Sertraline vs Non-Sertaline: A case study

Due to a suite of Unhelpful Behaviours (all since passed) and a persistent Depressive Tendency (there's two Culture ship names for free there) I've been taking antidepressant drugs of one sort or another for a really very long time indeed. I think I've used the following in total:

• Fluoxetine
• Citalopram
• Escitalopram
• Paroxitine
• Mirtazapine

Which is practically all of the SSRIs plus mirtazapine, and there's also been the odd sleeping pill or anti-anxiety thing but neither of those for about a decade. What I've been on for the longest time is sertraline. This is a fairly typical SSRI although not generally one of the first used. I've been on the lowest available dose for around five or six years but in recent times the dose has gone up. What tends to be the happen is this:

The red line is me on sertraline. Basically, feeling alright most of the time - rarely feeling very much good but also rarely feeling very much bad. This leads to a kind of lethargy; I'm not getting much pleasure from very much and so I can't be bothered doing productive or positive things. On the other hand, I'm also never wanting to go and freeze to death in a forest. What ends up happening is that I forget to take my meds for a day or so and I get a brief phase during which I can enjoy some things and I get stuff done. I enjoy feeling like this and so skip the meds a bit longer, the brain zaps will be kicking in at this stage but I tell myself I'll be fine. Then for whatever reason I have a massive crash and feel like going to freeze to death in a forest.

The latest episode of the (not quite) mania has managed to persist for long enough for the brain zaps to subside but the last day or so has gotten me into some really serious slumps. Looking at the current situation my choices are:

• manage alright but don't really do anything until I retire/die of natural causes
• get some stuff done while having to periodically talk myself down from going to freeze to death in a forest

Of course, there's a third option which is what I'm going to be aiming for - go back to the meds roulette table and spin it until my number comes up. I need to find something that blocks off the slumps but also brings the red line a little higher so I can start doing some more things. I'm booked in for next Tuesday and we'll see after that if find something that suits me a little better. The options to go back onto sertraline or freeze to death in a forest will still be there later after all, might as well try some other ideas first.

That's all to say for now, but it's meant to be helpful to talk about mental health so there it is.

PS: Anybody who finds this via a random search and posts about doctors being in cahoots with psychiatric medicine firms will receive very short shrift indeed. The shortest of shrifts.

The Drones of The Player of Games

Over recent years I've found myself listening repeatedly to the books of the late Iain M Banks, particularly the Culture series narrated by Peter Kenny. I've gotten mildly obsessed with the Culture society and one aspect I've been interested in is the design of Drones. Drones are sentient artificial entities running on a wide variety of substrates which hold their consciousness. Their appearances vary enormously and it's sometimes hard to visualise them in a story. They can be simple blocks roughly the size and shape of a suitcase or a hovering cube of components held together by fields.

To help my visualising I've decided to go through the books and find all the descriptions and then attempt to draw them. So here's the Drones from The Player of Games.

Mawhrin-Skel - Special Circumstances reject, de-weaponised offensive drone.

• Small enough to sit comfortably on a pair of hands.
• Looks like a model of an intricate and old-fashioned spacecraft.
• Surface of its casing is grey-blue with an odd mottled mixture of grey tones.

Chamlis Amalk-ney - good-natured but mischievous geriatric.

• 1.5 metres tall, 0.5 metres wide and deep.
• Plain casing, matte with accumulated wear - 'minutely battered'.
• Sensing band.
• Broad, flat top.
• Some slight bulges.

Loash - Gurgeh's initial contact from Special Circumstances/Contact.

• Able to sit comfortably in a rectangular sandwich plate.
• Gunmetal casing.
• More complicated and knobbly than Mawhrin-Skel but about the same size.

Worthil - Contact drone.

• Tiny, small and grey-white.
• Fieldless.

Flere-Imsaho - Library drone.

• Even smaller than Mawhrin-Skel - could have hidden inside a pair of cupped hands.
• Circular in plan and composed of seperate revolving sections - rotating rings around a stationary core.
• Spinning outher sections and disc-like white casing resembles a hidden wafer piece from the game of Possession (hidden piece is a circular white ceramic wafer which a location ID is dialled and locked into).
• Described later as 'a little white disk'.

I imagine I've missed some references (and I ignored Flere-Imsaho's disguise) but there you go.

Medicine is Hard

(edited for clarity, corrections 7th Aug 2015)


Medicine is hard. Nobody has ever been particularly certain of the best thing to do, we've all just been making it up as we go along. In the age before mass communication medics relied on anecdotes, personal experiences and texts of dubious provenance to decide what to do. Until relatively recently this amounted to little more than trusting luck and most of the time we would have been better off if they had left us alone. Nowadays we have randomised controlled trials, meta-analyses, epidemiology and sophisticated statistical methods. But it's still not always obvious what we should do.

A picture of some hard medicine

Every so often there is a tragedy that leads people to decide on some obvious course of action. Recently there's been a lot of attention on social media about a case of a newborn dying as a result of infection from group B streptococcus (strep). This is an infection caused by a very common type of bacteria that can lead to severe, life-threatening complications like septicaemia. It is transmitted from mothers to children during childbirth. The obvious course of action is to eliminate the bacteria in question from the mothers or to treat newborns with antibiotics to ensure that any possible infection doesn't get a foothold.

Unfortunately, reality is not so simple. While there is no doubt that screening and antibiotics would have (probably) saved the lives of the newborns who die from this infection we have no way of knowing in advance which ones are going to die. This is the root of the problem. We see that a child died and we can say, with some confidence, that if only we'd had a mass screening programme combined with preventative antibiotics then that child would have been saved, Many campaigns are founded on this sort of over-simplification. What these campaigns always fail to take into account is the number of people who would be harmed or killed by the intervention they recommend. The proposed solution is always 'do more medicine' but we're not yet at the point where medicine does no harm.

As a very brief run-through of this example - we'd need a screening programme that tests mothers for group B strep before birth. A screening programme is pointless unless is informs real clinical decisions - finding out somebody is a carrying group B strep isn't useful information unless there's something we plan to do about it. Assuming we have a perfect test (we have no perfect tests for anything) we'd identify a certain proportion of women who are at risk of transmitting group B strep to their newborns. So all we'd have to do is load them up with antibiotics before birth and do the same for the newborns. Bingo, no strep B deaths.

But there's complications. Tests for group B strep will identify somewhere between 25% and 40% of women as carriers. Not all of those women will even still be carrying strep B at the time of birth. Their status as carriers is unlikely to even be relevant in cases of caesarean section. Even during conventional births not all women will transmit the bacteria to the newborns. Ones that do probably won't get infected. Those that do get infected probably won't come to any sort of lasting harm. Some will. Some will die or will suffer permanent ill health as a result of doing nothing to prevent the infection.

The screening would identify at least a quarter of women as carriers of group B strep. There were around 700,000 births during 2014 in England and Wales. If we're conservative, we can say at least 150,000 women will be identified as carriers.

So that would be 150,000 women recommended to receive intravenous antibiotics in a hospital setting during the births of their children and about the same number of babies receiving preventative antibiotics. The overwhelming majority of these would never have suffered any health problems as a result of carrying group B strep. As previously mentioned, however, some lives would be saved as a result.

But that's not the whole story.

In addition to the lives saved, some will die or will suffer permanent ill health as a result of trying to prevent the infection. There's various risks of antibiotic use - discovery of latent allergies in the mother, unexpected toxic effects and all sorts. There's strong evidence that use of antibiotics in very young children increases the risk of antibiotic allergies as well as conditions such as asthma. There are risks associated with increased medicalisation of birth - does a positive strep B result rule out certain types of birth choices, such as midwife-led units, leading to more c-sections, worse overall outcomes? Mass use of antibiotics is widely recognised as a bad move due to the development of resistant bacteria yet screening for such a common bacterium demands it. We'd reach a point where we'd be forced to use more and more toxic antibiotics to treat new, resistant forms of strep. This would have the effect of increasing the death rates in the rare cases where a newborn gets infected.

That's only the start, there's all sorts of unintended consequences of any sort of mass health intervention. This is why we need really strong evidence of the benefits of a screening programme before we can introduce it. Medicine is a balance of risk and benefit - medicine does harm as well as good and any intervention needs to demonstrably do more good than harm. The mass treatment of healthy people is a very difficult as the majority of people will only receive the risks with no benefits. Until we're (reasonably) sure we're (probably) better off doing nothing. We're already pretty certain of the easy interventions, after all.

All of the outstanding  problems in medicine are extremely complicated and we're only very slowly figuring out the best things to do. We have to balance risks against benefits and in most cases that's difficult to work out. There are no easy answers any more. Everything left in medicine is hard.

Future Planning

The garden is divided into three main zones.

Zone 1 contains a bordered area covered in plum slate. It's got a rockery at one end and a plant at the other but largely it consists of a place to put planters and pots.

Zone 2 is at the back left and consists of a weeping-type shrub and loads of randomly-selected plants leading to a huge overgrowth of madness. Sweet peas and all sorts have grown like mad. The plan for next year is to hand this section over to Fran and Sam once I've raised and levelled it off and it will then mostly form a lawn with the odd low-lying meadow flower, plus a border etc for them both to plant stuff in.

Zone 3 is my tiers. Here's an old picture that I've scrawled numbers onto:

It's not a great representation as the whole thing looks a bit different now but you get the general idea. The tiers were put in place fairly late in the year so I never got round to planting anything much other than some shrubs and fruit bushes. We originally planned one of the tiers (3b) as being the lawn and Sam's play area but I ultimately decided it's too small and potentially unstable. This led to the decision to turn zone 2 over to lawn and Sam.

So the future plans for this are now under consideration. 3a is currently fruit and the odd shrub. I'll probably add what other fruit plants I can fit in there, possibly including a container dwarf plum tree - though this is likely to unbalance the look of the thing and may be better sited elsewhere. This is an ericaceous zone by intent but it certainly suffers a massive buffering effect from the tier soils and the underlying clay.

The remaining zones I think I will dedicate to colours. This isn't particularly radical but I like the idea of them acting as contrasting solid blocks of colour. 3e has a black sambucus (which is staying put) so I have dedicated this to Pink. I think this will work well as contrasted against the black of the sambucus. The sambucus also produces small pink flowers to tie it together. 3c will be white. It'll have pale foliage where possible and clean, white flowering plants. The shrub in this zone is (I think) a plant that produces small pink flowers and white berries so this should work nicely across from the black and pink zone.

3b and 3d are more difficult. I thought of orange for the front to go with the dragon (firey colours, etc) but I think that would be too distracting in the foreground. I may move the dragon to the back to switch places with the easter island head but I also think the positioning of them would then look wrong. I think I'd rather have the orange at the back.

3b is possibly going to be done as just green but then there's not many green flowers and I don't think I want just foliage. Blue I'm not very keen on, I think purple, yellow and red would all distract as well. Hmm, maybe I'll go with green. It'll be a challenge to find much suitable but I'm sure there has to be something.

So in summary:

Zone 1 - no change
Zone 2 - lawn, meadow plants, some bedding things
Zone 3a - no change, fruit and shrubs
Zone 3b - green
Zone 3c - white
Zone 3d - orange
Zone 3e - pink

Yes, that'll do.

Black chillis

I have been growing some cayenne chilli peppers this year from seed so as to avoid the hassle that comes with supermarket chilli-buying - that is, buying three, using two, binning one.

They were grown from a Sutton's Seeds pot thing - it was basically a bit of compost, some seeds and a container to propagate in. I got pretty good results and potted them out and they've been doing nicely outside. I ended up with six plants, though two were so stupidly planted that they never made it.

Anyway, I currently have four quite solid plants. They've needed staking to stop them flopping down but they're otherwise grand. Many fruit have now been produced but I've noticed some black patches appearing on them. The Internet seems a bit vague on the cause of these but I think I've come to a conclusion. This is what they look like:

There's a sort of burnt-looking region on this chilli. Now, at first this was the only chilli showing this so I imagined some sort of defect. However, several now show exactly the same thing so I researched online to see what the cause was. Internet reckoned:

1. Darkening before ripening to red.
2. Rotting.
3. Sun burning.

They seem good and firm and the one I cut up tonight (the one above in fact) was perfectly fine so no rotting. I'm not convinced they are going red. So that leaves us sun burning. I happened to notice that the black areas only appear on a single side of the affected fruits and that side matches the direction of the sun at around midday to 2pm - the strongest time for sun exposure, plus this is a heatwave year. In fact, if you look closely at the picture you can see quite a clear line showing what would match the strongest sun exposure.

I therefore conclude:

Black patches on cayenne chilli peppers are due to excessively bright sun.

On We Go

It's been a while since doing all that much with the garden. Firstly there was a heatwave which really limits what you can do other than watering every bloody minute you get. Then there was a load of rainy weather which is good and all but what can you do other than wait for it to stop raining? Combined with general business it's been mostly just waiting about and letting the garden do its thing.

So today we finally got a decent combination of bit of rain but drying up which is perfect. First thing in the morning it was quite reasonable too so I did a lot of inspecting and tidying up. From previous clearances I had a load of tubs and containers full of stray soil which had filled up with water and weeds and general crap. An hour of so of back-breaking labour cleared these via the medium of tipping them all out into a pile so they can drain and I'll deal with the bloody stuff later.

Other than that it looked like the two pieris in the rockery were slowing dying. This came as no surprise as they'd been hammered by the heatwave and also planted in the wrong type of soil - they want acid and I didn't realise so they've been sat in crappy multipurpose stuff. They have now been dug out and the rockery rearranged to give them more space and replanted into proper ericaceous compost. The rockery also had some attention regarding a hidden sedum being moved to a more prominent location and a euphorbia having it's long dying flower stems cut off. This left a nice little foliage thing:

I did discover after cutting it back that sap is toxic and that it tends to gum up secateurs. Fortunately I didn't get any on me, phew.

I did a load of rearranging of plants.

Those are both eucalyptus that have been moved. One is in an old disused lampshade. I remembered this time to soak them first so they don't wilt really sadly when repotted. They have had the crap eaten out of them and have fungus. C'est la vie.

I potted out some olive trees that I've been growing from seed. Only two of germinated and here's one:

I have chillis!

And olives!

And proto-raspberries!

Our garage door has also been colonised by caterpillars. I saw one stuck on it yesterday and it looked like it was dying but today it has turned into this:

It's a chrysalis! It swings about a bit when opening and closing the garage but it seems to be staying on. Fran saw another caterpillar climbing up the wall earlier and now I have found this:

It's chrysalising! We will have two butterflies of our very own to have and to hold.

Oh, and we got a couple of plants. Firstly a little patio rose. I thought about trying to bonsai it but from the sounds of it people who try to bonsai roses are on a hiding to nothing.

Secondly a little juniper. I wanted one of these ages ago for the rockery but couldn't find one. Now I don't want to plant it in the rockery due to the ongoing bamboo problem so it's going in a pot for the time being. I want to get some cuttings from it for bonsai and it may make it onto the rockery for next year:

And they also had this mad bastard:

It's another juniper and was heavily reduced so I got it too. It is now sat in another disused lampshade. They are good as they have drainage holes and everything. But aye, not really sure what to do with this, it was just spiky chaos so I got it.

And that's the state of the garden.

That'll do

It's with a sense of almost disappointed weariness that I finally finish the bulk of the garden work. After a load of earth-moving, smoothing, filling rubble sacks and planting we have my finished tiers:

There's a bit where I want another plant but I could live without it. It has a 'Black Lace' Sambucus:

A dragon:

And a face:

On my way out I also discovered that there were some late developers in the propagator that I'd already planted out from:

Not sure what to do with them. They're asparagus and I've already got tonnes of that planted out:

Got three of those troughs.. I don't really want to just kill them off though, after all they've been through..

The lavender is going mad, can't wait to see this lot flower:

Shallots doing well, I didn't really think they were like this - I expected something like the simple grasses of garlic but these are quite funky:

Spinach may be dead:

Chillis are shooting up. It seems like I look away for a bit and they double in size:

There's some other things too but that's the main stuff. Phew, tired now..