8 hours just for the sake of not using your voice or your hand!! I find that ludicrous, and really, unacceptable. This isn’t about victim blaming by the way, the incident happened no doubt about it, but it’s about why it shouldn’t have happened and it could have been prevented.

We have patients that can’t speak, or can’t put their thoughts into coherent speech, or can only make sounds, or who take what feels like forever to get the words out. We have patients who are immobile, paralysed, unable to move their limbs, or unable to know what to do to get help. She ain’t one of them!

I don’t think anyone likes to make a fuss, or a scene, or a big deal, or call attention to themselves, complain or whine. Maybe the odd person. But this isn’t about that. This is about bringing attention to an issue that needs to be fixed for the sake of your health. You aren’t putting someone out, or bothering them, the nurses are there to help; that’s their job! If they have something more pressing to do, they’ll let you know and come when they can. But the 8 hours overnight that she stayed in that wet nappy are the quietest hours in the hospital. Often nurses don’t have much to do other than be on call for patients…so call them!

Again, not victim blaming but a patient has to take responsibility for their care. If the nurse doesn’t know the nappy is wet, she won’t come and change it for a dry one. You aren’t a baby, your parent doesn’t come along and stick a hand down your pants into your nappy to check if its wet; it’s not someone else’s job to come by every 20 minutes to ask if you need a change. You’re an adult. You tell someone when you need something, right? No, apparently not! And this was only the start of it…

Medication number three. Trying to move along and get past that one. Codeine has been stopped while your mother has been in hospital, I start. Yes I know, that’s why she’s been in pain the whole time she’s been in hospital, she counters. Oh my, here we are again! Who leaves their mother in pain for 8 weeks instead of saying something? Who doesn’t speak up for themselves when they’re in pain? Oh I didn’t want to make a fuss, says the patient. Give me strength!! You either weren’t and aren’t in pain because if you actually were and are you would be begging for help, or you are competing in some martyr awards that I haven’t heard of! You don’t sit there in pain and not say anything. Do you? Am I on the right train here? Well, codeine is not the best pain killer, I try to continue, and we weren’t aware of any pain. She certainly hasn’t requested any pain relief. And I think, although nurses, doctors and allied health staff may be brilliant, we still can’t read minds! Surely anyone can see that making an official complaint about a patient being denied pain relief when no one knew that the patient was in pain isn’t quite logical!! And don’t tell me that she was never asked if she was in pain. It’s a rehab and geriatric progress ward, every pain is continually asked about pain, about their bowels, and obs are taken regularly. It all seems so unnecessary!

Well, what a way to start the day! I did get through the rest of the meds eventually, but I was ready to get out of there!

Didn’t want to make a fuss, didn’t want to bother anyone, didn’t want to get in the way, didn’t want to be a burden. I get that. Sometimes it’s hard to speak up when you need something. But you can’t have both sides, not speaking up AND making official complaints against care givers. I believe in the complaints process and wouldn’t discourage anyone from making a valid complaint. But this feels like making a scene over something that could have been nipped in the bud at the start. It feel like an attack on the nurses who try their very best, and who couldn’t have prevented any of it without the patient doing their part.

So maybe its something more people need to know about – for your own health’s sake, you need to speak up. Don’t wait til discharge to complain about problems when you never did your side of the job in speaking to your nurse during your hospital stay. It’s a two way street, nurses aren’t psychic so you need to tell them what’s on your mind. Is it too much to ask?

No reason why

This conversation happened more than a year ago now and I’ve just remembered it this week. Something prompted me I guess; I’m not sure. I was just sitting eating my tangelo outside in the weather on my tea break and it popped into my head.

This person was very well meaning. I’ve stripped back the conversation to those parts that are relevant to the point I want to make, which is that there is a difference between being sad, and having a disease called depression. This person offered several lovely and kind offers of sympathy and best wishes, and in the end we understood each other perfectly well, which is a satisfying and lovely point to come to between two people.

I don’t bear them any ill will, either now or at the time. I just understood then and now that when they said these things, they were meaning well and just didn’t understand what depression was and how it worked. So I explained my point of view, they understood that and asked several questions to help them get the facts straight, and we parted better friends. I’ve given the pertinent parts of the conversation below. At no time do I intend to reveal the identity of my friend. Honestly, the reason this conversation stands out to me is less because of who it was that said it, than that it wasn’t the first or last time I’ve been asked about sadness, or the cause of my depression, or had interesting versions of depression presented to me.

This post is to add clarity to what is depression, what is sadness or grieving or emotion, and why the difference is of any interest to you and me.

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Person, via text: “Danika, why are you so sad? Are you ok?”

Me: Yes I’m okay. I’m not sad, I have anxiety disorder and manic depression, or bipolar disorder.

Person: “You have everything a girl could wish for! A job. A loving husband. A place of work. A faith and I’m sure you have friendships and family. You have more than most. You have more than me. I don’t quite understand the reason for your depression”.

Me: There is no reason!

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This post is about you. And me. And everyone we know. It’s about how we think about mental illness. I’m not going to even go into the issues of stigma, discrimination, fear etc. There are many places where you can read about that. I just want to talk about how you, and I, and the next person think about, and talk about mental illness. I’ll narrow it down even further to my area of “expertise” which is depression, and manic depression or bipolar.

No one has more right or claim than anyone else to suffer from the medical condition that is depression. Depression just occurs. Like coeliac disease, or asthma, or cancer. There are people that are predisposed by genes or environment but at the end of the day, stuff just happens! We all know this about medical disorders but we tend to think differently about mental illness.

The opposite is true also. No one has less claim than anyone else when it comes to what diseases they get lumped with; their environment may be better but maybe their genes are worse or there may be life events that induce so much stress that the disease pathway is triggered. We don’t have to and don’t want to be competing for who should and shouldn’t have depression. Let’s just take it at face value and focus our efforts on supporting and caring for our friends who have depression.

Depression is not choosing to be sad. Depression is not a choice, just like grief and sorrow are not choices. Depression is feeling sad, mostly without a cause, and being bewildered by how extremely awful you feel in a situation where 5 minutes ago you were fine.

Bad things, very bad things happen in people’s lives. And the badness that they bring causes great sadness, grief, stress, sorrow, pain, hurt. When the badness can’t be removed or goes on for a long time or is so very hurtful that a person is under constant stress, mental illness can follow including post traumatic stress syndrome, depression and anxiety. I don’t dismiss or belittle any of the emotions caused by bad events. Like I don’t belittle mental illness. People suffering from either need our kindness and sympathy.

But I do believe they are two different things. And I do believe that knowing they are separate things, and talking about them in different ways will help the people suffering to know that you are trying to understand, and help them. And this is an extremely valuable thing when you are suffering; knowing you have people on your side who are trying to help as much as they can.

As far as I can see, there’s a) direct pain and suffering from specific situations, then there’s b) random pain and suffering from mental illness. I seem to suffer from random pain, for whatever the “reason”; but of course randomness doesn’t have a reason, it’s random!

At all times I have been very well aware of how blessed I am in life. That makes suffering depression worse in my view. Not easier.

I used to run this checklist over and over to find a source of why I felt so awful and like life was unbearable: a fabulous supportive amazing husband, a really nice house that we used to live in and now rent out, a satisfying career that pays well, a rented apartment in a great part of the city much closer to our families. Our lives looked picture perfect from the outside.

But looks can deceiving. Many people didn’t know then that I was depressed, my husband included to an extent. I don’t know what your life is like right now. I can look and see, but what does that really tell me? You’re smiling, wearing nice clothes, visiting your folks for the weekend and playing happy families.

I know that I don’t know you, or what’s going on with you unless I ask. Unless we have a chat, a bit of a delve into the goings on in each others lives.

So I try not to judge from the outside; easier said than done! It’s just impossible to know what’s under the skin of a person. You can try to figure it out, but there’s only one tried and tested method. Just ask.

So why am I sad? Or why was I seen to be sad at that time?

No reason. Absolutely no reason.

No fight, no situation, no happening.

I was happy, contented in my married life, satisfied with my new job, safely housed, no stress, no worry, no issues.

Believe me I have scoured my life for something to show me why.

I had the lovely-turned-awful awful ex job, the horrid horrid ex-commute of my husband’s and his very unsatisfying ex job, and the commute of mine turned solo for the part year plus not seeing each other apart from after 8pm at night. Those had brought a lot of strain over a year couple of years, but we’d fixed it, it was better now!

We both changed jobs, we both moved closer to work and to family support, we were getting on famously and then this! Just out of the semi-blue and into my head.

Crying, anxious, panic attacks, tired, exhausted, famished. .. Just spent! Barely surviving, hardly keeping on going, struggling!

And why?

There is no why.

This is my favorite saying about depression. There is no why!

I was and am well aware that apart from my mental health, I lead a charmed life. I consider myself very lucky, very blessed.

But that don’t stop those tears a falling!!! Doesn’t stop the hurt, the pain, the anguish, the struggle with to-live-or-not-to-live. Although of course it’s not really living to live with full blown depression.

It’s like this: you’ve gone to the seaside for a weekend getaway. You look at the sea. You know logically from experience, from knowledge, by other ways that the sea is beautiful. You love the sea. It’s your favorite place to be.

But. You. Can’t. Feel. It!

You can’t feel it. You stare and look and look again. You touch it, you taste it, you smell it. Everything you do increases your certainty that you should love it, you should be happy here, you should enjoy this moment.

But you can’t.

You try to put yourself through the motions. You walk barefoot on the sand like you used to love to. You let the waves wash over your feet. You breathe deeply and take in the salty, seaweedy smell. Something inside of you should be rejoicing at this moment; thrilling, embracing it, loving it, loving life.

But it isn’t.

Why?

Because. There is no why. That’s depression, that mental illness.

Just like you can’t change your thyroid function, your heart beat or the pain in your toe by wishing it, you can’t will your mind to work differently. It will happen eventually. Medications, counselling, mindfulness, GP consultations, psychiatrist consultations in my case, and simply time.

But it can’t be rushed, it won’t be hastened, and then one day you will feel something more, a bit of excitement, some happiness, some joy and it will be amazing, and you will know you’re starting up the path to regular emotions and a regular life. What a moment!!

I should explain one more thing. Depression is a lack of feeling, feeling awful, pain and hurt. But not every minute of the day. Sometimes in a bad day there are still moments that remind you of your previous life, that just work, and feel good. These can help to disguise and abate some of the depression. But going back to depression feels a little worse after that.

I think this is what throws people off, including me at the start. Did you know that the night before I went to the emergency department because I thought I might die, I went with my husband to our good friends house for dinner and we laughed for 3 hours straight until my belly ached, my face muscles went into spasms and I was completely exhausted? In hindsight it is possible that I was on a high that night, but it’s still a point worth making, that depression doesn’t take up every minute of every day, but when you’re in it, it certainly feels that way because you can’t remember happiness or the good times. So if you can, remember the good times. Write them down on your wall, set up reminders in your phone; anything to remind you that it’s not all bad, and maybe that will help you get through to the day when some of your feeling comes back, and you can see the light!

Success

It’s been a big week. I’ve been at opposite ends of the emotional scale and I’m a bit frazzled. A bit frayed, a bit stretched too far, a bit edgy and nervous. But I’m here, I’m overall doing okay so we press on. And let’s bear a thought for the people that have been there with me. Who’ve felt for me, who I’ve felt for; they’ve been all over the place and back again, some much more than me.

I’ve been higher than I’ve been for a long time. And not a high-due-to-mania high but a regular this-is-how-normal-people-react-to-good-things way, which is the awesome part! I had something good happen and I reacted and behaved just like a normal people-person. In a something-good-has-happened-to-me way, and in an I-want-to-jump-up-and-down-about-it way. Not with depression, not with mania, not with anxiety. Well not much anxiety anyway. Gotta have a little; its a big deal

So what happened? I got the job! I GOT THE JOB! I GOT THE JOB!!!!!! I GOT THE PERFECT JOB!!!!!!!!!!

The job that is 4 minutes walk from my house. The job that is part time; two days one week and three days the next. The job that is everything I’ve done before in my career. The job that has lovely people who are already very supportive and willing to give me a go. Cos it is a big deal for them to take me on. I haven’t worked full time since March 3, 2014 and I haven’t worked part time since October 14, 2014. They don’t know how I’ll go getting back to work but they’re prepared to take the chance which is just amazing.

I can’t tell you how much my confidence has increased in the last couple of weeks from rewriting my resume and looking at what I’ve accomplished so far; going to an interview and establishing a rapport with the interviewers, being able to sell my strengths and nailing the clinical question despite so long away from the hospital wards; hearing back that I was the best applicant and that I’ve been offered the job.

I lost so much confidence, trust and faith in myself after I went off work sick. Sitting at home not exercising my brain, not using any of my knowledge and skills, not able to keep up my practice was brutal on my self worth and identity. And has been brutal over a long time, to the point where I sometimes felt that I would never practice as a pharmacist again. I’d never proved that I could retain knowledge and skills over a period of non use.

But now I have, and it’s been an enormous relief to me! I’ve still got it! I can still do it. I’m not useless, I can go out and make a difference and earn a wage and contribute something to the universe. Pheeewwww!!

And then there was the darkness. A dear special friend in very real danger reached out to me. I was honoured they came to me. But the task given to me to save the day was a very difficult one and I experienced such fear and worry and helplessness. Nothing compared to what they felt, but still real to me. It made me return to some of my difficult days and use the pain and suffering I remembered and try to give the antidotes that I’d found. But ultimately the day was saved, by a combined effort of concerned family and friends. The success which gave me a whole other sense of relief and alleviated fear and even achievement.

Which got me thinking about success. Again. I’ve been thinking about it on and off for a while now. What is success? How to we measure success? How do we know when we have achieved success?

In my job interview I was asked a question that caused me to be a bit flummoxed. At the end of your work day, how do you measure success? What needs to happen in the day for you to feel that you have been successful at your job?

In every other job that I’ve had the number of patients seen in the day has mostly been the measure of success. You have this many patients and you need to provide this level of pharmaceutical care to each of them. Not meeting this demand was a stressful event!

But an unexpected thing happened. My new boss has a much different and very refreshing philosophy. Accepting that there is insufficient funding to provide the ideal pharmacy service that we all dream of, management have taken the view that seeing every one of your allocated patients probably isn’t possible.

So instead they want pharmacists to find satisfaction in the good work that they do for each patient that they see. They want pharmacists to do there best work for patients one by one instead of rushing yourself to show on paper that you’ve seen each patient, when in fact you’ve probably skimmed each one. By prioritising patients and doing your best work for each patient that you can see in the day, management hope that there is higher job satisfaction. And I believe that there will be! Which is a success.

That’s success on the high side. Me, back in a job, helping patients and providing a clinical service. Or anyone doing that, really. It’s not all about me. Holding a job, earning a wage, paying a mortgage, being financially independent, completing study and I’m sure you can think of more. Being a friend, achieving personal goals.

Success on the low side is totally different. It’s not about ideals and doing your best work and demands and expectations. It’s about survival. Surviving the night, the day, the hour, the next five minutes. It’s about accepting whatever help is necessary to get by, taking whoever’s hand you are able to grasp to pull you back up, using the little strength and will you have to just hold on. It’s a whole different picture and the contrast to success on the high side is enormous.

So whatever your success is, well done! You worked hard for it and you deserve to be acknowledged for all that work and for the courage that it took to start and finish that work. Whether it was getting a promotion or putting down the poison or making great strides in your fitness or deciding to keep on going. You have done a great job and I’m proud of you!

To my dear who kept living, my darl who keeps facing it alone, and each one of you who has had success in any part of your life: you are amazing and an inspiration to me every day!

Hindsight

Everything seems obvious in hindsight; we often remark on this theme:

If only I’d known that beforehand…

Well it all seems clear in hindsight…

With hindsight I would have…

But that isn’t how the world works.

We do not have a crystal ball with magical views of life and what is to come. We don’t have a written score or script to tell us what the path will be and when each event will occur.

We have the blessing of life, and breath, and relative health and wealth, and a brain and body and have at it! Go to and create out of what you have, what you will.

Some people argue, probably very rightly, that if we could see the path that our life would be, we wouldn’t be anymore equipped to face it, and the unknown bad moments ahead would ruin our happiness right from the start rather than at the time.

Imagine how it would be if you knew before you were born or in your early life which of all of your loved ones would leave you in death or in circumstances. Would you draw away from them to protect yourself? Would you cling to them to try to make the most of every moment? Either way, and I’m betting there are many other ways that people would respond too, it would make life unnatural I think.

It’s a moot point of course since it’s an impossibility that we could ever have that knowledge, or any other similar knowledge of the types of experiences that face us in our life.

I believe that God is in Heaven and has set us on earth for his pleasure. I believe that Jesus came from Heaven to earth to live as we do with all our limitations, temptations and experiences. I believe that He himself was tempted in every possible way that a human could be tempted and still never sinned so that He could buy salvation and eternal life for us by his sacrifice. I believe that God has planned every teeny tiny step of my life, of your life, of every life. And I believe that if we ask, and it’s right for us to know, that God can give us a glimpse of some past, some future, some present obscured moment to help us better understand and cope with our life as we live it.

Not our whole life’s map or pathway or span. Just a glimpse to help us on to the next step. In eternity I think we will see why everything happened as it happened for God’s good reasons.

You may believe the same. You may believe differently. You may not have a belief about a greater being. That’s up to you.

What I’ve been thinking about today is hindsight.

Imagine if, say, eighteen months ago I had been able to look into my crystal ball and see my future.

At that time, I had been suffering fairly severe abdominal distress for four months or so with frequent, sudden, violent and painful bowel motions each day, terrible wind and muscle spasms on and off. I’d had tests done for bowel cancer, Crohn’s disease, inflammatory bowel disease, rheumatoid arthritis and a bunch of other bowel and inflammatory conditions.

I’d had to give bowel movement samples and urine samples and have my blood taken. I was stressed to the max over all of these potential diseases, besides being embarrassed and inconvenienced by uncontrollable bowel movements, appalled at having to take poo samples, and absolutely shamed at having to hand these over to my doctor! My work was affected because I’d have to dash off to the loo in the middle of something and come back fifteen to thirty minutes later exhausted and horrified once more. My home life was affected by me having this uncontrollable loud angry painful stenchy monster inside of me that wouldn’t be calmed down even at crucial moments.

I was feeling pretty crappy about the whole situation!

I was given a diagnosis of irritable bowel syndrome, a fructose elimination diet and a reassurance that I could return to the tummy specialist at any time in the next twelve months. So hindsight.

What if, at that point in time, someone had said to me, Danika, have you heard that irritable bowel syndrome is usually diagnosed when people have some kind of stress in their life that’s gone on for a while? Tell me about the things going on in your life that stress you out. What things are putting pressure on you at the moment? Is there a chance that you have been undergoing stress for some weeks or months? Tell me what we can do to manage or alleviate your stress.

If they had then reassured me that none of the diseases I’d been tested for were going to happen, had assured me of the success of the fructose elimination diet and how my symptoms would all go away, and referred me to have a chat with someone sympathetic and capable of helping me with my stress, maybe my path would have changed.

Then again maybe not; who knows?

If at that point in time they had said to me, Danika, here is your pathway for the next eighteen months: your bowels will improve on the new diet, but your immune system is compromised from stress so you’ll be more susceptible to minor but irritating afflictions like colds and yeast infections. You will be diagnosed with generalised anxiety disorder and truly stress about EVERYTHING; the medications don’t work that well and the one that works best you’ll have to stop because of bleeding. While you’re off medication you’ll get sick again and you’ll be diagnosed with depression; the new medications won’t work that well and you will eventually have a nervous breakdown before finally they find out you have bipolar disorder. This diagnosis will change your life because you’ll start new treatments and they’ll work marvelously and you will get well for the first time in eighteen months!

What would my reaction have been? I’m guessing it would have been, and certainly was along the way, oh no that’s terrible, I can’t possibly have or go through that! Or would I have been far sighted enough to look through the pain to the end and decide to go with the pathway shown? Probably not, we humans with myself as the main example are pretty jolly keen to avoid pain of ANY kind!

Would I say, wait, I can’t let that happen, and take leave from work straight away to recuperate and sort out my life, removing all the major stressors (which I did six months later but maybe too late)? Would that knowledge followed by these actions have stopped me from continuing along the pathway? Would I have only got to halfway down and no further? Would anything have kept me from reaching the endpoint I got to?

What if they’d only told me part of it: you will change your whole lifestyle and method of cooking to eliminate fructose and will completely overcome your bowel issues; however not having your bowels to stress over will shift your conscious awareness of stress to the actual source: working with high workloads, no extra workforce in sight and in a group of similarly stressed colleagues that are piling additional stress onto each other. You will stress over your work ad nauseum and to the nth degree and it will severely affect your sleep, your motivation, your energy levels and your commitment to your job and profession and your general joy for life.

What would I have done then? Would I have looked more closely at my work situation and realised months earlier than in real life that I was putting way too much energy and thought and adrenaline into a dead-end? Would I have realised way sooner that the situation was never going to change and was only going to become more and more toxic as I advanced to a more and more senior role and shouldered more and more of the responsibility? Would I have cut my emotional and sentimental ties months before I did, and saved myself anguish and conflict? Would I have found it much easier then to walk away before the chaos descended? What if…?

What if they’d told me this much? You will seek help for this stress through the employee assistance program with a delightful lady who will be your mother and guide for the next six months. Then neutropenia and recurrent infections will send you to the doctor who will ask how do you do? causing you to melt down into a panic attack and this will start the diagnostic pathway to generalised anxiety disorder. You will learn many methods of controlling displays of anxiety but you still aren’t conscious of the severe degree to which your work is affecting you. This will come and you will start accepting that you need to leave this septic workplace and find work elsewhere. You will do your best to handle all of these things together with a friend your own age dying suddenly bringing death right into the room, your mother’s diagnosis of breast cancer with subsequent surgery, chemotherapy (in a naturopathic, homeopathic, everything alternopathic system!), your major supports in the workplace also having to leave for their health’s sake and whatever else this bully of a life has to throw into the mix!

Surely by now you would do the bleeding obvious: quit your job, look for a new one, cut ties and uproot yourself and do an anti seachange! Which you did, at this time. So would knowing earlier really change things? Would anything have made you move and change sooner? I just don’t know.

I don’t know. I don’t think anybody knows. There are so many combinations and permutations of thoughts and actions and decisions and autopilot and words and instincts. Can the past ever by viewed from the present, and a different path traced? Can we ever say for certain what would have changed the outcome? I don’t believe that we can.

What I can do is suggest; I can infer; I can consider it very likely. But fortunately or unfortunately there is no going back and changing the path we took. It’s done; it’s fixed.

Regrets? It takes some consideration but actually, I don’t think so.

I wouldn’t have wished myself a nervous breakdown. I didn’t enjoy all of the stress that was actually placed or that I mentally thought was placed on my metaphorical shoulders. I never ever want to be within 10 miles of suicidal ever again if possible be ANY means!

But, the slippery slope that I skidded down and down and down led me to make decisions I would never have made otherwise, to seek out opportunities and advancements and personal development that I wouldn’t have thought necessary in different circumstances, and to change my thinking, my behaviour and my take on life to (hopefully) come out at the end with a splash into a new and improved life!

It might seem strange but there is so much that I wouldn’t have today if it weren’t for this pathway that I may or may not have gone down if I’d been a different person or acted differently in the past.

All for the best? In hindsight, yes I think it was 🙂