By mid-morning, a succession of complex patients meant I was running half an hour late. But when I came to call the next person through, I saw there had been two short-notice cancellations. The vacated slots promised precious catch-up time. Suddenly my surgery was looking manageable again.
I collected Leanne from the waiting room, apologising for the wait. “That’s OK,” she said, “I won’t keep you long. I just think I need to restart my antidepressants.”
She seemed on top of things. Yes, she’d had depression in the past and fluoxetine had worked well. Over the past few months she’d recognised the signs again: no motivation, feeling glum the whole time. She was sure if she restarted the medication she would get things back on track.
It would have been easy to take her at her word. Had I still been running late then I might have done so. But those two cancellations had relieved the pressure.
“What are you off track with?”
It was weight loss. Aged 26, she’d hit 18 stone. Remarkably, she’d managed to shed five stone over the previous year. “But I’m stuck,” she told me. “I need to lose a couple more, but I just can’t get any off.”
What she’d already achieved had been spectacular and would greatly improve her future health, but it was clear she had a goal in mind and her failure to get there was affecting her mood. I wondered if she was caught in a vicious circle: depression leading to comfort eating and a loss of motivation to exercise, in turn causing faltering weight loss and a deepening of depression. Perhaps medication would indeed break the cycle. But other possibilities came to mind. I told her about the Healthy Lifestyle service; support from a dietician and a fitness trainer might help more than tablets. She appeared to brighten at the prospect.
I explored things further. Had she considered psychological therapy? Sometimes weight problems develop because of unresolved emotional issues, the pleasure from eating serving to soothe the pain of past trauma or low self-esteem. She was equally receptive to this suggestion, though her reaction was more sombre: “I do hate the way I look.”
I almost waded in with hasty encouragement. She appeared in great shape, and it was difficult to imagine her comparing her “before” and “after” with anything but pride. Instead I asked what she disliked so much.
It was the huge folds of redundant skin she’d been left with as a result of her enormous weight loss. “My arms and legs are OK,” she said, “but my tummy looks hideous. I sometimes think I was better when I was fat.”
Her stalled weight loss suddenly made sense. Far from improving her body image, losing five stone had left her with a completely different problem, one that further slimming would only compound. Her subconscious had slammed the brakes on. She was trapped: not wanting to go forwards, nor backwards, nor to be as she was.
There is much concern about GPs over-prescribing antidepressants. Workload pressures are undoubtedly a factor; our royal college has recently called for 15-minute appointments to become standard by 2030. I wouldn’t have got to the heart of Leanne’s predicament were it not for those serendipitous cancellations. But resources are crucial. Had Leanne had a gastric band operation, she might have been eligible for surgery to remove the sagging skin left behind as a result. But the cash-strapped NHS has drawn an arbitrary line, and those who have lost weight through their own efforts will find it virtually impossible to obtain such procedures.
Pills won’t help Leanne, nor any amount of Healthy Lifestyle input. Maybe psychological therapy will help broker acceptance of her new body image. But the costs of these might better be directed towards a surgical procedure to support her on the journey that has brought her to an unexpectedly distressing destination.
This article appears in the 12 Jun 2019 issue of the New Statesman, The closing of the conservative mind