This is a story about overcoming depression and also about coming to terms with loss. The two are closely related to each other. I know about this not just from my personal experience, but because I am a psychiatrist. I have specialised in treating those who suffer from the same problems which have afflicted me throughout my adult life. I've survived and come through it, and I know others can too.

  There are moments of sadness and even of frank despair described here, but this is not intended to be a depressing tale. My aim is to provide hope to other people who have lived as I have lived. I want them to know that it is always possible to feel better: about yourself, your life and the future. The problem is that when you are caught deep in the jaws of depression, recapturing a sense of hope seems almost unimaginable. Low mood colours the way we see our lives and clouds our judgement, not only about others but most particularly about ourselves. It is hard to think positively, as others often insist, when you consider yourself to be completely worthless. What I want to show in this book is that, whether you feel like this or are the one caring for someone who is depressed, there is always a way forwards.

  Depression is often triggered by loss, not only of relationships but also of other things which are important to us – our role in life, our health or our self-esteem – and the fact of being depressed can then result in further losses, because we become difficult to live with and unable to play our part in life. Human beings grieve when they experience a loss of something or someone special to them. Grief is normal, and usually resolves over time, but if it doesn't then it can become indistinguishable from depression. Both leave us vulnerable to the impact of further losses.

  Very few people know my entire story but my current doctor is familiar with most of it. She is the custodian, at least for the time being. The first time I saw her, about seven years ago, seems as good a place to start this tale as any.

I was in a bleak new consulting room at Wythenshawe Hospital in South Manchester, in the Laureate unit, a modern building where every ward is incongruously named after a writer or poet. Outpatient clinics take place in bare, impersonal offices where doctors camp for one or two 'sessions' every week. There wasn't even a filing cabinet in the room, which I could illicitly try to open and explore. Although it wasn't quite new enough then that I started to get high from inhaling the solvent in the carpet adhesive, I could still detect a faint whiff of Evo-Stik in the air. The only distraction was the previous month's dog-eared hospital newsletter on the corner of the desk. I read about fun runs for breast cancer to distract myself while I waited for my new doctor, who had rushed back to reception to collect my notes from the desk. I felt alone once more and more than a little afraid.

  Of course it wasn't my first time in the psychiatrist's chair as a patient. But it was a strange occasion because the person sitting opposite me, whom I shall call Dr V, was a colleague I had known for several years, who had agreed to see me and take over my care. She was polite and business-like, and looked at me in the way I know I look at people sometimes – over her glasses, which I have been told can be intimidating – but I could see that she wasn't entirely at ease with the situation either. She fiddled with her pen while I spoke. And it was almost as though I could read her thoughts, because this process of finding out about the patient's problem was so very familiar to me. My palms were sweating in anticipation and my heart jumped a beat. My tongue seemed inexplicably glued to the roof of my mouth and I had to take a deep breath to reassure my mind that I was still in control of my body. I knew these were physical symptoms of anxiety, but I worried: what would she make of me? How much should I tell her? When you are on the receiving end of a psychiatrist's questions, you find yourself subtly judging how much to give and what to leave out.

  'On a scale of one to ten, where ten is as good as you have ever felt, where would you put yourself at the moment?' She paused, waiting for my reply.

  'About six or seven.'

  This is a very hard question to answer. I tell people not to think about it and instead answer instinctively, but did I really feel like a 'seven' or did I simply want to justify taking up this time, this 'slot' that someone else could have used? I had most of the answers prepared, rehearsed even, in my head, because I knew exactly what was coming.

  'I know quite a lot already, from the letter,' she continued, indicating the notes that she had received from my previous consultant. 'But can you tell me more about your past? When did this all begin?'

  'When I was a teenager, I used to get very anxious, especially before exams,' I explained, omitting to add that I still had nightmares in which the main fear was not yet having passed my finals.

  'There was something about the death of…' she began, rustling through the letter.

  'Yes,' I replied. I didn't feel ready to talk about it; I didn't know her well enough yet. I wasn't sure whether I wanted to begin again, getting to know another doctor – or rather, allowing them to get to know me – because allowing that bond of trust to be forged makes it much harder when they disappear.

  Unaware of my doubts, Dr V carried on with her questioning: 'You had difficulty getting over it?'

  I have often asked the same thing to others. But is a death something you really 'get over'? I wonder how you can ever know the answer but I simply replied 'yes' because that seemed to be the right answer. I also know that it was many years before I really began to grieve, and successive losses, such as the retirement of my doctor, could resurrect the ghosts of the past once more.

  'And what treatment are you on at present?'

  'I'm taking sixty milligrams a day of duloxetine and two hundred micrograms of thyroxine,' I replied, considering how many different tablets I had tried.

  I had to stop a combination of lithium, which is a 'mood stabiliser', and venlafaxine, an antidepressant, because my electrocardiograph was abnormal (I had a 'prolonged QT interval', which increased the risk of my heart just forgetting to beat one day). I wasn't sad to see the end of the lithium, as taking this had resulted in my thyroid gland becoming underactive. And then, as now, if I don't take the thyroxine tablets, I get tired and put on weight, which makes me feel even worse.

  '… And I've tried psychotherapy, too; it was helpful, at least some of the time,' I added.

  'What type of therapy?'

  'Psychodynamic… I've never had CBT.' That was true at the time although I did try it later on.

  I've spent a lot of time trying to make sense of why I get depressed and understand why some things can tip me into utter despair in a matter of days. Psychodynamic therapy is about trying to understand the impact that past relationships have on the present. CBT (cognitive behavioural therapy) is different and more concerned with learning how to address unhelpful ways of thinking about the world in the present which can lead you to become depressed in the here and now.

  'And when was your last episode?' came the next question.

  'A couple of years ago I had to have time off because of problems at work… six months… but I am OK now.'

  Wasn't it always work? Or at least this was what I found most stressful. It was never the patients who kept me awake at night but my interactions with the system. My skin was too thin; I was too easily affected by what people said and did around me.

  '… But I do seem to get a bit lower in the winter months too.'

  We continued talking for about three quarters of an hour and then came to an agreement about what should be done next and when to meet again.

  As I got up to leave, Dr V said, 'You don't have to wait out there next time you come; we can find somewhere quieter…' I knew she was trying to spare me the embarrassment of being recognised by colleagues, but this was something I spent hours telling my patients not to be ashamed about.

  'That's OK, I'm fine out there.'

  I was quite happy to watch daytime television with the sound turned down, along with everyone else in the waiting room.

Perhaps my depression coincided with the start of every academic year and the subsequent increase in my workload. Or maybe there was a more biological explanation linked to the fact that I, like many people with depressed mood, find the absence of light at these latitudes intolerable in the winter months. I didn't know the answer – I still don't. This is who I am. I cope most of the time; I am well for months, sometimes even for more than a year, but there are recurring periods in my life when the world seems a darker, more hostile and unforgiving place. I am a person who gets depressed.

  In the last 30 years I have listened to many stories of depression and despair, and learned a great deal from the people who have shared their lives with me. Although their experiences have resonated with my own, I generally haven't revealed my own history of depression. Whenever I haven't been well enough to treat others, I have sought help and worked at achieving my own recovery first. It wouldn't have been ethically correct to try to treat someone when I wasn't well myself. Yet, I believe that my experience of depression has helped me to be a more humane and understanding therapist. Psychiatrists get depressed too, more often than other doctors. Being an expert in depression doesn't confer any immunity from it and I am aware that I don't have all the answers.

  What I do know is that when a person is first asked to explain what is wrong, they may find it almost impossible to articulate exactly what the problem is. They may not yet have matched words to the feelings they can sense in the hidden rooms of their mind. They may still have no clear ideas about the 'what', 'why' or 'how' relating to the origins of their difficulties. Instead of words, their angst may be expressed in behaviour which may be hard for them, or anyone else, to make sense of and can manifest itself as irritability, anger or withdrawal. Sometimes they will delay seeking help until they are in a state of crisis. It's not easy to ask; I struggled at first, too.

  History is not static but organic and changes over time as it is shared and retold. At any one time I only really know how I feel now. I sometimes struggle to remember how I felt a year ago, and what my worries were then, or perhaps I actively forget. What follows is an account of what I understand about myself today and what I believe will help others similarly afflicted. I have learned that when I talk with a patient, I should not simply 'find out about the history' of their problems but instead try to listen to their story.

  This book was initially meant to be just about me, but in the process it changed from a straightforward memoir to something more: my attempt to make some sense of how depression is experienced. The patients in each chapter are based upon a number of people from whom I have learned a great deal in my career. There is a mixture of original names that have been changed (as some people may not want to be a character in someone else's story) and events that are largely fictionalised but based on truths. I should also add that the alleged events described in Chapter 10 did not take place in that hospital during the time I worked there.

  My own personal journey through depression is real, though. Importantly, this is not only my story – it is also about what I have learned from all those who have shared their experiences with me. My aim is to help others in the same situation to have a better understanding of what they are going through and to cope with it more effectively – both essential tools in overcoming depression.

The easiest way to understand why a person becomes depressed is to think in terms of the concepts of vulnerability and stress. The former determines our personal risk of depression and is affected by family history, the genes we inherit from our parents and early life experiences. The stresses, on the other hand, are the many different life events that we experience along the way. So the more vulnerability factors we have, the more likely it is that when something stressful happens, it will trigger depression. Each of us seems to have a particular threshold level for depression, beyond which, if life throws up enough difficult experiences, we will begin to suffer. Some people seem to be very resilient, while others much less so in the face of similar levels of stress. Moreover, our vulnerability increases as we grow older and if we have long-term physical health problems, such as arthritis or heart disease.

I am in a dimly lit office in a clinic in the centre of Salford, where I sometimes see patients. The watery afternoon sunshine is struggling to penetrate the security grating bolted on to the outside of the window, and the air filtering in from outside is stale and heavy with tobacco smoke from the nicotine addicts' mustering point. A sallow-faced young man called Richard is attempting to tell me about his family history of depression. It isn't easy for him and he is struggling to concentrate on the task. His thinking processes are slowed up – severe depression can do this.

  'My mother… Well, she used to go very… odd, strange,' he begins to say.

  'What do you mean?'

  Richard looks down at his hands before continuing, 'Well, frightened like. She used to stop speaking to us sometimes. She would tell us she could hear… voices… She was in Prestwich a couple of times when I was a kid… I think.'

  Prestwich was at one time the asylum for people from this part of the world.

  'Anyone else?'

  'Well my dad had… a drink problem, and he used to pick on me and my younger brother…'

  'Did he hurt you?'

  Richard's mouth moves but no sound emerges. A tear rolls down his cheek. He tries to speak again, his voice choking with emotion. Then his words come in a rush, as though they have been expelled from him.

  'He used to beat up my mother… I tried to stop him once, and he broke my arm.'

  Yes, it had hurt, but not only physically. I can begin to understand why Richard started to suffer from depression as a teenager and why now, in his mid-twenties, his mood is quite severely low. He managed to rise above a difficult start in life and get a good job in an office, only to feel that he had lost everything he had worked hard to achieve because of complications caused by diabetes, which he has had since childhood. His mother had diabetes too. Richard is now beginning to have problems with his eyesight and, given his early life, he is also particularly vulnerable to getting depressed. And although we can understand why that might happen and how it might feel to develop a serious illness like diabetes, most people really don't get significantly down; they manage to find ways of coping and carrying on. Richard has not.

  Doctors sometimes make the mistake of assuming that feeling low is simply understandable given the circumstances in someone's life – a case of: 'Well, you'd be down if that had happened to you, wouldn't you? I would!'

  They don't recognise that there is sometimes more to it than this: a person might actually be depressed, and depression is not the same as unhappiness. It is a much deeper and more powerful sense of despair which colours how you see the world and interferes with your ability to go on with your life.

My own past reveals the reasons for my particular vulnerability. My maternal grandfather, who was a coal miner in the west of Scotland, died of tuberculosis when my mother was only 17 years old. My grandmother had already died suddenly from a brain haemorrhage, when Mum was 12; they were out together in the street when she collapsed. I cannot begin to imagine what impact this had on Mum and she never talked much about it. I do know that she had a difficult childhood, in a place which is still, like Salford, one of the poorest corners of Britain. This is where an important part of me comes from and explains something about the person I am today and perhaps why my mother and I had such different expectations of what our lives would be like. Even though on the surface of things my mother and I have so little in common, I know that the deprivation of the west of Scotland is recorded both in my genes and in the impact that my mother's personality and beliefs had on me during my early childhood years.

  My mother moved down to England in the early 1950s to look for work and met my father at the seaside in Skegness where he was working on the Figure Eight, a huge wooden 'switchback' ride built at the turn of the twentieth century.

  Some of the most vivid images I carry around in my head of my dad are of him climbing up the steep track of the Figure Eight, repairing the chain which pulled the cars up to the top of the ride. When the cars reached the top, gravity eventually pulled them down but when the chain broke, which it did frequently, everything came to a standstill, which meant no fares. Dad was never afraid to walk the tracks, high up above the beach, checking for problems. Yet I can only remember once going on the Figure Eight with him. My heart pounded as we clanked along in the red wooden car with only a thin metal bar to cling on to, and my sweaty legs stuck to the scratchy leatherette seat. Each time we reached a bend, I was certain we were going to launch off the track into the sky.

  'Calm down! Don't cry, we are nearly there!' he had tried to reassure me.

  'I can't! It's awful. I just want it to stop.'

  'We can't stop. Just try to enjoy it!'

  I was crying as we came back down to the entrance. Dad jumped out of the little car and looked like he wanted to pretend we were not together; this tearful girl was not his daughter. Even then I understood something fundamental about my father: although in many ways we were very alike, we were also different. He was at least as physically strong and brave in the face of outward danger as I was anxious and fearful.

  My earliest memories of my dad are of his coming into my little bedroom over the front door to help me get to sleep by stroking my head and whispering gently to me, 'Just relax, drift away… go to sleep.'

  The feared bogeyman would retreat behind the worn green baize screen by the window, as his huge gnarled hands, the fingernails bitten away to the flesh, caught the tender skin of my temples. They smelled of engine oil from the amusement park and the greasy white Brylcreem he combed through his hair each morning as he stood in front of the bathroom mirror. Mum would always be outside the room somewhere, and from an early age I think I sensed she was unhappy – really quite deeply unhappy at times – but I did not understand why. I wonder now how much the chronic shortage of money, unvoiced disappointment at my father's lack of career success and my brother Alan's mental illness all contributed to the constant and growing sense of unease in our home.

  'What's wrong?' I would ask as Alan put his T-shirt on and took it off again several times each morning before school. I was responsible for getting both my brothers out in the morning, as my parents started work at 7.30 a.m. Ian, the youngest and 11 years my junior, was no problem and cheerfully munched on his cereals. Alan, seven years younger than me, was tortured by something to which no one could put a name. 'Go away and leave me alone,' he shouted.

  'Tell me,' I pleaded in an effort to understand.

  'Too many creases.' His replies would usually be muttered or spat out between tears.

  I tried to insist, 'We're going to be late.'

  'I don't care! Leave me alone.'

  He would rip up his clothes in fits of frustration as he tried to get dressed. Then once more, in the evening, he would stand by his bed in the dark for hours before getting into it, because something was wrong in his execution of the complex bedtime ritual that he was unable to explain in words.

  This drove my father to despair. 'Alan, please try to put it on won't you, son?'

  'No, I can't.'

  'Ray… it's nearly midnight,' my mother would implore as she stood at the bedroom door.

  'Leave him. Let him stand there and put the light off,' she pleaded.

  I would see his silhouette, poised next to the bed but unable to get in, petrified into immobility. Then the door would bang shut, and all we could hear was quiet weeping. Eventually, my father too would retreat, to his bedroom and his bed, crippled with disappointment and anger. It would be many years before my brother was finally given the diagnosis of obsessive compulsive disorder (OCD).

  'Mum said a while ago that she sometimes thought of leaving, running away and going back to Scotland; it was all so awful,' Alan told me during one of our long telephone conversations many years later.

  But she didn't. She stayed.

I do wonder whether I would have stayed rather than tried to escape, if I had found myself in the difficult place where she had been.

  My father became increasingly affected by what I now recognise to be social phobia, which for him manifested itself as a fear of talking to people in public places so that, for example, my mother had to persuade local shopkeepers to let her bring home shoes and clothes for him to try on. This anxiety extended even as far as going into the library to collect books. Although a little alcohol eased the difficulty, he rarely drank, preferring instead to smoke up to 40 cigarettes a day.

  My mother always seemed more confident, at least on the surface. As a young person she had always loved singing and dancing, and would say, only half-jokingly, 'How did I come to marry a man who won't dance?' But she became increasingly anxious too, beset by physical symptoms of tension, such as headaches, acid reflux and stomach pains. As time passed, she began to take tranquillisers – Valium and Ativan – which were willingly provided by the doctor.

  A sense of anxiety and unease gradually became the usual emotion in our house. Dad argued with us all at every opportunity and after a particular vicious row with my mother, he went to bed for several days, barely eating anything.

  'Just bring us a cup of tea, Linda,' he said, 'then leave me alone.' He turned his head away from me to face the corner of the darkened room.

  'Aren't you going to get up?'

  'There's nothing worth getting up for, is there?'

  Mum and Dad went to family therapy sessions with Alan. Dad hated the way the consultant psychiatrist peered at him and didn't explain anything. 'I honestly don't know what they are trying to achieve,' he said. 'They just make me feel guilty.'

  The doctor had asked for me to go along too, but I refused, telling myself that this was nothing to do with me. I was too busy with my schoolwork.

  Biological explanations for mental illness were largely unknown then. Parenting was more likely to be blamed than faulty wiring of the brain, whereas the real reason, as I know now, is likely to be a complex combination of nature and nurture, rather than simply one or the other. My brother had, I suspect, inherited a tendency to suffer from anxiety from both my parents. He had a difficult birth, with a few crucially important minutes when his heartbeat could not be detected and which may have caused some minimal hypoxic damage (this is an injury caused by insufficient flow of oxygen) to his brain. Subsequently, the tension that his problems caused between my parents served only to make him more anxious, leading to a vicious cycle of bizarre behaviour, anger, recriminations, and more difficulties with dressing and going to bed.

  My brother was not their only child to show signs of mental health problems.

  In my early teens I, too, started to experience the physical and emotional symptoms of anxiety which would later become so familiar to me: a fear that something terrible was going to happen, severe headaches, a churning stomach and sweaty palms whenever I was stressed.

I now realise that growing up in such an environment, where getting through the day required the full use of my emotional antennae in order to assess what mood everybody was in at home, prepared me well for empathising with my patients in my everyday work as a psychiatrist. Yet it also resulted in the development of a sometimes crippling oversensitiveness to the actions of others, such that I have learned that I cannot always trust my own instincts in relationships. It also predisposed me to becoming, from my early twenties, quite severely depressed. As well as inheriting the neurotic genes, I also struggled with the fact that my family never really provided a safe, emotionally secure base for me to grow up and learn how to explore the world with confidence. Though my mother had a naturally confident way of approaching life despite her anxieties, I think I inherited more of my father's quiet reserve, and in my early years I was much closer to him. But the quality of my attachment grew increasingly more anxious and fearful throughout my teenage years, and this change contributed further to my own particular (fairly low, it sometimes seems) threshold for coping in the face of what life throws up for me.

So, as I listen to Richard, I can understand why he has been vulnerable to depression. His early life was far more deprived and detrimental to his health, both emotionally and physically, than mine ever was, but in our own way we each carry within us the seeds that could germinate into future problems with our mood, given the right (or perhaps wrong) circumstances.

  'I know it's been awful, and the way life seems at the moment you probably think it can never get any better at all…' I offer to Richard.

  He looks up but says nothing. I can sense his scepticism, but also his growing desperation.

  'But I'd like to see if there are ways we can help you to feel better. I feel sure there are. Would you like us to try to work on it?' We need to approach this collaboratively if the treatment is to be effective. The silence lasts for seconds, but seems much longer. Then Richard makes eye contact with me and there is the merest hint of a nod.

  'Yes I would,' he eventually says.

  'That's great,' I reply, 'and I guess we need to think about what problems you would like to try to work on. There is quite a lot you've told me about the past, and what happened to you growing up, but there are also some things to do with how you are coping in the present.'

  'Do I have to talk about the past?'

  'No, we can start with the present to try to help you get going again and managing life better.'

  Richard begins to work with one of the psychological therapists, setting simple goals to try to move forwards. This is called 'behavioural activation' and is based on the theory that when we get depressed, we stop doing all sorts of things: those which are pleasurable, those which are routine like getting up and getting dressed, and also important ones like opening bills and paying them. In order to recover, we gradually need to start becoming active again, as our level of activity and involvement in life is closely related to our mood. It isn't a case of waiting to feel better to get on with life, but rather of acting better to feel better. There is good evidence that this really works.

  Richard embraces this, and over time his mood begins to improve.

  'I've started to check my blood sugar again regularly,' he says during a later appointment. He makes eye contact, and his face cracks open into an uncertain smile. 'I'm feeling much better… but…'

  'But?'

  'I can't help being afraid. I mean, I am worried that one day I will still end up like my mother. I mean, it's in my genes, isn't it? Madness… It's hereditary.'

  I understand what he is saying because I know that fear too, but I can also tell him quite honestly, 'Just because it's in your genes it doesn't mean it cannot be overcome. Lots of people are vulnerable to getting depressed, as you are, but there are things we can do to prevent it and to treat it early if it returns. It doesn't mean you are going to go mad.'

  'Really?' He sounds surprised.

  'Yes.'

  There is a long silence and then he says, 'I don't think I want to talk about the past now. I want to forget it.'

  It is his choice and I think it is probably the right one for him, at least for the moment.

  People brood about the past when they are depressed but can more easily dismiss those thoughts when they are well. It isn't always necessary to work through past memories in order to feel better in the present. What is more important is being aware that our vulnerability to depression does not mean that we are weak or lesser human beings in any way. This is sometimes difficult to remember but it is crucial to our survival.

At times of stress I become increasingly fearful and anxious, and when I feel as though I am losing control over my life, despair soon sets in. That sense of being in charge is important to me. Yet I also know that this need to retain control can prevent a person from seeking assistance when they really need it, as accepting help can also be seen as relinquishing power over one's own life, of giving in and losing personal freedom, which can feel very frightening indeed.

Jess was frail and thin but did not understand what people were concerned about. 'Look, there is nothing wrong with me. I'm fine. I don't want to be here. I just want to go home,' she told me. 'My mum will be worried about where I am.'

  'I think the ward sister has let her know that you've come in. Your mum is very concerned about you. She wants you to stay here.'

  'No, you've got it wrong. I know I told the professor I'd stay but I've changed my mind; I need to be there to look after her, don't you see?'

  She rubbed a tear away from her eye with a bony finger. Her hands were beginning to look quite blue, but it wasn't particularly cold. Her nose was turning a dusky shade of purple. She seemed fragile, but her will was still strong and determined.

  Jess was one of the patients I saw when I began studying psychiatry as an undergraduate medical student at the University of Edinburgh. She was 17 years old and desperately unwell.

I hadn't always wanted to be a doctor. The idea came to me quite suddenly around the age of 15, when I realised that I didn't want to be a biology teacher, which was the direction in which I thought things were heading. I was, quite simply, good at science, the first member of my family to go to university and, when I wasn't feeling anxious, determined to make the most of the opportunity. The problem was that I did feel anxious about it, quite a lot of the time. Anxiety became my default state of being.

Some consider anxiety and fear to be interchangeable concepts, and the distinction isn't always very clear. I find it easier to think of fear as a negative emotion evoked by a specific stimulus; quite simply, we can identify what it is that's generating the feelings and emotions within us. In contrast, we experience anxiety when our personal safety is threatened in some way and we can't identify a cause. We just feel unpleasant sensations in our body and begin to worry about everyday things without understanding why. What we fear may be something in our lives that we haven't yet acknowledged or something we are brooding about but have still to put a name to.

  During most of the five years of my medical training in Edinburgh I had never considered focusing my career on the problems of the mind. My friend Jane was going to be the psychiatrist and I would be the physician, concerned with the diseases of the body.

  Jane had become my best friend, although I never really felt I was hers. She was a diminutive, fiercely bright southerner with long, untidy dark blonde hair and a raucous laugh. Dressed in our brown overalls sodden with the formaldehyde used to preserve the cadaver in anatomy, Jane and I had worked on the same 'body' throughout our first year. The oily smell of partially dismembered torsos and limbs, with carefully dissected nerves and blood vessels hanging like loosened latticework, penetrated our clothes and hair, and followed us home at night. We all lived in collective fear of oral examinations from one of the anatomy teachers, an elderly woman with a tight grey bun who indicated the muscles and nerves in a dissection with a pointer fixed into a hook where her hand should have been. She barked questions at a girl a couple of tables away from us.

  'What happened to her?' I asked, transfixed by the dexterity with which she manipulated the cadaver with the hooked limb.

  'She broke her arm,' Jane whispered to me, 'and the casualty officer made a mess of it. The blood supply was cut off and it had to be amputated.' Jane turned and fixed me closely, adding 'And she likes to make female students cry.'

  'Because…' I knew what was coming.

  'The casualty officer was a woman.'

  The five years of medical training were essentially about learning how to talk with confidence about something you had precious little knowledge of. The problem for me was that confidence was something I had in short supply. I felt out of place in Edinburgh. I didn't share the same background as most of my fellow students, including Jane: my mother worked in a factory, assembling transistor radios, and my father in an amusement park.

  'You are not happy,' my friend Stephen announced one evening. Stephen was Irish and very bright. The week before, we had spent an evening drinking together and fortunately I had remained sober enough to turn him on to his side into the recovery position after he had consumed half a bottle of Glenmorangie.

  'I should thank you because you saved my life,' Stephen mumbled, changing the subject.

  'What do you mean "I'm not happy"?' I retorted, changing it back.

  'Separation anxiety – that's what I think.' We had just started 'behavioural science'. He looked a little nervous as he raised the possibility and couldn't look me in the eye.

  'Why would I feel that?' I enquired.

  I didn't know what it meant but it sounded uncomfortably accurate. I was missing something about home but I could not work out what it was. There was nothing I felt I needed to rush back to. Dad and I had become distant and angry with each other during my rebellious teenage years, and I didn't really understand why. I applied to go to university in Edinburgh to get so far away that I could not go home during term time.

  'Separation anxiety,' repeated Stephen. 'I know I'm right.'