Antidepressants; a GP ponders the urban myths…

I’m writing this blog purely as a GP who, every day, sees patients who take antidepressants. So these are my thoughts, based on experience, as well as evidence.

I also see patients every day who should consider taking antidepressants, because they clearly have all the signs and symptoms of significant clinical depression, anxiety, obsessive compulsive disorder or social phobia. Up to one in three of my consultations is for a mental health problem, and I suspect most of these people have finally come to see a doctor because they have reached a crisis point, or no longer know how to cope. They do not come lightly, and I understand that. They will often have already tried sensible measures, though we usually discuss those anyway, such as minimising alcohol or drug use, better sleep and eating routines, and exercise.

I always suggest counselling or other talking therapies, though again, many have had unsuccessful experiences of these. I will probably mention giving them another go…a different approach or technique perhaps?

But finally we come to medication, always approaching the subject gently, knowing that everyone comes with preconceptions and concerns.

“But they’re addictive”

“I don’t want to feel like a failure, needing medication”

“They’ll make me fat”

“They’ll make my acne worse”

“My parents won’t approve”

“I’ll be on them forever”


I have heard all of these, and many more, hundreds of times in the 15 years I’ve been a GP.

And it takes time and patience to pick my way through the concerns, which are mainly based on hearsay/myth (especially because they are NOT addictive or dependency inducing, and only one specific antidepressant is classically associated with possible weight gain. They have no effect on acne!).


But it’s worth the time, and listening to the concerns, because often a patient will then agree that it might be worth ‘giving them a go’, and that there is little to lose by trying them. Side effects are usually minimal for most people, especially if started at a half or low dose, and we always like to review how things are going at 2-3 weeks. And then when they have given them a go, and they return 4-6 weeks later, I have lost count of the number of people, but it is the vast majority, who have noticed an improvement, and as time goes on, at 8-12 weeks, say “I wish I’d tried these sooner”.


So all I would say is this; if you’re struggling and unsure about medication, then talk to a GP, sooner rather than later, and discuss your concerns, so we can see if antidepressants might help you too. And if they’re not right for you, we will still support you, and meet with you, to discuss other options and therapies.

You are not alone, and we are here to help.


Self-injury awareness day

March 1st marks ‘self-injury awareness day’, a global movement signified by the wearing of an orange ribbon, which aims to increase the awareness of self-injury and challenge many of the misconceptions surrounding this.

What is self-injury? Self-injury, also known as ‘self-harm’ or ‘cutting’, describes how someone intentionally inflicts physical injury to their own body without any suicidal intent. It can take on any form, whether it is cutting, head banging, hair pulling, burning, recreational drug or alcohol abuse, non-lethal drug overdoses or taking excessive risks to personal safety.  It affects people regardless of age, gender or ethnicity, although it is known to be particularly common in younger people.  Due to the shame and self-hatred often associated with self-harm, many sufferers will go to great lengths to hide scars, making it difficult to identify those needing help, and also to estimate how prevalent this is.  Research suggests that at least ten percent of 15-16 year olds have self-harmed at some point in their lives.

Why do people self-injure? Self-injury is recognised as a coping mechanism for overwhelming emotional distress relating to current traumas or difficulties from the past.  The distress might be grief, anger, loneliness, emptiness, anxiety or self-hatred and sufferers may describe how the ‘real pain’ of self-harm numbs their emotional turmoil, and in some cases acts as a way of avoiding attempting suicide. Over time self-injury might become a person’s ordinary response to everyday stressors, sometimes increasing the frequency and severity of injury.

What to do if you are self-harming? GPs are well placed to provide confidential advice and support, put you in touch with local and national self- injury organisations (see below) and check for any underlying depression/ anxiety or eating disorder symptoms. The Student Counselling Service is also somewhere safe and non judgmental to go to.

Is there treatment for self-harm?  Yes there can be, and the aim of treatment may be to both minimise harm from acts of self-injury and to help the sufferer find new coping mechanisms and develop problem-solving skills.  Strategies to minimise harm include recognising triggers for self-injury, learning less dangerous ways/locations for cutting, carrying dressings and understanding the dangers associated with certain medications. However, stopping the self harm is not necessarily the aim of treatment, which may be more directed towards underlying issues.

Talking therapy (e.g. cognitive behavioural therapy/ dialectical behavioural therapy), creative therapy, support networks and the promotion of the development of self-help skills all help in supporting a sufferer to learn new coping mechanisms.  If self-harm is part of an underlying mental health illness, specific treatment for that condition may be warranted.

I am worried that my friend is self-harming?  It is upsetting to discover a friend is self-harming but it is important to provide non-judgmental support and acceptance, acknowledging that they are distressed. Encouraging them to talk to health care professionals or contact a local support group will show them that you care. Asking a person to stop self-harming will not help the situation as you are asking them to take away their coping strategy.

Will I/my friend get better?  There are no quick fixes for self-harm, but by getting a person the right support and treatment, they will start to learn new ways to deal with their emotional distress.

References/ literature available:


  1. Life Signs Self-Injury Fact Sheet for Health Care Workers-
  2. Information resource pack- Bristol Crisis Service for Women –
  3. NHS self injury fact sheet-
  4. MIND- ‘understanding self-harm’-


Support Groups

Self Injury Self Help- support groups for women and men who self-injure in the Bristol area.

TESS- Bristol Crisis Support for Women, text or email support service for girls and women who self-injure- up to age 25., or text 07800472908

MIND- for information sheets/ advice about local resources-



Research at SHS

Research is crucial to all parts of the NHS, helping us to understand, adapt and respond to the challenges faced. Traditionally, research was viewed as the job of academic departments in large hospitals, but that is no longer the case. The vast majority of peoples’ contact with the NHS takes place in general practices like Students’ Health Service (SHS), so it makes sense that more research is taking place in this setting too.

SHS has been a research active practice for several years. We participate in a wide variety of studies, most of which are featured on our research notice board. We are only involved in NHS funded studies approved by our local Primary Care Research Network (PCRN). They will also have been considered in detail and approved by a Research Ethics Committee. Some studies involve our GPs, nurses or Health Care Assistants recruiting students during consultations. We have recruited to studies which have resulted in important findings and been published in very well known journals. For example, we were one of the main recruiters to a study called IPCRESS, published in the Lancet in 2009. IPCRESS showed that Cognitive Behavioural therapy (CBT) seemed to be effective when delivered online in real time by a therapist. This method of delivery of CBT has since grown, enabling broader access to CBT, impacting significantly on how mental health problems such as depression are managed. We also recruited students to a study published in the British Medical Journal (BMJ) earlier this year, which found that offering people initial telephone contact with physiotherapists (PhysioDirect) was equally clinically effective as usual care, provided faster access to physiotherapy, and seemed to be safe, (although it could be associated with slightly lower patient satisfaction). These findings will be shaping how physiotherapy services are delivered nationally.

Interestingly, there is also growing evidence to suggest that people who take part in a research study, even in the control arm, tend to do better than equivalent individuals who are not involved in research!

We are very grateful to those students who respond positively when we approach them about taking part in research (almost all of you do!). The studies we take part in are designed to be user friendly, both for us and for you, and the rewards of taking part for the NHS as a whole can be really significant. So don’t be surprised if we mention research to you, and take a look at our research notice board next time you visit the practice.

A student’s account of depression

I’m sick of waking up every morning and just being unbelievably tired, I never get to not feel tired, especially now. And it’s so frustrating because when I’m not tired, or when I’m working well then I’m actually pretty good, but when I’m not I’m just awful, and I can’t work and it’s horrible. I literally have very briefly seen how good I can be, and that’s always in my head somewhere being chased around and held down by being suicidal and being always tired and self-hatred and guilt and regret. I don’t know how to get it out, or bring it to the forefront or anything. I think suicide is different now, it’s not actively wanting to die, it’s wanting to not exist, because existence is 90% tiredness and guilt and regret and hate, and trying and failing to cover all of that up. 
I tried to meditate this morning and for a couple of minutes actually felt alright, it was like I had picked up and wrenched my life around out of this horrible black river of depression, and slowly scraped all of what I wanted out of that river, and piled it up into an island, and that island is what I clung to before, and it was a horrible island, it was self-harm and video game addictions and drinking and promiscuity, but it wasn’t death, which I think is what the river is, or at least it wasn’t suicide, for as long as you were on the island. And eventually you’d get sucked back into the river; because the island would get washed away, and you’d have to gather it all back up again, with more of the same. And medication helps, I think that in this played out river- metaphor, the medication doesn’t teach you to swim, it just gives you something to hold onto to stay afloat whilst you teach yourself.
Anyway, in this meditative state I was in, I’d made a fire on that island, and that fire was everything that I’d ever hated about me, and me paying for having been who I’d been, and it was awesome. I don’t really know how to describe a somewhat spiritual thing, and I know this is tangential, but it’s like writing down one of your dreams, so excuse the self-indulgence for a second. I’d made this fire, and on the fire I’d put everything, I’d put all the stuff that I’d done to stay here, it was weird, it was like putting events on the fire but they were like pictures of the events, so I put pictures of me cutting myself, and me crying, and pictures of me isolating myself from my family, so many pictures of all of that, and they were all things I did to survive. And then this fire was growing, and it wasn’t really a fire, it was me, and it was the person that I wanted to be, and it was taking all the bad stuff that I’d done to get to where I am, and burning it, not in a sense of burning it away, just in a sense of it was what was fuelling the fire, it was still there on the fire. And my dissertation was on there, and all the times that I’ve beaten myself up when I’ve been an idiot in social situations were on there, and the fire was quite big now. 
Slowly out of the fire, and this is quite weird, all the people that I care about and want to protect came out of this fire, and they were standing round the fire, on this island in the middle of a river of black suicidal thoughts and death, and I was the fire, I was making myself better by having been through all the stuff that I’ve been through, and they were slightly warming themselves by the fire, like I’d made this fire so that they could be warm, and so that I could be warm too. But it was a really surreal feeling, because there were hundreds of people, and they were all sort of standing around this fire, with the people who I’m closest to standing nearest and then everyone else taking a slight back step, and they were shifting, and in the front row of this circle were my family and my friends from home and university people, although I’m not sure how much to read into that. But everyone was standing around this fire which I’d made, and I think in this dream/whatever, I was supposed to think that the benefits of me getting better and giving myself wholly to this fire, was that it didn’t just warm me, it could warm other people, and then once I thought that, everyone sort of lit up, not like a light bulb, but as in, if you imagine people standing in front of a fire they were lit in this flickering light, and it made no sense because obviously the people in the front would cast shadows but there were no shadows. 
And then everyone really gradually started smiling, not sympathetic smiles, just like a compilation of all the smiles that I’d ever made them smile, and it was only really small, like a little twitch in the corner of their lip, but it was there. And it made me want to carry on, and it made me think that I wanted to carry on with that fire, despite how awful it has been, and how awful it still is, because it’s not just warming me, it’s warming other people too, or at least preventing them from heading into the river. And that was the other thing too, it made me think that in my life if I could ever stop people from going into that river, then I should, and I will, that’s what I want to do with my life. And at the end of it all, I was crying, in real life, because I hate it like 99.99% of the time, I hate having to make a fire, and not just jumping into the river and giving it all up, but then sometimes it is worth it, having a fire, not just for your sakes, but for other people.
And I think in some sense, and this whole thing sounds massively martyr-y, and I hope you don’t judge me for that, it’s genuinely not like that, I think it’s something that I’d thought before, I’ve probably mentioned it before, that if you can’t find a reason to live for yourself then you should find it in others. I thought that first when I tried to kill myself, but couldn’t because I thought I heard mum coming home. That was when I was first like “if it weren’t for other people I would almost certainly be dead right now”. And that’s okay, I think.

But yeah, I’m actually semi-smiling right now, because I think in thinking of that fire thing a couple of hours ago, that’s what I’ll think about now, when I feel myself heading down that path, because, and this is huge, and that’s why I’m smiling, I felt myself coming down this breakdown path when I started writing this, but now, I’m actually okay, that is the first and only time that I’ve ever managed to avoid a breakdown, and it’s just because I typed out this fire thing. So even if you don’t read it, then it’s served a huge purpose for me, and really great. So thank you for reading this.


This account was written by a student who wanted others to know that they are not alone, and that they too can get help from Students’ Health and the Counselling Service. Just give us a call or pop by if you are feeling down and would like help.


Self Injury; a paradox…

It is a strange truth that people self harm to make themselves feel better.

Some people have a glass of wine after a bad experience, some eat a huge bag of crisps or a bar of chocolate. But some people cut themselves, or burn their skin, take an overdose, or punch a wall. All of these options are a human way of coping with stress, though not a healthy way.

Most days at Students’ Health Service we see male and female students who have recently harmed themselves. Our nurses are very sympathetic, brilliant at wound care and completely non judgmental. The GPs would like to help you too, and discover what’s behind the self injury and distress. We are not easily shocked and we have seen many unusual ways that students harm themselves, secondary to depression, anxiety, obsessive thoughts or psychosis.

Alcohol usually makes self harm more frequent, or the injury worse.

Nationally self harm is thought to affect about 5% of people, though this is likely to be an underestimate (Meltzer et al 2002). In a school survey 13% of young people aged 15/16 reported having self harmed at some time in their lives, and 7% in the previous year (Hawton et al 2002).

It is important to assess and treat those who self harm, as the behaviour is often related to an underlying mental health condition, which, if treated, may lead to improvement not just of the depression/ anxiety/ schizophrenia etc but also of the self injury.

If you would like help with self injury, or would like to talk about your mental health in general, please come and see us soon. Don’t forget that the Student Counselling service is also there to help, and the team is very experienced in supporting students with such issues.

 Other support in Bristol;

Contact the Self Injury Self Help Bristol organisation, who provide services for men and women with self injury issues. They run support groups, and also run workshops related to achieving good mental health in general.


 Phone; 0117 927 9600

Or, Bristol Crisis Service for Women; 07788142 999

Runs a text support service for managing your self injury and emotional distress.

Reflections on Body Image

Last month the Students’ Health Service had a visit from our local MP Stephen Williams, a member of the All Party Parliamentary Group on Body Image. He was interested to hear about our work with students with eating disorders, but we also talked through the challenges of being a student with a condition such as Body Dysmorphic Disorder, and the misuse of body building drugs such as anabolic steroids in some parts of our population.

Negative body image underlies much of the mental health work we do, whether it leads to low self esteem (which can itself lead to depression or self harm), anxiety, social phobia, and more obviously anorexia and bulimia.

The report highlights more positive ways to view ourselves and our bodies, such as the Health At Every Size movement, which focuses on health rather than weight/ Body Mass Index. This movement tries to encourage us to eat healthily and engage in appropriate amounts of physical activity and has been shown to lead to higher levels of self esteem, and better blood pressure and cholesterol levels.

Anecdotally the medical community is certainly becoming increasingly wary of using BMI as a ‘one size fits all’ measure, as we watch the generations increase in height and muscle mass. Even traditional children’s measurement charts have had doubt thrown over them, with a current study from the University of Worcester identifying healthy children as being incorrectly labelled ‘obese or overweight’ by the National Child Measurement Programme. This could then lead to those children developing neuroses about their height and weight in the future, in our ‘weight obsessed society’.

Fixating on a particular weight may not be the best approach for us, and it might be better to take a more holistic approach  with better health being the best outcome measure to aim for; focus on Fitness rather than Fatness, if you like.

If you are worried about your weight/ shape or health, then please do come and see us to talk it through. We are very used to discussing these issues, and I hope you will find us good at listening and keen to help.



Antidepressants; friend or foe?

Antidepressants; friend or foe

 Two (unrelated) students asked me to write this blog. Independently they mentioned at the end of their consultations that there was a lack of positive stories about using antidepressant medication, and that other students might like to hear about some success stories such as theirs. They felt that these ‘good news’ tales might balance some of the very negative opinions that they and their peers were reading online.

Well I have worked at the Students’ Health Service for over 10 years and it has certainly been my experience that the vast majority of students that I treat with antidepressants get better. Treatment times vary, as does the need to try more than one type of pill before finding that one that works for an individual, but alongside psychological therapies, medication is usually successful in helping students return to normality.

Of course we must consider possible side effects (minimised by starting with a half dose for the first week in many cases), and appropriate length of treatment (6 months for a first episode, 2 years or more for recurrences ). It is also vital to withdraw the medication very slowly tailored to an individual’s response. The GPs at SHS are fastidious in planning regular follow up for patients on antidepressants and strive to have continuity of care to allow us to get to know each student as best we can, therefore giving a better overview of treatment response.

Evidence suggests that medication is most appropriate in cases of moderate to severe depression, so we are much less likely to prescribe it for mild cases, and we always encourage other supportive treatments such as increased exercise, counselling and psychological input as necessary.

Six million people are thought to suffer from depression in the UK, and in the last few years the NHS has noted a significant (26%) rise in the prescription of antidepressant medication. Much has been written and theorised on the reasons for this, but it is a phenomenon noted throughout the population, and students are no exception unfortunately. In the face of rising numbers of people with mental health issues it is good to have a treatment that works to offer them, and which shows benefit within usually 4 to 6 weeks. Sometimes people need to take something just to be able to get back to a point of functioning well enough to start talking therapies, of which there is steadily increasing availability on the NHS.

Antidepressants work for the majority of students that we treat, though it needs to be the right one for the individual. They can be life changing, and should always be considered and discussed as an option, though decisions should be made on a case by case basis of course.

I am confident in stating that antidepressants are an important option to be considered in the consultation between the GP and any student who is feeling depressed, and we see significant positive effects on an almost daily basis in our population. It is true that these good news stories don’t excite the media in the same way as negative stories, but that’s no great surprise.

If you are worried about your moods, or feeling low, please do come and talk to us, we really do want to know and help you, in whatever way suits you best.


Dealing with Exam stress part 2

Hi, my name’s Rick and I work at Students’ Health two days a week, delivering cognitive-behavioural based talking therapies to students struggling with difficulties such as anxiety and depression.

 As the dreaded exams loom, the people I see often find that their problems become more difficult to cope with. This is because, frankly, there are various aspects of studying at a University that are psychologically downright unhealthy:

 The perfectionism, the isolated nature of the work, the unrealistic amounts of work expected, the competitive nature of the whole thing, the lack of instant reward for the hours and hours of hard slog put in, the uncertainty about what the future holds beyond University… etc etc etc

 I still vividly remember my own struggles with all this; and anyone who was in the vicinity of the Psychology department at Exeter University in 1989 will maybe recall my own less-than-ideal attempts to cope with it.

 The good news is that 23 years later, I’m full of good ideas about how to deal with the stress of University work, most of which I’ve learned fairly recently from working here with you.

 Here are 5 top tips for psychological wellbeing at this difficult time:


1.   Use a diary/ schedule to plan your work and your revision

     By planning work you can break it down into manageable chunks and hopefully find it less overwhelming. Try not to plan unrealistic amounts; 5-6 hours a day is realistic for most people. Plan breaks and relaxing/ fun activities as well and try to start as early as you can: If you’ve already done 3 hours work by lunchtime, you’re less likely to get stressed as the day wears on.

     Above all, see what works for you.

 2.  Try not to compare yourself with other people

 There are always going to be people who seem to get up at 6.00am and spend their whole day in the library, working for 14 hours without a break. Do not compare yourself with these people and on no account try to compete with them. Work at a pace that suits you, and try not to pick up on other people’s stress.

 3.   Try to avoid falling into spirals of negative thinking

     There are various unhelpful styles of thinking people can fall into when under pressure. These include predicting the future, catastrophising, and  black and white thinking, among others. There’s a link to 12 of these and what to do about them attached below.

 4.   When work stress and anxiety do start to get on top of you, take a look at what you do in response to this

      Do you dive under the duvet? Go to the pub? Switch on daytime TV? Phone a friend? Go for a brisk walk around the block? Surf the internet? Go to the gym? Jump up and down and scream?

      Try writing down what you do, and try to notice what’s helpful and what isn’t, in terms of keeping you calm and allowing you to complete what you need to complete.

 5.   Remember that the whole thing is time-limited: It will not last for ever and you can only do what you can do in the time you’ve got

Soon it will all be over…


If you are struggling with anxiety and/ or depression and would like help and support, you can contact Rightsteps Bristol on 0117 9431111 and self refer. It is a free service. Alternately you can e-mail me at


Mental Wellbeing Week (20/02/12)

Look around you.

Wherever you are, whatever you are doing,  1 in 6 of the people around you will be struggling with a mental health problem at this time. 1 in 4 will have a problem at some time in their lives. Maybe it’s you, maybe it’s your flatmate or friend, partner or another student on your course.

The important thing is to know how and when to get help if you or your friends need it, or advice if you’re not sure what to do.

At the Students’ Health Service 1 in 4 of our doctors’ consultations is for a mental health problem.

Students, like anyone, can develop anxiety, depression, social phobia, obsessive compulsive disorder, eating disorders, bipolar and schizophrenic disorders, as well as rarer problems such as body dysmorphic disorder and borderline personality disorder. (For more information see )

If you are thinking of harming yourself, we want to help you.
If you can’t leave the house because of fear or low mood, we would like to hear from you.
If you think that life’s not worth living please talk to us.

If you know someone who is suffering, please encourage them to make an appointment with a GP or bring them in yourself. We don’t judge, we listen. We really want to help you.
This is what we do, this is why we are here.

It is time we as a society started talking more openly about mental health issues and how to deal with them positively.
Less stigma would lead to quicker access to help and better long term health.
So look around you… 1 in 6 of us is suffering.

Can you act today to help that person feel better?

Talk to the Students’ Health Service or Student Counselling Service for guidance, support or treatment.

Mental Wellbeing Week starts 20th February, at locations around the precinct, especially between Senate House and the Library, with free activities and much more.

 Students’ Health Service; 0117 3302720

Student Counselling Service

Other good sources of info;


Living Life to the Full  (depression advice)

Moodgym  (depression advice)

b-eat  (eating disorders information)

Bipolar UK  (bipolar disorder support)