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I know how alcohol can ruin our mental health. So why is it so rarely discussed? | Matthew Todd

It’s amazing to see the British finally begin to talk about our feelings. But even as we mark this year’s Mental Health Awareness week, there’s still an elephant in the therapist’s waiting room: alcohol.

The physical health risks of drinking are well known. Less discussed are the mental health consequences. These are real and significant, and seem to be getting worse. For instance, the number of people admitted to hospital with alcohol-related behavioural disorders has risen in the last 10 years by 94% for people aged between 15 and 59, and by 150% for people over 60.

Alcohol played a key part in my own problems but it took me years to come out of denial about it.

I never drank in the morning or in parks, just in a British way, bingeing along with, well, everybody else. I didn’t question it because no one else seemed concerned.

Presenting to therapists over the years with anxiety, patterns of self-destructive compulsive behaviour, swinging between thinking I was the most important and the most worthless person on the planet, they barely asked how much I was tipping down my neck. And it was a lot.

The more I drank to medicate my low self-esteem, the worse my anxiety got and the more I drank to dull it. Years passed and I couldn’t see I was stuck right in the classic “cycle of addiction”.

Eventually a friend of mine who had gone into Overeaters Anonymous sheepishly suggested I might have a problem. I resented it hugely. I was successful with a good job. There was no problem.

Eventually, it was a work incident that woke me up. As editor of Attitude magazine, I believed it would be culturally significant to have Harry Potter on the cover of a gay magazine. When Daniel Radcliffe, who played Harry in the film franchise, agreed, the only gap in his schedule for a shoot was early on a Sunday morning, which was annoying. Saturday night was my favourite time to go out. But fine. I could do this.

'The next thing I remember was waking up, empty cans everywhere, with a bunch of messages on my phone asking where I was.'


‘The next thing I remember was waking up, empty cans everywhere, with a bunch of messages on my phone asking where I was.’ Photograph: David Jones/PA

I decided not to drink the day before. No wine at lunch, nor during the play I went to see, and then straight home. All went well. Just as I was about to go to bed, ready for the shoot the next day, curiosity got the better of me and I logged on to a dating site, just to check my messages.

The next thing I remember was waking up, empty cans everywhere, with a bunch of messages on my phone asking where I was. Daniel and his publicist couldn’t have been nicer when I arrived with my lame excuse, insisting I go home to bed and that the shoot would be OK, and he found time later in the week to do our interview. Disaster was averted but it was the wake-up call I needed.

Since finally giving up alcohol, I’ve learned many things. First, that addiction is everywhere. That it is not about the drinking (or whatever the substance is), but the feelings underneath. Usually there is some kind of childhood trauma that needs to be addressed. I’ve learned that it isn’t about when or where you drink but about whether you can easily stop once you’ve started. I’ve also learned that there is an astonishing lack of understanding about addiction in general, not just from the public but sometimes by professionals who, being human too, often have their own issues to deal with.

The positive news is that despite alcohol being a socially acceptable carnage-causing drug that is pushed on us from an early age, it too is beginning to be talked about less furtively. Brad Pitt spoke in an interview last week about his struggles, Colin Farrell recently spoke on Ellen about being 10 years sober. Daniel Radcliffe himself has spoken about his problem drinking.

Last year I did another interview, with Robbie Williams and singer John Grant talking about their life-saving experiences of recovery from alcohol, drugs and sex addiction – and this time, I wasn’t late for it. Studies continually show a link between alcohol abuse and violence, domestic abuse and suicide, so talking about it is not a luxury, it is a necessity.

The British drink too much. Alcohol must be next on the mental health agenda.

How do we know we can trust the latest polls? | Brief letters

Drs Mellon and Prosser explain (Letters, 6 May) why the opinion polls were wrong at the last general election – a failure to obtain representative samples. Specifically, pollsters did not contact enough people from hard-to-reach groups that do not vote in elections. What I want to know is, has this mistake been eliminated in the current polls, which are being respectfully reported, on voting intentions? Are the pollsters now doing the job properly? Can we trust these polls?
Oliver Williams
London

I agree with Chris Birch (Letters, 9 May). Subtitles flash on and off, cover translations, appear at different places on the screen and sometimes continue over the following programme. Theresa May gabbles, Jeremy Corbyn has a beard, both impossible for lip-readers. It’s no wonder we retire to bed, exhausted.
Jean Jackson
Seer Green, Buckinghamshire

I don’t find it at all strange that a teenager would have Margaret Thatcher’s picture on his bedroom wall (G2, 9 May). Our son had her picture on his dartboard.
Barbara Freeman
Leicester

Richard Carden (Letters, 8 May) perhaps misses the point when he attributes English councils’ democratic deficit to first past the post. Since 2001, every council without an elected mayor has by law had a quasi-mayor (the leader) making almost all the decisions. In effect that’s one-person rule (give or take a small sofa cabinet chosen by the leader) irrespective of the council’s political balance.
Nick Beale
Exeter

The correspondence regarding grandparents (Letters, passim) reminds me of a very old joke: My grandparents were called Pearl and Dean but we knew them as Grandma and Grandpapapapapapapapapapapa.
Steve Vanstone
Wolverhampton

A friend of mine used to refer to his daughters’ long-term unmarried partners as his “sons-in-love” (Letters, passim).
Dr Brigid Purcell
Norwich

Join the debate – email guardian.letters@theguardian.com

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‘I don’t know who I am without it’: the truth about long-term antidepressant use

Sarah never planned to take antidepressants for 14 years. Three years after she began taking them, when she was 21, she went to her GP and asked to stop: 20mg of Seroxat a day had helped her live with anxiety and panic attacks, but she began to feel uncomfortable about being on medication all the time. Her doctor advised her to taper down her medication carefully.

At once, “I was a mess,” she says. “I thought I was losing my mind. My appetite completely went. I lost the best part of two stone. I was anxious constantly. My mouth was dry. It was difficult to sit and be calm.” She became withdrawn, refusing to see friends, and remembers asking her mother to get her a couple of boxes of paracetamol, thinking, “I’m going to have to take all these tablets, because I can’t live like this.”

Sarah’s doctor encouraged her to go back up to 20mg. “Within a week, I was much better. I feel anger when I look back. That wasn’t me relapsing, that was withdrawal. But I was so unwell, I didn’t stop to think, ‘I’ve never had this before.’ I truly thought it was me. Now the only reason I am on the drug is because I am dependent upon it. And that is not good enough.”

Prescriptions of SSRIs (selective serotonin reuptake inhibitors), the most common type of antidepressant, have doubled in the past decade. There are now more than 70m prescriptions dispensed in the UK in a year, the “greatest rise” of any drug in the last year, according to NHS research. But while the side-effects of starting and then withdrawing from these drugs are reasonably well known (the patient information leaflet accompanying the SSRI Seroxat is six pages long), there is very little research into the long-term effects of using antidepressants.

Last year, an all-party parliamentary group began hearing evidence as to whether there is a link between a measurable rise in mental health disability claims – 103% between 1995 and 2014 – and that in antidepressant prescriptions. (Claims for other conditions fell by 35% in the same period.) “We need to have a serious rethink about current levels of prescribing, because it may well be that the drugs are in fact contributing to the disability burden,” Dr Joanna Moncrieff, a consultant psychiatrist and senior lecturer at University College London, told the committee.

Reports both anecdotal and clinical have included side-effects such as constant pain, an altered sense of smell, taste or hearing, visual problems, burning hands and feet; food or drug intolerances and akathisia (the medical term for a deep inner restlessness). When a patient begins tapering down their dosage, these effects are generally ascribed to the drug leaving their system; if it is long after withdrawal is supposed to be over, however, patients are often disbelieved (according to the drug companies, withdrawal should take just two weeks for most people, though they acknowledge that for some it can be months).

Professor David Healy, director of the department of psychological medicine at Cardiff University and author of 22 books on psychopharmacology, believes that antidepressants are overprescribed. “If you go into your average doctor – if you’ve been off the drug for half a year or more – and you complain [of a range of symptoms] and say, ‘I think it’s caused by this pill I was on’, he or she would say, ‘It’s been out of your body for months. You’re neurotic, you’re depressed. All we need to do is put you on another pill.’”

GPs, Healy says, are “relying on your word, and if it’s a choice between believing what you say and relying on what drug companies say to them, they [tend to] believe the drug companies”. Healy, who has been a consultant for, and expert witness against, most of the major pharmaceutical companies, has long argued that long-term side-effects are routinely ignored or misunderstood.

But many experts believe these drugs do more good than harm. “Most of the people I see who have moderate to severe depression benefit from them,” says Daniel Smith, a professor of psychiatry and researcher into bipolar disorder at the University of Glasgow. For some, medication can be no less than “transformative. It can get them through a really critical period of their life.”

However, when it comes to long-term impact, especially after a person stops taking SSRIs, Smith says it can be hard to work out which symptoms relate to the drug use and which to the underlying conditions. “There’s obviously an issue of cause and effect. How can we be certain the SSRI caused it? Depression affects libido and sexual interest. How much [of the reported effects] is depression and/or anxiety symptoms coming back?”

A Seroxat box and pills


By 2003, worldwide sales of Seroxat, manufactured by GlaxoSmithKline, were worth £2.7bn. Photograph: Alamy

SSRIs have been around for more than 40 years, but grew in popularity in the late 1980s and 90s after pharmaceutical company Eli Lilly launched fluoxetine, otherwise known as Prozac. Time magazine put the drug on its cover twice, asking, “Is Freud finished?” and describing SSRIs as “mental health’s greatest success story”. In 2001, a landmark report on a clinical trial into paroxetine (sold as Seroxat in North America and Paxil in the UK), called Study 329, concluded that it demonstrated “remarkable efficacy and safety”. Study 329 led directly to a massive increase in prescriptions: by 2003, worldwide sales of Seroxat (manufactured by GlaxoSmithKline) were worth £2.7bn.

But concerns were raised about the study –the US food and drug administration (FDA) officer who reviewed the data disagreed with the findings, calling it a failed trial – and in 2015 the British Medical Journal published a re-evaluation. Seven authors went through as many of the thousands of individual case reports as they could, and found not only that “the efficacy of paroxetine… was not statistically or clinically different from placebo”, but that “there were clinically significant increases in harms, including suicidal ideation and behaviour”. The original study reported 265 adverse reactions; the BMJ found 481. The re-evaluation also found that psychiatric responses were grouped together with “dizziness” and “headaches”, rather than given their own category. In 2003, the UK banned the use of Seroxat by anyone under 18; and in 2004 the FDA required a “black box warning” on all antidepressants, its strictest level of patient warning.

“Patient safety is our number one priority,” a GlaxoSmithKline (GSK) spokesperson tells me. “We believe we acted responsibly in researching paroxetine, monitoring its safety once it was approved and updating its labelling as new information became available.”


It’s more reliably predictable that they’re going to get rid of sexual function than get rid of depression

Many SSRI users report blunted emotions, even long after they have ceased taking pills, and an impact on sexual function. “They should be called anti-sex drugs rather than antidepressant drugs,” says Jon Jureidini, a child psychiatrist of 30 years’ standing, a professor of psychiatry and paediatrics at the University of Adelaide and co-author of the BMJ study, “It’s more reliably predictable that they’re going to get rid of sexual function than it is that they’re going to get rid of depression.” Again, some people find this persists long after they cease taking the drug. One person I spoke to, Kevin, had taken Prozac for six months when he was 18; now 38, he hasn’t had an erection since.

Last September, Healy and colleagues published a further examination of the data gathered for Study 329. This data followed the trial participants for six months after they started taking paroxetine (the “continuation phase”) and while they were tapered off it. GSK, which in 2004 published a clinical study report, had argued that “the long-term safety profile of paroxetine in adolescents appears similar to that reported following short-term dosing”. Healy and co, however, concluded that the “continuation phase did not offer support for longer-term efficacy”. More alarmingly, they found that the taper phase, when patients were being taken off the drugs, was the riskiest of all, showing a “higher proportion of severe adverse events per week of exposure”. This, they said, opens up the risk of a “prescribing cascade”, whereby drug side-effects are thought to be symptoms, so are treated with further drugs, causing further side-effects and further prescriptions – thus increasing the risk of long-term prescription drug-dependency.

In October, the British Medical Association published its response to a two-year fact-finding exercise into long-term use of psychoactive drugs. It noted that while benzodiazepines, z-drugs, opioid and antidepressants are “a key therapeutic tool”, that their use can “often lead to a patient becoming dependent or suffering withdrawal symptoms… the evidence and insight presented to us by many charity and support groups… shows us that the ‘lived experience’ of patients using these medications is too often associated with devastating health and social harms”; it was therefore, the report concluded, a “significant public health issue”.

The BMA made three key recommendations: first, and most urgently, that the UK government establish a 24-hour helpline for prescribed drug dependence; second, that it establish well-resourced specialist support units; and third, that there should be clear guidance on prescription, tapering and withdrawal management (they found the current approach to antidepressants, in particular, to be inconsistent: too many patients were suffering “significant harm”). There are also increasingly urgent calls for studies into long-term effects that are not funded by drug companies, because, Moncrieff says: “We don’t have very much data. This research is really important, but hasn’t been done. It’s a massive blind spot. It’s extraordinary – or maybe, given the pressures and interests at work, not extraordinary at all – that it hasn’t been filled.”

In March this year, members of the BMA, along with MPs and researchers from Roehampton University, went to parliament to lobby Public Health England, armed with research estimating that there are 770,000 long-term users of antidepressants in England alone, at a cost of £44m to the NHS per year (a figure that does not account for the cost of GP appointments, or the impact of side-effects, withdrawal effects and disability payments).

“I think you have to adopt a very conservative approach,” says psychiatrist Jon Jureidini. “These are brain-altering drugs, and our overall experience with brain-altering drugs of all kinds is that they tend to have a detrimental effect on some proportion of people who take them long term. All we know about the benefits is from short-term symptom-reduction studies. The careful prescriber needs to say, ‘Well, in balancing the likely benefits and harms, I need to be very cautious about how much benefit I’m expecting, and I need to be very generous about the possibility that the harms might be more than they appear to be.’”

Quite a few long-term users, such as those I spoke to below (and who wished to be anonymous), would agree.

‘Tapering off is the hardest thing I’ve ever done’: Sarah, 32; has taken Seroxat for 14 years

I was prescribed Seroxat when I was 18, the year I started university. I grew up with a disabled sister, so things at home were very stressful, and I had a history of anxiety and panic attacks. I had counselling, but the problems persisted, so I went back to the GP. I don’t remember everything that was said, but there was no conversation about side-effects.

Within the first two weeks of starting Seroxat, I remember I was sitting in the front room watching TV when out of nowhere I had this intense feeling of heat, like an electric shock. It started in my hands, went all the way up my arms and through to my head.

The GP said it was probably just my body getting used to the drug. And after a few weeks the weird sensations did ease off. I had a fabulous time at university. I still had panic attacks, and there were certain situations I would avoid – as I still do – so it wasn’t a wonder drug, but there were no major problems.

But in 2006 I tried to come off it. There were a couple of Panorama documentaries about the side-effects and I was starting to become concerned. The GP said, “That’s fine, but do it gradually, over three weeks.”


I thought I was losing my mind. I was going to work, but it was difficult to get through the day. My mouth was so dry

I immediately became incredibly unwell. I thought I was losing my mind. I was going to work, but it was difficult to get through the day. My mouth was so dry, I was constantly drinking water. I had bizarre thoughts – not hallucinations – that were frightening or distressing. I had a strong sense of detachment from reality.

Eventually, the doctor said, “Look, you coming off is obviously not working: we need to get you back to 20mg.” Within a week I was much better.

A few years later, when I realised my mental health was getting worse, even though I was on the medication, I started to do some research, reading case studies about withdrawal. I find it so offensive when a GP says, “This is who you are.” I didn’t have these symptoms 10 years ago. I didn’t have this sense of detachment. I saw various psychiatrists. They just kept saying, “The drug is safe, you need to be on it.” A couple of others told me the reason I was having these problems was because I wasn’t taking enough. Another said, “If you were diabetic, you’d take insulin and you wouldn’t have an issue. Why are you so bothered about taking this drug?”

I’ve been on it since I was 18, so I don’t know who I am without it, as an adult. Who knows? I might have all kinds of problems, but I need to know I’ve tried. Tapering off is the hardest thing I’ve ever done. It’s taken me three years just to get from 20mg to 5mg. I’m no longer with my partner – we were together for six years. I believe Seroxat has played a part: it affected my moods, it made my anxiety worse and, by necessity, I’ve had to be selfish, really. I don’t want to say all my problems are to do with Seroxat, because they’re not. But I do believe that it has caused me harm.

‘I don’t have much of an interest in interacting romantically or physically with the opposite sex’: Jake, 24; took SSRIs for eight years

I had been dealing with symptoms of OCD and anxiety for a lot of my childhood. It’s in my family, affecting two siblings and one parent. I was prescribed Zoloft when I was 12; I took a variety of SSRIs, Zoloft to Prozac to Lexapro, and then two others, for eight years.

Did they help? You know, I can’t really tell you, because I got through school. I got high marks, I had a lot of friends. So, in that sense, they must have helped. That’s the thing: for people with major depression, it’s easy to say, this has a measurable effect. But I kept taking them just because that’s what I’ve always done.

I went to university right out of school. I did very poorly. I had a bit of a breakdown, isolating myself, not sleeping. I was still on medication. I came home and enrolled at a community college. That was my worst period – I was very depressed. And I started to think, “I’ve been on these medications a long time. I’m not doing well – why not get off them?” I don’t recommend this at all to anyone, but I stopped going to a psychiatrist and took myself off.

prozac


Prozac. Photograph: Getty Images

For months I had trouble sleeping. I was jittery. I had brain zaps. My anxiety was pretty ramped up. I would feel numbness in my extremities – generally my arms. My psychiatrist told me these were just normal withdrawal symptoms, and they’d be gone in four to six weeks: “Anything you feel beyond that is your anxiety and depression returning.” Basically, if you still feel anything beyond this window that the medical community has established, it’s all in your head.

Eventually I went back to school full-time, and I remember doing OK, feeling somewhat better.

I’ve now been drug-free for four years. What’s lasted are the sexual side-effects. They were definitely worse in withdrawal than they had been on the drug, even though I didn’t really realise or understand it at the time, primarily because I started to take SSRIs at 12. While my brother took the same medicine over the same period and had a normal sexual life, I had a lack of sexual interest. I had erections, and I have regularly masturbated my entire life. But I don’t have much of an interest in interacting romantically or physically with the opposite sex.

I didn’t even start thinking about sex until a couple of years ago. It’s almost like I woke up one day and thought, “OK!” I started getting these windows – days or weeks – when normal sexual feelings would appear. But they’re new to me and I don’t know what to do about them. And because I don’t know what to do, I get anxious, and the anxiety kills any feeling – and then I’m anxious because I’ve lost all my feeling.

Online, I’ve come across a big asexual community. Some also took antidepressants; I think there are a lot of people like me out there. I’d like to think that if I keep going to counselling and sleeping and eating properly, I can rectify these things.

In the end, it’s about pros and cons. If you’re lying in bed and can’t get up, is it better to function? If it was up to me, I’d say that, barring extreme circumstances, nobody under 18 should be prescribed these things. Your brain develops around them. Drug companies should be thinking of the long-term effect on people who can’t even consent.

‘If I missed a dose, I’d get shocks down the side of my body’: Chris, 43; has been taking Seroxat for 26 years

I was originally prescribed Seroxat for mild anxiety about my GCSEs. It was 1991, about the time GlaxoSmithKline released Seroxat. I was one of the first people to be given it.

I was prescribed 20mg, the basic dose, to start with. It helped me: I got through school, I went to uni, I went to work. But I had side-effects from the off: profuse sweating, low libido. I’m quite a placid person, but I became aggressive. I never suffered, in the beginning, with the suicidal thoughts that people talk about now, but what I did notice was that if I missed a dose – especially after eight years of taking it – I’d get shocks down the side of my body. I’d be nauseous, my limbs would become weak. I’d be in a constant state of confusion and was very impatient. I couldn’t communicate well with people. I said this to the doctor, and he said, “We’ll up the dose to 40mg.” That was 1998.


I tried to go back to 20mg, but my words became slurry, so the doctor put me back up to 60mg

The 10 years after that weren’t too bad. I managed to work, as a sales rep, for 18-20 years. But by 2012, by which time I was up to 60mg, I had tried on numerous occasions to withdraw. I tried to go back to 20mg, but my words became slurry, so the doctor put me back up to 60mg.

By the time I was 38, even that wasn’t enough. I tried to take my life. The doctor wouldn’t prescribe a higher dose. I couldn’t do my job, I couldn’t concentrate, I couldn’t drive. A psychiatrist once said to me that coming off Seroxat is harder than quitting heroin. That really hit home.

I have now been unable to work for four years. I’m still seeing a psychiatrist. I’ve also been diagnosed with fibromyalgia: constant tiredness, aches in the neck, and in the lower back and lower limbs. I’m 43 and still live with my mum and dad.

I also have no libido. Since the age of 30, I have had no feelings in that regard whatsoever. I have had relationships, but they’ve all failed. I haven’t been in a relationship for 10 years, which is a long time to go without sex, but I just don’t get the urge.

I don’t really have emotions, to tell you the truth. The drug takes your emotions away. I’m sort of existing, not living.

And when the drugs do work…

‘I wanted to be able to feel good when good things were happening, bad when bad things were happening’

By Simon Hattenstone

I suppose I was a depression snob. A purist. Why should I take antidepressants? Yes, there was something rubbish about crying all the time, not functioning, being unable to answer simple questions because of the fug in my head. But, hey, at least I was true to myself.

My depression went back to my late teens. I didn’t like to think of myself as depressive, because depressives were losers. And I didn’t think I fitted the bill: I was pretty funny and able, and I could get girlfriends. I guess most depressives don’t think they fit the bill.

It might have been genetic. My dad had paralysing depression, and so did his father. As a young boy, I’d spent three years off school with encephalitis – an inflammation of the brain that is often fatal. Survivors are often left with depression.

I remember as a teenager being on holiday in Greece with friends. The weather was gorgeous, and I thought, “Why can’t it piss down, because then at least I’d have a reason to feel this way?”

That is what I always craved – objectivity. To be able to feel good when good things were happening, to feel bad when bad things were happening. I hated the fact that my feelings rarely correlated to what was going on in my outer world.

In my 20s, I got by. I held down a good job, fell in love, had kids, made friends, had a pretty good life. But things came to a head when my best friend killed herself. I’d find myself weaving in between traffic wondering what the impact would be like. I took a period off work and gratefully accepted my Prozac prescription.

Things had changed since I first rejected them. Prozac looked cool (lovely green-and-white pills) and rock bands wrote great songs about it (even if REM’s Shiny Happy People was supposed to be dystopic). After telling people I was off work with depression, I ended up feeling like a priest at confessional. It turned out that virtually everybody I knew was a depressive and pilling their way out of it; now it was “our secret”.


I would try to come off the pills and felt rubbish again – not more rubbish than before, but the same. So I returned

Initially, Prozac made me feel sick. And then magically, after a couple of weeks, I felt lighter, as if something had been lifted. I could hear questions properly, answer logically, enjoy a sunny day.

My partner said I was transformed. Occasionally, I would try to come off the pills and felt rubbish again – not more rubbish than I had before, but the same. So I returned, and after a while, I thought, “What’s the point of even thinking about coming off the pills if they make life work for me?”

There are times now when I wonder if I weep and fret and withdraw too much, and whether I’m becoming immune to the Prozac. But on balance I think not, because life is still so much better than it was.

If Prozac was no longer working for me, would I stop taking it? Probably. Would I stop taking antidepressants full stop? I doubt it. I’d simply look for another super pill.

Are you a long-term user of antidepressants? Tell us about your experiences

  • If you are affected by the issues raised in this piece, contact the Samaritans here.

9 Things You Need to Know About Allergy Shots

Do allergy shots really work?

Allergies—whether they’re seasonal or year-round—can put a serious damper on quality of life; in some cases, they can even be deadly. But for certain types of allergies, allergen immunotherapy (commonly known as allergy shots) can be a big help.

They may require a lot of time and effort, but the benefits of allergy shots can be life-changing and long-lasting for people of all ages. Their effectiveness for children and young adults is well known, and a 2016 study also found that they can be effective for older adults, as well—reducing symptoms of hay fever in people ages 65 to 75 by 55% after three years, and reducing the need for medication by 64%.

“Everyone is different, and it’s true that some people don’t have a good response,” says Laura Dziadzio, MD, a pediatric allergist and assistant professor at the Virginia Tech Carilion School of Medicine. “But for others, it’s like night and day. I have lots of patients who were really miserable and are now doing much better, and can finally enjoy the things they couldn’t before.”

If you’ve tested positive for an allergy and are considering immunotherapy treatments, here are 10 things you should know.

A letter to … My brother, who doesn’t know that I’m a heroin addict

You came to visit me last year. Together we planned your trip. You were to stay at my house – I didn’t even realise that your grown-up form (so much taller and broader now) would be far too long for my short couch.

I came to meet you at the airport. I woke up early so that I could be there, ready and waiting. I imagined standing in arrivals, watching for you to emerge from the crowd. I knew that I would recognise you, even though I hadn’t seen you for many years.

I was late, of course. I’m late for everything now. I used to be so obsessively punctual, anxiously arriving at least half an hour early for appointments, studiously mapping journeys and carefully estimating travel times. But I overslept and then, at the airport, I spent a good 20 minutes in the first bathroom I could find, nervously at first and then gradually becoming less nervous, smoking heroin off the tin foil that I carry with me everywhere I go.

I came out of the bathroom and was calmer and happier and a little bit dozy. I saw you right away. Everything was great. You smiled so wide and hugged me. And everything was comfortably numbed and blurry.

I love heroin. I love it more than I love anything else in this world – more than I ever have loved or will ever let myself love anything or anyone else. My heart is beating so fast as I write this, and my palms are prickling damp with sweat. I’m eight hours without heroin and two hours after methadone.

I love heroin because it numbs me. It gave me just what I needed the first time I tried it, which was the ability to remove myself from my life at last, to remove myself from the self that I loathe so deeply and without reason. When I am high – which is all of the time, now – I can negate everything. Nothing else matters any more. I have chosen to reject prevailing lifestyle norms and the desires, both material and emotional, that come with these norms. I never thought that I could achieve anything anyway, so it is really just me in my 20s, mumbling a neat, easy and lazy “fuck this” as I remove myself from the world and sink into an opiate haze to hide.


Keeping my drug use from you is exhausting and you deserve my honesty, not the lie I present to the world

I meant to tell you, of course. I mean to do a lot of things. A lot of these things are simply forgotten – heroin is very good for forgetting, for removing from conscious thought anything that is not about how much heroin I have right now, or how badly I need it and how much I can buy as soon as possible – but some things, like this, are things that I just cannot bring myself to do.

I wanted to be honest with you. I wanted to start your visit off right, to make you breakfast after your flight and then, when the time was proper, to try my very best to explain to you that, yes, I am a junkie. I’ve got zero money and I’m only just hanging on to a job and I’ve just started on an opiate replacement for the first time. Some days, I do want to stop using heroin; most days, I don’t.

I really wanted to tell you everything. Keeping my drug use from you is exhausting and, more than anyone else, you deserve my honesty, not the duplicitous, multi-natured lie that I present to the rest of the world. I really wanted to tell you, but you’re my little brother. And for some reason you didn’t see the person I have become since we last met; you still saw me as your big sister.

Anonymous

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Do you know how to protect yourself from viruses?

The best way to protect yourself from any virus is to arm yourself with knowledge of how they operate inside you. Learn their survival mechanisms and vulnerabilities. There are more than 4000 known viruses. Scientists have argued whether viruses are even living beings.

From conception to death, proteins (amino acids) play a huge role in cellular health. Every living being is endowed with both external and innate protective mechanisms to ward off bacteria, viruses, fungi, and intruders. Indeed, pay attention to the protective protein coat that surrounds individual cells. And pay special attention to the enzymes that break down and repair amino acids. This is the key to all disease and a vibrant life.

Viruses invade a cell by changing the structure and permeability of the cell wall. Viruses can’t survive on their own—they must hijack a host cell, inject their own nucleic acid, and replicate themselves like an out of control copy machine. Viruses use a type of agglutinin (big word meaning a substance that glues things to itself) called hemagglutinin to bind themselves to sialic acid links on the surface of epithelial host cells. Once attached, the virus begins to alter the permeability of the host cell wall—it makes the cell wall soft, causes it to bend apart, and creates holes (pores) in the sialic acid links on the surface. Viruses enter the host through these pores to hide inside and evade the immune system. They do this by using an enzyme called neuraminidase. This particular enzyme can catalyze (break apart) sialic acid links on the host cell surface. These two important molecules classify viruses: Hemagglutinin (H) and Neuraminidase (N). Each virus has one type of H and one type of N. H1N1 for example, was responsible for the pandemic of 1918 while the swine flu pandemic was H2N2. As a virus mutates or jumps species, the H and N numbers change to reflect the shift. As newer, more virulent strains of viruses are formed, human antibodies against the older ones no longer recognize them and reinfection can occur.

Neuraminidase is a key player in the ability of the virus to enter and exit the host cell. This enzyme breaks apart chains of sugars and other glycoproteins. Mucin is a protective glycoprotein secreted in the mucus of the respiratory and digestive tract. The sugar molecules attached to mucins give them increased water holding capacity and make them resistant to digestive enzymes. The disruption or pore created in the chain allows the virus to escape the protective mucus fluid in the respiratory tract and travel via the spleen to the brain and other tissues. Viruses have evolved to use this enzyme to their advantage—neuraminidase prevents them from aggregating (sticking) to each other and being trapped in protective mucous.

A key player in virus prevention is the “Aquaporin.” Defined by the Farlex Medical Dictionary (link below): “A member of a family of trans-membrane channel proteins found in epithelial membranes that serve to regulate trans-epithelial water movement in tissues involved in body fluid homeostasis.” In other words, essential membrane proteins that tunnel into every cell, bring essential nutrients into every cell, and carry toxins out of every cell.

Ever heard of them? Doubtful. Are they important? Critical. Aquaporins are essential for cellular hydration and oxygenation. Hydrated cells protect against and remove toxins. Viruses in dehydrated cells have more time to multiply. And so it is with cancer. An external acidic pH, along with cellular dehydration, increased metabolism of sugar, and poor water perfusion—allow cancer cell invasion, replication, and metastasis. (Viral Infections are pH Sensitive; link below)

Neuraminidase inhibitors are effective treatments that work by reducing the fluidity of both the host and virus cell membrane; making it rigid and inhibiting the ability of the virus to enter the host cell. There are several herbal antivirals that are known to do this. Ginger, Rhodiola, Elder, Chinese Skullcap, and Licorice are neuraminidase inhibitors effective against both influenza A and B strains. (Buhner, link below)

A large part of your immune system is located in the gut—so proper digestion is critical. Digestive enzymes, hydrochloric acid, probiotics, and fermented foods are essential for gut health. Viruses, bacteria, fungi, and parasites are all made of protein. Protease enzymes digest protein membranes surrounding viruses, leaving them unprotected and vulnerable to destruction. The Herpes Zoster virus has been successfully treated since 1968 with enzymes and no side effects. The Medical Enzyme Research Institute found that enzymes significantly limit the progression of early stage HIV. In HIV positive patients— enzyme therapy can delay onset of the disease—sometimes permanently. (Enzymes for Life, link below)

Hydrochloric (stomach) acid not only breaks down food, but also kills pretty much every pathogen known to man. Proton pump inhibitors like “the purple pill” inhibit the production of stomach acid. This is counterproductive. Hydrochloric acid supplementation is necessary. Probiotics and fermented foods like kefir, Kombucha, and fermented vegetables contain live cultures that repopulate your gut with beneficial bacteria that restore a healthy microbial balance. Healthy digestion means your immune system can spend less time breaking down food for energy, and more time identifying and destroying pathogens.

Finally—one absolute superstar—Colloidal Silver. Colloidal silver was considered an essential part of the human immune system until the late 1930’s. Ancient Greeks lined water and wine urns with silver. The Romans made poultices for burns. American settlers put silver coins in milk and water to keep it fresh and kill germs. The expression “born with a silver spoon in their mouth” came from the time when wealthy people put silver spoons and silver pacifiers in their children’s mouth to protect them from the germs of commoners. In the bubonic plague of the 1400’s—wealthy people remained mostly unaffected. In 1920, Alfred Searle wrote a book, “The Use of Colloids in Health and Disease,” designed to help doctors understand the healing properties of colloidal silver. Good old Louie Pasteur turned humans against the essential protective innate mechanisms, and critically essential microbes that will soon be our only hope against mutant resistant pathogens.

We’re poised to come full circle. Everything new is simply well forgotten old.

RESOURCES:

http://www.sciencebuzz.org/topics/2009-h1n1-flu/what-letters-h1ni-mean

http://www.barnesandnoble.com/w/herbal-antivirals-stephen-harrod-buhner/1116395381

https://www.amazon.com/Enzymes-The-Fountain-of-Life/dp/B004C32H48

http://medical-dictionary.thefreedictionary.com/aquaporin

https://www.ncbi.nlm.nih.gov/pubmed/15242101

http://www.biology-online.org/articles/aquaporins_-_perfect_water.html

http://drsircus.com/general/viral-spread-ph-sensitive/

http://thesilveredge.com/benefits.shtml#.WNR2IhLyuRs

Thomasina Copenhaver

Thomasina Copenhaver is a naturopathic doctor and registered nurse with over 30 years experience in the healthcare profession. Her passion is writing, researching, and empowering all humans with knowledge of healing at the cellular level; to enable them to make educated and informed choices regarding their health. For more information visit her website www.notesfromanaturopath.com or to buy her book, “Notes from a Naturopath” visit Amazon or Barnes and Noble.

Sex education: what do today’s children really need to know?

From 2019, children will be taught about healthy adult relationships from the age of four, and sex education will be compulsory in secondaries. But there are caveats. Schools will have flexibility in how they teach the subjects and can develop an approach that is “sensitive to the needs of the local community” – and, crucially, to religious beliefs. Parents are expected to retain the right to withdraw their children from lessons.

What details do children these days need to know? And how much freedom should headteachers have to decide?

Education worker, Brook sexual health charity, in Coleraine, Northern Ireland

Fiona Johnston


Fiona Johnston: ‘Most of the time, the information young people have is completely wrong.’ Photograph: Paul McErlane for the Guardian

Although sex education is already compulsory in Northern Ireland, our education system is run by religion, and lessons have to fall into line with the ethos of the school. Most of the time, the information young people have is completely wrong because they’re getting it either from each other or from pornography. One of the main things they ask about is things that they’ve heard about from porn – things such as fisting, or other sexual acts.

The worry is that young people believe everybody is doing these things and that it’s normal – when the truth is, it’s not. Things like fisting are physically damaging, and they’re not for pleasure. But pleasure is one of those things that people don’t like talking about because they don’t like to think that young people enjoy it, and that one of the main reasons we do have sex is because of pleasure.

Karl Young

Karl Young
Karl Young

Father of two boys, who blogs as the Yorkshire Dad, based in Harrogate

As children get older, I do think that, around the online stuff – people asking for photos and so on – I don’t really have much experience of that. I’m happy having a chat about it, but teachers are going to have all the right resources and they’ll probably be better than parents would be at offering advice.

Stephen Tierney

Stephen Tierney


Stephen Tierney. Photograph: Studio 3000 Ltd

CEO, Blessed Edward Bamber Catholic multi-academy trust, Blackpool

For me, there would always be a desire to have a degree of flexibility within the teaching of SRE. Respect for others is crucial so it seems odd to insist all these elements are taught even where a particular community would say “that’s not our way”. I can’t think of a school that wouldn’t want to engage with the human relationships element of it, or with the sex education, in terms of the biological element to it, which is just part of science. There’s very little that as a Catholic school we’d say “we’re not comfortable with that”. We would teach about the different types of contraceptives, what the church’s perspective would be. We’ve been doing that for decades. [If we started giving information on how to access contraception] we would get into difficulties because our parents have expectations of how we will behave.

Goedele Liekens
Goedele Liekens

Sexologist, goodwill ambassador for sexual health and broadcaster best known for presenting Channel 4’s Sex in Class

I have seen biology books in the UK without the word clitoris in them. But you cannot talk about sex education without talking about the clitoris or without talking about masturbation. Young people need to know that they don’t need to be ashamed of masturbation – and that girls do it as well. It’s a good thing that SRE is going to be compulsory, but you need travelling teams of specialists that come to schools to train teachers and because it can’t just be a one-off lesson you need two or three teachers to continue this.

The other thing young people need preparation for is that sexual experiences come with stress, confusion and the huge emotions that come with the heat of the moment.

Jennifer Dhingra

Jennifer Dhingra


Jennifer Dhingra

Sexpression:UK, a student-led sex and relationships charity

Consent is a crucial topic because it can give young people the confidence to take control, and it provides protection against sexual exploitation. We get a lot of questions about gender identity and what the terms are. The main thing is that SRE is inclusive and comprehensive. It should reference people of a variety of sexual orientations, races, religions and cultures.

Andrew Moffat


Andrew Moffat. Photograph: David Sillitoe for the Guardian

Assistant headteacher, Parkfield school, Birmingham

We need to talk about relationships and different families. Children need to know from a very early age that all families are different. Some have a mum and dad, some have just a mum or just a dad, some have two mums or two dads, some live with their nan, some live with foster parents. Work on LGBT issues has to be a whole-school initiative and not just in sex education.

Evelyn Greeves

Evelyn Greeves


Evelyn Greeves

Girlguiding advocate and student, Durham

The overall impression I had from sex education was that sex was something you should put off doing for as long as possible. But, if I was going to do it, I should make sure my boyfriend really loved me and that we used a condom. As a lesbian that wasn’t much use to me.

A lot of people assume that you can’t catch an STI through lesbian sex or gay sex, which obviously isn’t true. The use of things like dental dams, and condoms in sex between gay men often isn’t discussed, which is a really poor show.

Cindi Pride

Cindi Pride


Cindi Pride

Deputy headteacher, Stroud high school, Gloucestershire

One of the things that we’re working on is empowering young women to feel they can say no to requests for images, or anything that makes them feel uncomfortable. Girls are being bombarded with images sent from boys – very often completely unrequested – and they are being pressed to send images of themselves, which they clearly don’t want to do, but they come in for a lot of abuse and ridicule if they say no.

Most Still Don’t Know ObamaCare Penalties Waived by Trump Executive Order

The I.R.S has been instructed by the Trump Administration via Executive Order  not to collect ObamaCare Penalties. Giving millions of Americans and small businesses a huge break and boosting the economy. Ordering the I.R.S. not or ask about your healthcare situation makes sure no further penalties can be assessed. Effectively throwing a monkey wrench into the ObamaCare tax and penalty system that has wrecked the American economy. As Congress sits on their hands and does nothing this one act alone has given millions of families much needed help. Millennials who don’t get ObamaCare will actually get a tax return this year. Small business can expand not having to worry about the mandates. Majorly boosting the consumer confidence and adding to the stock market rally. Trump can do this because the President has the responsibility to direct all employees of the federal government. Congress may wait and try to introduce ObamaCare Lite but Trump has beat them to the punch back on January 20th.

Why is this not more widely reported on mainstream fake news? Nothing on nightly news. A couple begrudging mentions in the national papers. Local or city newspapers and television? Forget about it. Alternative sources and conservative economic media have reported on it. The answer is obvious. It is not politically convenient.

This is such cause for celebration for all Americans yet almost nothing is being done by the 5th column to advertise the fact to the people. This is important. A lot senior citizens who rely on these “news sources” are not even aware of this. Lower income people and even low information consumers are still making financial and healthcare decisions based on old information.

Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal

Section 2 of the Executive Order of Jan 20th reads.

Sec. 2.  To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.

Small businesses over 50 people that don’t comply with the Obamacare can pay as much as $ 5000 per employee as places like Macdonalds get waivers. The penalty to an individual can be as high as $ 2800 in the higher tax brackets. Even at the lower end even $ 600 can be be a low income earner’s entire tax return. The effect goes far beyond that.

Now families and individuals can effectively ignore the disastrous law all together. No longer saddled with having to get useless health insurance with high premiums. Saving many hundreds of dollars a month for an average family. Choosing alternative means of healthcare not prescribed under the draconian ObamaCare. If they know about it.

Sources:

RaptormanReports

https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and

https://www.forbes.com/sites/kellyphillipserb/2017/01/20/trump-signs-executive-order-to-roll-back-obamacare/#7858a7643eeb

‘So, you know I have bipolar?’ – the perils of dating with a mental health problem

Dating is hard. It’s paved with heartache and unrequited crushes and the blurting out of gabbled nonsense in front of the unimpressed person you like. When I finally found myself in a conversation with someone I liked at work, whose head I had resolutely stared at the back of for a full three months, I answered an innocuous, “So, how’s your day going?” with, “I am awash with existential despair.” She stared, confused and unblinking, back into my face. I then followed it up with a tiny, pathetic, “Woo!” She sat down again. I continued to stare at the back of her head from my desk, in the full knowledge that she would never speak to me again. This isn’t just me, right? This is how it is for everyone. This is what it’s like to date. It’s awkward.

But what is it like when, in addition to your inability to say anything remotely funny or interesting to the person you are into, you have a mental health problem as well? How does that affect the way you interact with them? How does it affect a relationship once you are actually in one? And, more pressingly: how do you even tell someone you are, or have been, ill? At what point during the dating process is it appropriate to bring up mental health?

The pressure of not knowing when or how to reveal your mental health status can be an additional and very valid source of anxiety. If you tell them too soon it can feel like you are setting the stakes too high; but if you leave it too long you might find that the person you are dating has offensive views on mental health, doesn’t want to deal with it or just isn’t equipped to handle it at all.

As a serial dater it’s something I’ve contended with a lot. It’s also something I’ve done badly a lot. You would have thought there was a finite number of ways to do this wrong. There is not.

How not to tell someone you are mentally ill

Let’s start with some of the poor ways I’ve handled this so far.

Avoiding telling someone until it was catastrophically too late

Hey! I thought, after a month or two of relative tranquility. I think maybe I don’t have mental health problems any more! I think maybe things are going to be perfect for ever and I’m never going to have to think about this ever again. There’s absolutely no point telling my new boyfriend about it, is there? Nah. It’ll be fine. I’ll be fine. I’m fine.

It was not fine.

At that point I was deeply embarrassed by my previous psychotic episode, and tried to distance myself from it as much as possible. It was easier for me to avoid the topic and skirt around it awkwardly than to confront it. I chose to blame my breakdown on the stress of starting university, moving away from home, and spending all my time drinking. I didn’t want to think about the possibility that it might continue to affect me for the rest of my life.

But eventually my boyfriend and I did end up talking about self-harm and suicide. It was two years into the relationship and we were in the pub. “It’s all just attention seeking, isn’t it?” he said. “It’s just people who want to feel special: ‘Oooh, look at me, I’m on antidepressants!’ Just get on with it.” He went on to tell me about an ex-girlfriend who had gone on antidepressants after her dad had died unexpectedly; he complained that she lay in bed all day and wouldn’t have sex with him no matter how much he bugged her. It was brutal to hear him write off what was clearly a traumatic experience for his ex as her being “lazy” and trying to “avoid sex” – as if her depression wasn’t about her at all, but was a punishment she had decided to enact upon him. After two dates, this would have been fine – I’d have just dumped him. After two months, even, I could have escaped from the relationship pretty much unscathed. After two years, though, it came as a horrifying blow, one that precipitated the end of the relationship. It forced me to consider how well I really was, and how integral my psychosis, my depression and my mania all were, in their own ways, to my self-image.

We argued about it a lot that day and from then on. He blamed me and said that he wished I would kill myself already and just get it over with if I was so serious about it. There’s no doubt that he was a dickhead about the whole thing, but I can’t help feeling that if I had talked about my experiences earlier in the relationship it might have been avoided.

Rule No 1: it is definitely a good idea to actually, at some point, tell them.

Couple on a date in a restaurant


Don’t do it! There is a time and a place for everything. Photograph: Jupiterimages/Getty Images

Blurting it out on a first date

I was on a genuinely brilliant first date. He was tall, good-looking (in a kind of dishevelled professor way) and the first person I had met who had piqued my interest since the breakdown of my previous relationship. I was very invested in not messing it up.

And I was nailing it. There was lots of wine and I was pulling out all of my best anecdotes. Then came this exchange:

Him: “So, you know I have a son?”

Me: “Oh. No. I didn’t, actually.”

Him: “Yeah. He’s 10.”

Me: “Don’t worry about it. I have bipolar.”

Not only had I completely failed to acknowledge anything he had just said, but I had also equated his beloved child with a debilitating and heavily stigmatised mental health problem. I felt like his child and my bipolar were both things that could and would put someone off, and that he had somehow just issued a dealbreaker amnesty by mentioning his son. In fact, he had just wanted to tell me a boring anecdote about a trip to the zoo.

Rule No 2: don’t compare someone’s child to a mental health problem on your first date.

Telling someone during sex

Things you can say during sex: “That feels amazing”, “Keep doing that”, “Could you stop leaning on my hair please?” We’ve all read Fifty Shades of Grey. We know what’s allowed.

But things you should not say during sex? “So, you know I have bipolar?” Don’t ask me why this happened. Don’t ask me about the chain of thought that led me to blurt it out like that.

Just remember rule No 3: never say it when you are literally having sex with someone. Never.

How to tell someone you’re mentally ill in none of the ways outlined above

I would love to be able to say, “Yeah, you should definitely say X after Y number of dates”, but relationships don’t work like a PlayStation cheat code, much as I wish they did. You have to play it by ear, pick up on the person’s vibe and try to work out how best to communicate it to them. I can give you some tips, though.

Actually tell them

Yes, this is obvious, but it’s important. Even if they are the understanding type, it’s best to tell them before you have an episode, because you will need to have a conversation about what you expect from them or what you might need. If they don’t want to date you because they can’t handle it, that’s fine, but it’s unfair on both of you if they are forced to make that decision while you are ill and will cause undue levels of stress when you really don’t need them. It may cheer you to know that a 2013 study undertaken by the charities Mind and Relate found that 77% of people with mental health problems actively told their partners about their mental health problems and just 5% experienced a breakup because of it. A further 74% of partners of someone with a mental health problem said they “weren’t fazed”. So you have almost nothing to worry about.

Couple walking down street


An honest approach is best Photograph: Hinterhaus Productions/Getty Images

Be honest

You don’t have to tell them all the gross minutiae, but it’s best to be broadly honest. Detail the type and severity of your illness. Tell them how it has affected you in the past and how it is likely to affect your relationship.

Don’t sugarcoat it.

For me, there are two major things that tend to go as soon as I become depressed: being able to leave the house, and being able to take a shower. These are obviously fairly big hurdles in a relationship – having a girlfriend who smells like a bin and who sits in the same spot on the sofa for three weeks may not be the most appealing prospect. But by talking about it – telling someone how best to coax me into leaving the house, how to encourage me to look after myself, how I might respond – I’ve found that these hurdles are far less daunting than they first seemed.

Offer some advice

You’re an expert on your own condition, but your partner might not be: help them out.

Encourage them to research your diagnosis so they know, roughly, what they are dealing with. Tell them what you might need and when, or how they might be able to spot warning signs. As with many people who suffer from mania in some form, the first symptom for me is a complete inability to sleep combined with a desperate compulsion to talk all of the time. Telling someone that those things are meaningful parts of my illness, rather than just random occurrences, means that they’re much better equipped to recognise and deal with them when they occur.

You should also, as a couple, draw up a contingency plan in case of emergency. Which family member or friend should your partner contact in a crisis? What resources do you need? This could be anything from bubble bath, music, books or puzzles to calm you down, to something more serious – do you have spare medication, for example? Make sure you are clear in advance about what actions you are happy to explicitly consent to – it’s important that your partner knows what you are comfortable with. And draw up a list of contacts – local authorities, your psychiatrist or doctor, your support worker, or whoever might be able to help.

Don’t be too hard on yourself

Having someone decide not to date you because they can’t cope with your mental illness sucks. It feels deeply horrible and personal. Talking to a newly single friend recently, she told me that several relationships that seemed to be going well had mysteriously withered away as soon as she mentioned her severe clinical anxiety. Some told her that was the case – that they were unable or unwilling to deal with it – and others mysteriously disappeared as soon as she mentioned it. It, understandably, bummed her out.

There is a silver lining, though: it is far better to be with someone who is willing and able to help you with your illness. Having a mental health problem obviously doesn’t define you, and it’s the same with relationships. But knowing that someone has chosen to stick with you on the bad days as well as the good can significantly reduce anxiety.

This is an edited extract from Emily Reynolds’s A Beginner’s Guide to Losing Your Mind (Yellow Kite, £14.99). To order a copy for £12.74 go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99