We NEED to talk about anxiety, Ireland's silent epidemic
It's one of the biggest health problems facing Ireland today - but even though one in 13 of us suffers from clinical anxiety, it's often dismissed as a personality quirk. That school of thought, coupled with under-funded mental health services, has given rise to a silent epidemic, as our reporter discovers…
'The first time it happened was during my sister's illness. We didn't know if she would die, but we didn't know if she would live either. It's not really surprising that I began to obsess about dying.
"I remember being in the shower when the first panic attack hit. I was paralysed with the fear that I was going to die. I became convinced I was ill and I was going to die.
"I can see how a normal person might assess this fear and dismiss it, but it was as if all logic had been disabled.
"I was due to meet my boyfriend and a friend for drinks that evening but that seemed impossible. It took all the strength I had just to keep from falling apart," says Joanna (32), a management consultant from the Midlands.
If that day was the earthquake, what followed was weeks of aftershocks for Joanna. Each accompanied by the same nest of symptoms - inability to breathe, severe stomach cramps, heart palpitations, loss of appetite, inability to sleep, concentrate, focus, or engage with her partner. "I wasn't sleeping and my endless hours of wakefulness were exhausting - my head was besieged by worries which demanded immediate attention, each one more poisonous and toxic than the next."
Joanna needed help.
That help was found through her GP, who referred her for six sessions of CBT (Cognitive Behavioural Therapy), conducted by a psychologist and for which she paid privately at a cost of €80 a session.
It has become, she says, the toolkit to which she returns whenever she feels the familiar pangs of anxiety creep. "It taught me how to address my fears. And in the case of the health issues, that sometimes did mean having scans and tests. But I have repeatedly returned to the strategies I learned in those sessions. Without doubt it has prevented what would have - inevitably - become a much more serious problem later on."
Anxiety has gained something of a global profile of late, in part thanks to a phalanx of celebrities who have come forward about their own issues. Among them are Jennifer Lawrence, Lena Dunham, Emma Stone, Adele and, most recently, former One Directioner, Zayn Malik. Given this new-found prominence and the patina of celebrity respectability, are we witnessing anything more than the navel gazing of Generation Snowflake or a disorder worthy of genuine concern? The data suggests it is the latter.
In her brilliantly researched book, Anxiety For Beginners, the journalist Eleanor Morgan writes: "In 2015 anxiety disorders were the most common kind of mental health problem, and overall, one of the biggest burdens of illness in the world. A major study conducted in 2012 by researchers at the University of Queensland, surveying nearly half a million people across 91 countries suggested that, globally, 1 in 13 people suffer from clinical anxiety."
So, as a society are we more worried than previously, when we all heard stories of friends of our parents who were "bad with the nerves"?
While anxiety was referred to by both Cicero and Hippocrates, its prevalence is increasing, in the western world at least.
In 2013 The Guardian newspaper conducted an investigation into antidepressant consumption in 25 countries across the world, and found that, in each one studied, consumption had risen since 2000.
The scale of the disorder has been described as a ''silent epidemic" by experts. Dr Harry Barry, whose Flagging series of books covers anxiety, phobia and depression, recounts the principal of a large Dublin school telling him that: "The single greatest problem in our school is the extraordinary level of anxiety." Dr Barry says there are many schools who maintain special rooms during exams to cater for students worried about panic attacks.
Certainly the research bears this out. The Mental Health Of Young People in Ireland - a report published by the RCSI in 2013 - illustrates the scale of the issue. The research, conducted by Psychiatric Epidemiology Research across the Lifespan Group, found that approximately one in eight young adolescents had experienced an anxiety disorder, and by the age of 24 one in four had experienced either a mood or anxiety disorder.
ReachOut Ireland, the organisation which provides support for young people worried about mental health issues, reports a significant spike in the numbers of young people seeking information on anxiety in the past year. While traffic to its website landing page on anxiety is up 23pc since January, traffic to content on social anxiety has increased by 108pc. Meanwhile, its social media posts on anxiety have a 20pc higher engagement rate than posts on other topics such as depression, self-harm, or eating disorders.
On the flip side of this, there are many experts who believe that social media takes a disproportionate toll on its users. This is partly because of the conflict of the controlled communication environment of social media and real life, where interactions cannot be calibrated in advance.
Dr Mark Smyth is senior clinical psychologist at the North Dublin Child and Adolescent Mental Health Services (CAMHS). "I see young people who literally can't leave their room, whose only interaction is online. So while social media gives them connectedness, it's a double-edged sword. WhatsApp or Messenger - where you can stop, edit, change, delete - have a perceived safety because you can consider what you're writing. The real world doesn't have that comfort.
"Profile pictures have a terrific importance. It's the creation of an idealised version of yourself - with a flat stomach, or a six pack or perfect make-up.
"A girl recently changed her profile picture for her birthday and she wanted 50 likes for the new picture. But she didn't get 50 likes, so she took it down and replaced it with a profile picture which had gotten 50 likes."
Dr Smyth's observations are mirrored by those of Dr Barry, who believes that the pressure of perfection is producing a generation beset by anxiety and panic attacks. He believes we are on the cusp of a social anxiety epidemic. "People are comparing themselves to one another and trying to match the virtual world with the experience in real life. So much of the interactions are based around needing to be liked and popularity and lives are consumed with it."
Of course, adolescents aren't the only group affected. Of particular concern, says Dr Barry, is anxiety among women in their 30s and 40s. However, this group is less likely to seek professional help. "There is increasing evidence that social anxiety in this group is being treated with the nightly large glass of wine. Which is, of itself, another issue. They're dealing with that anxiety by self-medicating," Dr Barry says.
Anxiety is best treated with early intervention - it not only provides better outcomes for patients, but it saves the State money in the long term. While there are no exact figures available for Ireland, a 1999 paper published in the journal Clinical Psychiatry, estimated the cost to the US economy of each anxiety sufferer at $1,592 (between €2,322 and €4,251 in today's value). Meanwhile in England, the economic and social cost of poor mental health costs some £105bn (€119.5bn) according to the charity Rethink Mental Illness.
But in Ireland - where mental health resourcing is still an area of need - getting access to that early intervention depends, largely, on either ability to pay or living in the right area.
While there is the National Counselling Service (NCS) provided by the HSE, it is only available to medical card holders who are over the age of 18. This provides for up to eight sessions with accredited counsellors or therapists. Patients are referred through their GP.
To access a qualified CBT practitioner through the public system, however, one would have to be first assessed by a psychiatrist on a mental health team, which can take, says Dr Barry, "up to a year". And while the HSE is endeavouring to plug the gaps in services at a time when resources are stretched, there are real consequences for those left waiting for treatment.
"People end up with moderate to severe mental health difficulties because there's an absence of primary care help to intervene," explains Dr Mark Smyth. "If someone develops mild-to-moderate anxiety disorder and they have to wait a year for treatment, then that disorder could become moderate to severe. By that point, instead of needing six to eight sessions of counselling or CBT, they might need 12 to 15. So there's a significant cost and there's a greater chance of them requiring a longer relationship with the services," he says.
"With mental health when you don't have primary care, it's the equivalent of having an A&E with no GPs - there's no first line of defence. Often the reason people have ended up in CAMHS is because they haven't had any primary care. In some areas, and certainly for the under-18s, there are no primary care psychologists. Where I work in North Dublin, for example, there is no primary care psychologist for the under-18s.
"And while some cases of anxiety will go into spontaneous remission without intervention, there would be a significant proportion which won't."
For some the consequences of inadequate treatment stretch on for years.
Saoirse from Dublin, now 23 and in university, was in secondary school when the symptoms of her anxiety began. A straight A student who was also gifted at sport, it initially manifested as ambition.
"I felt like I had to achieve," Saoirse, who now volunteers to help others in similar situations, recalls. "Once, I got 90pc in a maths test in first year and I was devastated.
"Achievement was everything. I became obsessive about studying. I brought my books everywhere - to sports practice, to restaurants. I would wake up in the middle of the night to study. All of a sudden I had this intense focus," she says.
Her anxiety cut her off from a social life. Everything suffered. She, with the help of her family, sought help.
"I had been dipping in and out of the public system. I'd been on Effaxor, (an antidepressant) since I was 14 and also on Lustral."
Having been diagnosed with lasting anxiety and depression, Saoirse was admitted into the CAMHS services where she was seeing a psychologist and a psychiatrist.
By her late teens, having been in the system since she was 13, Saoirse had to move to the adult services. But few concessions were made for her youth.
"You're in a waiting room surrounded by people with very severe mental health problems, including those with drug issues. Thankfully, my mum used to come with me because it was intimidating."
What eventually helped Saoirse becalm her mind was group therapy, where she was surrounded by other young adults with similar issues, and later exercise. She joined a local gym which she largely credits with her recovery. "I started to do things for enjoyment rather than achievement. I started to slow down. I was with other people who were similar to me. And because I wasn't judging them, I learned to stop judging myself."
Resourcing, as always, is part of the issue.
In its pre-budget submission for 2017, the College of Psychiatrists of Ireland called for an increase in the mental health budget, currently at 6pc of the overall health budget, to be raised to 12pc, as it is in the UK. It also called for 25pc of that budget to be ringfenced for CAMHS.
The submission is a succinct appraisal of mental health service provision. It recommends that "counselling and psychological services, including community-based therapies for children and adolescents must be revitalised to provide ease of access based on need nationally. This includes assessment of individual abilities and needs at an early stage." They also called for "funding for the nationally based primary care counselling service must be sufficient to ensure ease of access through General Practice for people in need."
Breaking the cycle of fear around anxiety is paramount. As Saoirse says, "I needed to be around people who didn't judge me." The first step is asking for help. But the help must be there when it's asked for.
How to talk to someone with anxiety
Scenario 1: failure
They say: "I'm really worried I'm going to fail my exams. I can't stop thinking about it. It's going to ruin my life. I'll never get into college. I won't get a job."
What to say: "What do you think you could do to prevent this happening? What could you change right now? You can't control the future but you can control the present."
What not to say: "It'll be grand. It'll never happen."
Why not to say it: You're invalidating the person because while it probably won't happen, it could happen.
Dr Mark Smyth says: "This is a typical example of a catastrophic thought. Anxiety generates 'unhelpful thinking' that gets in our way. This is when our thought process and emotional state generates predictions that probably won't, but might, happen. So in this case it's important to remind people of previous predictions they may have made when feeling anxious and remind them that those predictions didn't come to pass.
"The idea is to undermine the anxiety and undermine that conviction that the person can predict the future, to remind them that we cannot control the future - we can only control the now. It is, in essence, problem solving - breaking the problem down into small achievable parts."
Scenario 2: social media
They say: "Nobody likes me. All of my friends are more popular than me. I'm not good enough. My pictures never get any likes. My friends hate me."
What to say: "I sometimes worry about that too. It's normal to worry that all your friends might not like you."
What not to say: "Don't be silly. Of course your friends love you."
Why not to say it: Nobody is liked by all of the people all of the time. It's normal to worry that people don't like you, and not everyone will.
Dr Smyth says: "For adolescents in particular, social media is a huge part of their life. We know that 90pc of cases of social anxiety develop in adolescence and social media is integral to their identity.
"In a recent group session, we asked participants through an anonymised survey what issue they most wanted to address, was it self-harm, suicide, depression, or social media, and overwhelmingly, the response was social media because it's pervasive across their life. Some will spend hours crafting their replies, photoshopping their pictures, etc, as they if they don't achieve a minimum requirement of responses, of likes, then they have failed.
"So in this case, I might do an empty chair scenario: Imagine your friends are listening to you right now. Imagine they can hear what you're saying, that they don't like you. What do you think they would say?
"Often I'd show clients a bell curve. There might be 50pc of people I know whom I get on OK with, a small percentage of people I like, and a smaller percentage of those whom I consider to be best friends. Adjust the expectation of what's OK."
Scenario 3: health problems
They say: "I'm sick. There's something wrong with me. I'm going to die."
What to say: (After a medical problem has been ruled out). "Your tests have been negative. That doesn't mean there's nothing wrong with you. It means you're struggling with anxiety. And you can be fixed."
What not to say: "You're imagining it. It's all in your head. "
Why not to say: You're encouraging them to keep their worries to themselves and cut off communication. They think, "Nobody believes me".
Dr Smyth says: "This situation arises a lot. We have a lot of young people come to us from hospitals where they've been for a series of tests - possibly ECGs, blood tests, various scans - having been referred by a GP, because they are worried about the symptoms. But when the tests are clear the hospitals refer them on to us, as there are no physiological reasons for them feeling the way they do, but there is a psychological reason.
"Anxiety tends to make us believe that the most complicated thing is the cause. Google doesn't help with this, as people will search for their symptoms and jump to the worst conclusion.
"So in this case, the consultants have performed all the necessary tests and they've been negative. However, that doesn't mean there's nothing wrong. It means the patient is struggling with anxiety. They are experiencing pain, but it isn't physiological. It can be fixed, it's just not a medicinal solution."