When I first met Mary it was with feelings familiar to most GPs and, more so, Emergency Department staff, when faced with a patient - who clearly has a significant mental health issue - lying across two or three chairs in the waiting room in a state of disassociation. Frustration, resignation and helplessness arise in equal amounts.
During the ensuing consultation there was no eye, or even face, contact; she kept her head bowed for the whole consultation and spoke only in a mumble, quite hard to hear. And that was the pattern of our consultations for the next eighteen months, interspersed with quite long psychiatric admissions when suicidal ideation became too obtrusive for either of us to stand.
Have you ever wondered what goes through the mind of a person when they are in that situation; mute and suicidal? Mary, when well, is intelligent and articulate and describes her spells of illness very clearly:
‘I sensed soon after waking this morning that my mood was veering towards that familiar abyss, an unsettling place where judgements shift and alter like dunes in a sandstorm. The fragility of life becomes all too apparent and it is not a place where the vulnerable sit comfortably.
Nebulous images, spectres of death and horror hang – as if somehow suspended. And I’m all too aware of their presence as my sense of uneasiness heightens and a faint sense of nausea ensues. That word “hang”, disturbs me whenever I encounter it, regardless of the context.
The imaginary noose that stalks me on occasion has returned and is circling my neck once more. It is thick and coarse, like something you might chance upon, abandoned on the beach – brought in by that same tide. And today that noose is particularly menacing since it flows down the length of my back reaching the floor, where it trails following my every move.
Those walks I took so often, surveying high buildings and multi storey car parks with my young daughter in her pushchair or on my back in her backpack. Gauging their suitability for launching my unworthy body and beautiful child from is now no longer necessary. We are all huddled in the same bed and it is the dead of night.
The detail of these memories has become excruciatingly clear and I dare not look directly at them. The total detachment I experienced at the time and the acceptance that my reasoning was entirely rational during those prolonged murderous musings, is horrifying to recall.
I wish a doctor had asked that vital question sooner and before I endured such desperation. Used words, unutterable to a loving mother: “Are you planning to kill your baby?”. I was so grateful to the GP whom I had never met before, but who had the guts to ask just that, when I appeared at the surgery desperate and dishevelled. He spoke with kindness, compassion and crucially, with not a hint of judgement.
I am absolutely not a mad woman. What I’ve recounted is the actual workings and the reasoning of a mind so grotesquely skewed by depressive symptoms that it operates and draws conclusions in a manner which is horrifying to all but its owner. For she is barely present.’
*Mary is not the patient’s real name
Dr Peter Weaving is the GP-clinical director for North Cumbria University Hospitals Trust and a GP partner in Carlisle. @PeterWeaving.
