Follow-Up With The Psychiatrist

This morning I saw the psychiatrist again. We discussed the side-effects and agreed that I would continue taking venlafaxine / effexor, as it appears to have some mildly mood-stabilizing effects on me by now, and that I’m going to stay on this dosage until my next appointment at the end of May. Since it’s been only two weeks on 75 mg so far, it might take more time to make the side-effects go away completely: my main complaint was that I felt even more tired than before, but since citalopram had that same effect, switching to another drug does not seem worth it as chances are that I react this way to all antidepressants.

The psychiatrist asked me how I felt on a scale of 1 – 10, with 10 being absolutely awesome, and I rated myself a 3, even though I had to think about it quite a bit. That rating was more influenced by my physical complaints, and by feeling exhausted and stressed out about the welfare process; otherwise I would have given myself a 4. The goal for now is to make me reach 5 – 6 on this scale, and he asked me what had to change for me to feel that way, which I answered with: “I’d need more energy to actually manage my daily responsibilities sufficiently to feel that way.”

I told him about the recent problems with the job centre and the energy provider, and he was so nice to give me the medication I need until my next appointment out of the stock at his practice, so that I would be relieved from the self-pay contribution necessary at the pharmacy. (One of the benefits of welfare is that it eliminates the self-pay contribution for medication, but right now that obviously doesn’t apply yet.)
He also gave me an incapacity certificate valid until the end of May for the job centre, and I will see him again right before this one runs out. That is important both for proving that I am actually unable to work, and so the job centre can’t put me into an apprenticeship programme – if you cannot prove you are incapacitated, they can take away your benefits if you don’t comply with their orders, or they won’t even let you get on welfare in the first place.

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The First Day On Venlafaxine

Googling venlafaxine yesterday did not do me a whole lot of good. For a while, I was pretty scared, but then decided to judge it according to my own experiences with it. After all, the effect citalopram had on me was different from what the majority goes through as well.

Well, my first experience with it was rather horrible. The psychiatrist had told me to take the venlafaxine in the morning, with my breakfast, and so I had a banana, took the pill, and ate a sandwich afterwards. About 20 minutes later, I started feeling a little queasy and dizzy. I went to lie down on the bed, where I felt very ill very quickly. 45 minutes after taking the pill, I found myself in the bathroom, vomiting violently. I don’t want to gross anyone out by too graphic description, but it was so bad that while vomiting I thought: “This isn’t going fast enough! This stuff needs to get out NOW!!!”
Once my stomach was empty, I felt better instantly, but it was not over yet, because apparently my whole digestive tract was affected and I got diarrhea as well, while a couple more waves of nausea washed over me – those did not result in vomiting, though. In the early afternoon, the worst was over and I slept for two hours as I was completely exhausted.
After the nap, my stomach had calmed down and I only felt a bit of dizziness, but was left rather weak. I don’t dare eating anything but dry bread, plain rice and apples either, because I am afraid of getting sick again.

I just hope it will be easier tomorrow, because I don’t see myself lasting very long if I have to vomit that violently every morning. When starting citalopram, I got queasy too, but nowhere near as bad.
Originally, I’d wanted to cut the first pill (37.5 mg) in half and start with an even lower dose, but the pills are too small for that (I don’t have the extended-release capsules).

Back From The Psychiatrist

And thus begins the new treatment regimen with Venlafaxine (Effexor), starting tomorrow.

Everything went well; I was a little nervous first and not particularly in the mood for dealing with a stranger, but the psychiatrist turned out nice. He asked: “What leads you here?” I told him that I was in therapy for chronic  depression for two years and generally was really satisfied with it, but couldn’t get a handle on some symptoms like concentration problems and energy, and wanted to see what medication could do for me in that regard. He knows my therapist and has a superficial idea of the CBASP programme I’m in, and I guess that was enough credit to not let me do all the lab tests and ECG again. I also gave him permission to send reports to my general physician.
I recounted a brief history of symptoms and the treatment I received so far: First depressive episode at 12, second at 16 (this time with suicidal ideation), since the age of 19 / 20 only oscillating between different stages of major depression; panic attacks at 30, treated with citalopram, then therapy; therapy major success, but then the start of a slow decline. The psychiatrist asked about living situation, family, family history of depression, school education, what I am studying. Whether I smoke, drink, ever did drugs, take any kinds of medications.
He performed some tests on my cognitive capacities, because I had complained about them:
– “Spell the word ‘radio’ backwards.”
– “What’s the difference between a river and a lake?”
– “What’s the difference between a ladder and stairs?”
He had me memorize the words “street, traffic lights, flower” and asked whether I remembered those in between other questions, and had me do a chain of mathematical exercises: 100 – 7, then subtracting 7 from the result again, and again, and again. I scored 100% and obviously am not demented.
Some questions on differential diagnoses: do I see or hear things nobody else sees or hears, do my thoughts race, do I think I am being watched or that people talk about me behind my back, etc.?
The most difficult question actually was, “How do you feel these days?” I honestly had to think about that, and answered, “On average days, I feel subdued. Pessimistic.” I told him about the insomnia, problems falling asleep and the stomach aches, that I like to withdraw from people, worry a lot and occasionally get anxiety attacks because of the worrying.

All of that took about half an hour, then he proposed that due to my previous experiences with SSRI in the form of citalopram, I should try out what an SNRI does for me. He explained that SNRI give most people more energy, explained possible side-effects and finally gave me a prescription for venlafaxine. Unless I experience really bad side-effects, I’ll see him again in four weeks.

Edited to add: Yikes, maybe I shouldn’t have googled venlafaxine / effexor, because the results sound pretty bad… “The antidepressant everyone loathes to have taken.” Sounds like I am in for a bumpy ride…

Getting Ready For The Psychiatrist

Tomorrow is my appointment with the psychiatrist. I have a vague idea of what to expect, based on the psychological examinations at the hospital and internet research, and I’m quite used to recounting my history with depression. Hopefully, he will accept that physical reasons behind the depression have been excluded two years ago; I have documentation on the lab tests of my blood, but not on the ECG, for example – that’s still in my file at the hospital. I just don’t want to go through all of this again only to come to the same conclusion… Other than that, I’m open for any kind of neurological or psychiatric test he might want to perform.

I’ve been thinking about what I’m going to tell him. My top priorities are the lack of energy and the cognitive deficits; if we manage to do something about those two “symptom clusters” with tolerable side effects, I’ll call it a success. It might sound odd to some readers, but medicating the sadness away is not very important to me, because I feel that there is a reason when I am sad – even if I am not immediately aware of it. I just want to reach a state where I am able to deal with those reasons sufficiently.
I also hope I can skip the citalopram this time around. Here in Germany, it’s the most widely prescribed antidepressant, and usually the first antidepressant you will get prescribed. While it helped me in some regards, I feel that in my current state the side effects would outweigh the use I got out of it. Not to mention that it made me extremely sleepy in the beginning, which is certainly not what I am looking for currently.

Well, tomorrow I will know more.

Sleeping Problems & Depression

As someone who had no experience at all with sleeping medication, I did not really know what to expect when taking zopiclone. My sister said it had knocked her out within two minutes, but that she woke up only six hours later. With this in mind, I took my little pill at 10.30 PM, after I already was in bed. I read for half an hour without noticing anything, but after switching the lights off it really was a matter of minutes only until I was asleep. I shortly woke up in the middle of the night and when my husband left for class, but it was not before 9.30 AM this morning that I became fully conscious.
Obviously, I am quite happy about this and hope that my cycle is corrected now so that I will be able to sleep tonight as well, without the help of a hypnotic agent. However, it also was a good demonstration on the limitations of sleeping medication: it was not a refreshing rest, and I have been tired all day long. It felt more like I had been knocked out instead of sleeping, and I did not dream either – which I usually do every night.
The best thing about it was that when my husband came home from class, I was not only awake, but had also showered, dressed, eaten breakfast and opened the shutters. Instead of a zombie-like “…. heyyyyy…” from the bedroom, he got a “Hi!” from the kitchen – and I got a hug in return, because he was so happy to see the zopiclone had helped.

Sleeping problems are a very common symptom of depression, but a lot of publications only focus on insomnia and /or early waking, entirely leaving out hypersomnia. In fact, back when my doctors were still throwing diagnoses like MS into the ring, I myself already suspected it could be depression, but the insistence on insomnia and early waking made me doubt my own feelings: if depression was tied to decreased hours of sleep, I surely could not have that, since as a rule I was sleeping too much.
Early waking is defined as waking up significantly (an hour or more) earlier than one intended to and not being able to go back to sleep, coupled with excessive worrying while lying awake. This happens very rarely to me only, about once or twice per year.
I do have massive problems falling asleep, though,even on my best days. I read that the average healthy adult needs seven minutes to drift off, and while no source for that claim was given, it matches what I see in my husband: once the lights are off, it takes only a few minutes until he’s gone, whereas I stare into the darkness for at least an hour, often longer. About once a year, I will have a period where the problems with falling asleep grow into a full-blown insomnia, even though I have never had it for as long as now.
However, once I am asleep, I usually do not wake up until I had my full share – unless being interrupted by external signals like the alarm clock, of course. According to the IRS-SR, my nine hours of sleep within a 24-hour-period count as slightly elevated; when I first started therapy, I would need twelve. Under the influence of citalopram (at least in the beginning) and before receiving thyroid medication, it would be even more.

I just hope I can get a handle on this now and will have plenty of restful sleep tonight!

Help Me, Zopiclone

I did not think it was possible, but the last night was almost worse than the one before. It started promising: Got tired and went to bed at 10.20 PM, read for half an hour and switched the lights off at 10.50 PM. Fifteen minutes later, I was asleep – until 1 AM, when I woke up and was so alert that I could not force myself back into the realm of dreams. Got out of bed for a couple of hours, then back into bed, where I read until 6 AM. Lay awake for another hour and finally dozed off just after 7 AM again.

At least I did not cry this time, but it was even more confusing than simply staying awake. So for tonight, I asked my sister for one of the zopiclone pills she got prescribed for her insomnia last autumn. A definite first, as I never took any kind of hypnotic agent before, but I just cannot go on like this. I have tried everything to rectify my sleeping cycle and it only got worse, and even though I am generally not keen on using pills, I feel like I am going to lose my mind if I don’t get back to normal hours soon.

In other news, I have an appointment with the psychiatrist in four weeks. As the psychotherapy is covered by the fundings of the clinical trial, he has pretty much free reign to do with me whatever he deems fit, because with the exception of the citalopram two years ago, the health insurance did not have to pay for anything yet.
I’m not quite sure how I feel about all of this yet. I would have prefered to see my therapist as the psychiatrist as well, because nobody else knows my mental health history as well as he does, and quite frankly it would save me the hassle of having to get to used to another “stranger”. However, I have hardly any right to complain, and maybe it will even be good for something to keep the two treatment fields separated.

Going Back On Antidepressants?

(For the past couple of days, I have been under the spell of a virus infection which is currently on a rampage in my neck of the woods – sneezing, coughing, sinus pains, yadda yadda yadda. Not that I really dare complaining; having suffered through a real influenza two years ago, I know how bad it can get and how far away I am from that still.)

For a little while now I have considered going back on antidepressants. Taking citalopram was a mixed blessing, which I have written about in one of my first blog posts and in the Pre-Treatment Diary, and for a long time I was adamant to not go back on medication. However, my perspective on it has changed since: To begin with, I believe I was too depressed in 2010 that antidepressants alone could have “cured” me – even on medication, I still was severely depressed. After two years of psychotherapy, I can feel and tell apart varying degrees of depression, even within the same category of “severe”, “moderate” or “light” depression, but was not attuned enough for doing so two years ago. I can also tell where citalopram worked for me and where it did not, and it undeniably helped with the panic attacks, even if it could not eradicate the depression enough to make a difference.
Maybe a different brand or class of antidepressants will work better than the citalopram did.

The reason why I am even considering going back on antidepressants is that I feel myself slipping – very slowly, but it is happening – into another episode of depression. My energy levels are getting lower; concentration lapses; the cognitive deficits are becoming worse; insomnia. I just want to curl up on the sofa, hide from the world. (And none of that has anything to do with the cold; it has been going on for a much longer time than this.)
What worries me is an unpredictable sadness flooding me out of nowhere, making me tear up from one minute to the next. It is so difficult to explain to other people… sometimes, it is as if I am in a bubble, and inside it time goes by much slower than for everyone else. I am too slow, too lethargic to keep up with the rest of the world….

Due to my husband’s integration class finally starting and me being unable to fall asleep, he has gone to bed earlier than me all week long: I would just stay in the living room and join him a couple of hours later, so that I would lie awake only one or two hours in bed instead of four of five. Sitting around at night all by myself has somehow emotionally transported me back to the times of my deepest depression, and I always had a pattern where my mood would tank over the course of the evening. The sadness increases with every hour, and I feel more and more lonely until I fall asleep. It is like being the only person in a vast, empty land, with nothing to distract or occupy the mind, where only bitterness and desolation thrive. Everyone around me is asleep.
I went to bed at two o’ clock in the morning, hoping I would be able to sleep. Instead, I found myself falling into sadness again – so badly that it cost all my self-control and restraint to not wake up my husband. I knew it was silly; after all, I was lying right next to the person I had married, no reason to feel lonely. And yet, there was this strange sensation of being completely isolated from everyone else in the world.

Exhibit B: A (Not So) Hopeless Case

Exactly a week ago I appeared in front of a group of 19 psychology students as an example for chronic depression, but was (still am) so swamped with homework that I didn’t have the opportunity to write it down yet.

I went to the hospital straight from university, so I was a good half hour too early and had plenty of opportunity to get nervous. It was a part of the hospital building I did not know too well either, so I did not dare going to the restroom out of the irrational fear I would miss my therapist. Fortunately, we had about ten minutes to spare when he came to pick me up…
We spoke a few minutes outside – about how I was doing in general, and about being nervous and how curiosity got the better of me. We also discussed which personal information my therapist was allowed to disclose (he was very discreet, though, and spoke only of my “significant others” instead of naming a person, and he did not talk about anything personal). I gave him free range on whether he wanted to wear his white coat or not and on whether we’d sit at a table or not, so my therapist decided to recreate the therapy setting – no white coat and no table.

As mentioned, the group was rather small, creating a somewhat intimate setting – as far as that is possible given the circumstances. My therapist acted as a moderator, introducing me and my diagnosis, and I smiled a hello into the round. They had already learned about the characteristics of depression before and seen an in-patient earlier that day, who had also volunteered to talk about her depression. The in-patient, however, had been an example for biological reasons behind depression: a disturbed transmitter chemistry and psychiatric treatment with cipralex. I had come in as a representation of environmental and character-related factors, with the biological components playing only minor roles.
I started off recounting how I got misdiagnosed by my former general physicians, how I suffered from panic attacks in summer 2010, got on citalopram but could not shake the depression, and finally got in contact with the hospital. My therapist elaborated on the importance of behaviour in medical caregivers – had my first contact not been such a positive one, I might never have followed through with everything that followed.
There was a sheet with the results of all the clinical tests I did during the first 48 weeks of therapy – BDI-II, IDS-SR, MADRS and possibly some more I forgot, plus the results of the “therapy cards”. My therapist was not supposed to know the results until recently, because they evaluated the level of trust between him and me, but from the beginning of their evaluation (from therapy week 4 on), they had shown I trusted him. All the other tests showed the same pattern: a very high score in the beginning, then a steep decline over the course of a few weeks only, and a long phase of slowly fading out. Towards the end, my scores went up a little again, when I decided to go back to university.
We spoke about how important it is to trust the therapist and I listed some of the irrational fears the therapy setting could have evoked – fear of being ridiculed, getting yelled at, not being taken seriously, or cancellation of therapy as a punishment for increasing depression symptoms, for example.

I did surprisingly well during the presentation. My biggest fear had been to just freeze or being unable to get proper words and sentences out of my mouth, but I spoke with a loud and clear voice, looking at all the faces around me and also taking in their reactions. Everyone looked friendly, some even smiled encouragingly, and I found it easier to open up than expected. Of course, we did not discuss anything private, but considering that in university I have not told anyone anything that is even remotely close to the truth, it was a pretty huge step for me. Part of what kept me calm was that I knew no matter the outcome, the people would learn something from my appearance. If I could talk about it all, they’d learn from my report, and if I froze up completely, they’d get a demonstration of what depression can cause.

Today, I had a regular therapy appointment, and my therapist said he could tell the very moment I relaxed during the presentation just from observing my body language. He gave me quite a lot of praise and also thanked me for doing this: “Half a year ago, I wouldn’t have asked you. Not that you couldn’t have done it back then, but the risk would have been too high.”
There are several reasons why he asked me: for one, I’ve been long enough in therapy to know the process very well, to have recovered enough for being able to reflect, and something he has been stressing a lot over the last weeks is the fact that I went back to university. Last month, he told me about a colleague’s patient who had a similar diagnosis as I do, and she actually quit her job – whereas I went back to a place that terrifies me quite often. On about four days per week, it gets so far that I think I can’t take it anymore. I fantasize about quitting. But, there’s no realistic alternative, and so I struggle from week to week. My therapist knows this – he gets to hear plenty about that, of course. University was one of the catalysts which propelled me further into depression, so he thinks that it is of utmost importance now that I confront those situations and master them. He never influenced my decision on whether I should go back or not, but clearly approved of it afterwards.

One reason why he asked me might have been that the outlook for me without CBASP would have been pretty bad: “Early-onset chronic depression with life-long co-morbidity of panic disorder.” He called it a “horrible, horrible diagnosis” which without this special therapy programme would be pretty much treatment-resistent. CBASP actually works on both a personal and an environmental level, whereas other schools of psychotherapy concentrate on one aspect onely: classic Freudian psychoanalysis operates on the personal level only, classic cognitive psychotherapy on the environmental level. Neither of them would have been sufficient for me.
They didn’t even put me through pre-treatment self-evaluation as they usually do, because they thought it would trigger my flight instinct and drive me away. Yet, despite the very bad odds, here I was – more or less functioning now, and definitely able to talk to a bunch of strangers without running away.

At the very end of the presentation, everyone clapped and I blushed and looked down to the floor, until my therapist told me: “Look up and take it in. This situation will be over soon, so this is your only chance at grasping of how well it went. You need to take this memory home with you.”

Change Of Plans

Due to health reasons, I had to cancel my mother’s attendance for the therapy session on Friday and it will just be a normal appointment for me. My mum had been sick last week already and even though she’s not bedridden anymore, she’s not 100% either. Nor am I, and if being honest, I’m secretly relieved about the turn of events: there are so many other things on my plate that I’d like to discuss with my therapist before my mother joins us – last Friday, for example. Also, I’m going to have a friend visiting all weekend long, and regardless of whether our joint session leads to a long amicable discussion or a long argument between my mother and me, I would need a lot of time for that…

I’ve been put on the sick list for the rest of the week because of a stomach bug myself. There are three general physicians who share the practice I go to; some of the patients only see one of them, others – like me – go to whoever has the first slot available that day. So I ended up with the same doctor as back when I fainted on my way to work and broke down crying in the practice (check the “Pre-Treatment Diary” for the entry of October 19, 2010). He’d urged me very much to find a therapist then, which was just the extra encouragement I needed to actually call the hospital three weeks later.
The memory of losing my composure last time, even though more than a year in the past, embarrassed me a little, but fortunately the doctor didn’t ask any questions about it. He had my file already open when I walked in and thus doubtlessly was reminded of the incident, as well as my stint with citalopram and the fact that I get a referral for psychotherapy from them every three months. He was especially nice, though – a kind of cordiality that goes beyond good manners and agreeable behaviour. It reminded me a little of my therapist. There was nothing he could do about the stomach bug (“That just takes a couple of days to get through.”), but he did inquire about university and I told him about changing to geosciences.

The doctor actually asked me how long I wanted to stay home and despite really being sick, I feel a little guilty for making it the whole week. Not that attending classes would do me any good, and thus (as my therapist would say) there’s no reason to even debate the matter.
It’s more than the stomach bug, though. I’m constantly tired – Christmas break didn’t do much to change that. In fact, only the last two nights I managed going to bed and falling asleep at a decent hour, following several weeks with insomnia.

Not to mention that I have been missing my boyfriend insanely. Now that we can actually count down to the day he’s arriving and almost reached a single digit number of days left until our reunion, it’s worse than all those last months. Like the last mile of a marathon: you know you are almost there, but because you’re so close to the finish line, you just want to be done with it and let go of all the self-discipline which got you so far. Every single step makes you ache more, every muscle is sore, every breath laboured. I just want to be at the airport gate and wrap my arms around him, and then the world may end.

Looking Back At 2011

The year is coming to an end and it’s time to take inventory. Over the last twelve months, I have time and again observed anniversaries and compared my life to what it used to be, but it’s because of New Year’s Eve that I feel like I’ve truly come full circle.
A year ago, I was just experiencing the very first days together with my boyfriend, I had just started therapy (but was still in the anamnesis phase, not yet learning coping / healing techniques), was still in the last throes of quitting citalopram. I had an incredibly bad year behind me, full of anxiety and panic attacks, physical and emotional pain, cognitive deficits and side-effects. 2010 was left behind tired and exhausted, but with a tiny spark of hope.

There’s so much I have to be grateful for in 2011:
– My boyfriend. We only lived together until the end of March and certainly didn’t think we’d still be on different continents on Christmas and New Year’s Eve, but even if most of the year was spent geographically apart, we’ve remained emotionally closer than ever. If anything, this forced separation has galvanized our desire for being together, and the bureaucratic process – which took far longer and was far more costly than anticipated – proved that we are serious about our commitment to each other.
He’s made me laugh (despite myself, sometimes), held me when I cried (both literally and figuratively), endured my endless therapy talk without complaining or becoming jealous of my therapist once, cared for me when I was bedridden with influenza for weeks on end. Through him, I learned to enjoy life again, learned to want something more out of life again than just the mere absence of pain. Through him, I lost the fear of giving myself to another person.
– My friends. All of them have been incredibly supportive, encouraging and generous with their feedback as well as very patient listeners. I owe lots of laughter to them and many a good idea. After having been largely unable to maintain social contacts, I am grateful that nobody held this against me and that I actually did have a social life again this year.
– My therapist and the team behind him. Everybody at the hospital I ever had contact to has been nothing but friendly and highly professional. A special mention must go to the psychologist who was my very first contact person ever there; who did the phone interviews and various formal clinical interviews with me as well as the two MRi scans, and who coordinated most of the appointments with other specialists for me. Her kindness ensured that I even made it past the initial phone interview stage without getting scared away.
Towards my therapist I have to be thankful not only because of his skilfulness and expertise, but also for his constant support beyond the requirements. In addition to the therapy sessions, we must have exchanged about a hundred emails over the course of the year. He’s helped me getting a sabbatical at uni and wrote to my health insurance. In crisis situations, his response was quick and most helpful. Most importantly, he treated me humanly when I felt most inhumanly.
– My family. That might come as a surprise, but despite all our problems and dysfunctional ways, I want to be grateful for the good times we shared.
– The progress I made. I learned to verbalize my problems, ask for help, selectively trust people, maintaining social contacts better, take care of my needs, find solutions for my problems. I can read books again and am attending university again. I found out what “normal” feels like and was euthymic for the first time since childhood. Over the course of the last year, I gave my life a completely new direction. I learned to have hope. Last but not least, I started a blog which I’ve managed to maintain for seven months already and which brought me much joy.

To my readers, all the best wishes for the new year – may it bring you much happiness and joy!