Depression Symptoms & Antidepressant Side-Effects Assessed

It’s becoming very clear that despite taking twice as high a dosage of venlafaxine / effexor now, the timed-release capsules work much better for me. The nausea and vertigo vanished completely, and in the mornings I don’t go through withdrawals anymore either. I do feel quite drained from the experiences of the last three weeks, though, very tired and listless. I lost 6 kg (13.2 lbs) – 4 kg over the first weekend and another 2 kg since – and even though I would welcome further weight loss very much, it goes without saying that vomiting, diarrhea and skipping meals due to nausea is not exactly a healthy way to drop the kilos and at least partially responsible for the feelings of weakness. On top of that, venlafaxine also suppresses my appetite for a good part of the day, until it returns in the evening and I suddenly start scouring the kitchen for all the stuff I did not buy when shopping…
There has been no improvements of the symptoms I primarily started taking venlafaxine for yet, the cognitive impairments and lack of energy, but I do feel more emotionally stable recently. Next Friday I have a follow-up with the psychiatrist, when I’ll find out whether I’ll increase the dosage further or stay on it for the time being.

As for the welfare process and related paperwork, the main appointment at the job centre had been cancelled on Tuesday already because the lady had become sick, and the one who works on our case at the employment agency was replaced with a colleague due to illness as well. While being very friendly as well, this colleague could do little more than collect the forms we had filled out at home and the documentation we had brought. Other than that, we will have to wait for them to get back to us. I handed in the questionnaire on my medical complaints today; the question was: “Do you have medical conditions which influence your current job or have done so in the past? Please give a short description of your illness respectively your symptoms and tell us which kinds of occupation would be influenced by these.” The space left blank was less than a quarter or a page, so I could not go into much detail:

“Diagnosis: chronic recurrent depression with comorbid panic disorder.
– permanent / daily symptoms: muscle pain in legs and arms; social anxiety; slowed-down thinking; word finding problems; problems falling asleep (at least 2 hours / night); severe lack of energy; hypersomnia; decreased libido
– frequent symptoms (at least 3 days per week): stomach pains; digestive problems (diarrhea); back pain; memory problems; concentration problems; depressive emotions (sadness, emotional emptiness, hopelessness); headaches
– periodically appearing symptoms: insomnia
– under stress also anxiety attacks
– currently (since mid-March 2013) additionally vertigo, nausea and vomiting due to starting an antidepressant regime (venlafaxine)

Because of the diverse symptoms, I am physically, intellectually and emotionally affected with any kind of occupation.”

That is as accurate an assessment as I could give of my daily problems in such a small space, and each of my healthcare providers should be able to confirm them. I learned today that the medical service will first contact my general physician for information, which is a bit of a problem since at least 80% of my depression treatment has been done by my therapist; the general physician does get reports from my psychiatrist, but except for the fact that I have participated in the medical study he does not know anything about the psychotherapeutic treatment. I do hope they’ll get in contact with him as well – if our regular case worker had been present today, I would have asked her, but her colleague was not familiar with the protocol in such cases.

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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.

Counting Sheep In The New Bedroom

The last week has been very busy, as we attempted to put together the new-to-us wardrobe and bed. The wardrobe did not survive, however – even though still looking good, the connections between the individual parts were rather worn out already, and we not only had to dissemble it twice, but the units actually collapsed several times. In the end, so many different parts were damaged that after a day and a half we had to give up on it. We will have to make do with my old one and just improvise for the time being.
The bed was a more successful enterprise, and since Saturday we actually get to sleep in a proper bedroom as “normal” people do, not on mattresses on the floor. As my husband put it: “It feels like we moved into a completely different place!” And indeed it changed the room so profoundly that it was like going to sleep in a hotel room, not at home.

Unfortunately, right now I am in my second consecutive week of insomnia and it is getting worse – last night it was almost half past four when I glanced at the clock, and an hour later I already was awake again. The biggest problem is falling asleep, but staying asleep is becoming increasingly difficult too. I doze off just to wake up again an hour or two later, struggling once again to get some more rest.
Lack of exercise or oxygen, the sleeping position, room temperature, what and how much I eat (or not), caffeine intake… I checked all of those. I tried staying awake during the day in the hopes of being so fatigued that I would fall asleep at a normal time in the evening, not watching TV in the evening and staying away from the computer – none of it worked. In short, I ruled out everything but the obvious: depression.
Problems falling asleep are pretty much standard for me: there is hardly a night when I am awake for less than an hour before drifting off, but right now I am looking at several hours. In the past, I have had such spells of insomnia once in a while; there were times when I would go to work with no more of two or three hours of rest. So chances are that I can just ride it out until it goes away again, even though the lack of sleep does not exactly improve my cognitive capacities. I never tried sleeping pills, but right now I am awfully close to it.

Cognitive Deficits Revisited: Coca Cola Addiction

Chances are, at some point during the last few days you came across the headlines claiming a link between the consumption of soda, especially diet soda, and an increased risk of depression. The idea itself is not new and has been circulating the media before, but surfaced again this week – even though at a closer inspection there is room for scepticism.
Most of the following text I had written almost a week ago already, but not quite finished the post yet when it suddenly became a hot topic.

Some of the most persistent symptoms of the chronic major depression I suffer from fall into the category of cognitive deficits: word finding problems, temporary inability to access memories, concentration and learning difficulties, generally slowed-down thinking and speaking. There is no doubt that I have improved in all those areas over the past two years, but the progress has not always been linear. The subjectively best I felt in September 2011, when according to the BDI-II my overall depressive symptoms were in the range of 10 points and lower, a score equal of euthymia (non-depressed, reasonably positive moods). That was also the time when I experienced the least cognitive impairment, in all aforementioned categories.
The biggest differences between now and then are that in September 2011, I was not yet back at university, and I had been on a number of short trips that year, providing both recreation and intellectual stimulation. Over the course of just a few short months, my cognitive capacities had improved greatly. In 2012, it was mostly classes, homework, written exams and office appointments instead. As a result, most of the cognitive deficits made a comeback or got worse again. The only exception is access to memories, at least concerning personal history. I remember a lot more now than I did back in May 2011.
It’s a vicious circle: the depression causes cognitive deficits, and I get depressed over those cognitive deficits…

Most days, it is as if I have a cloud in my head; every brain activity appears somewhat hazy. The closest approximation I can give is that feeling when you are just about to fall asleep and your thoughts start drifting, and then you are being forced to rouse yourself and do some task. Except that for me, this sensation can last for hours and is present at any time of the day, without being tied to sleepiness. Brain fog. Mental cotton-balls. A muddy pond in your head.
The only remedy I have for this is drinking Coca Cola – there’s something about the sugar-&-caffeine-rush that clears out the clouds and suddenly makes me more alert, more concentrated, more “intelligent”. Strangely enough, coffee does not nearly have the same effect. Nor do fresh air or anything else I tried. Only cola gets me out of the sedation.

I don’t want to drink coke on a regular base. I am worried about all kinds of negative effects this might have on my health, from diabetes to cavities in my teeth to osteoporosis (the sweeteners in diet coke severely upset my digestion, so that is no option). But more and more, I do crave cola due to the effect it has on my brain and thinking abilities. Nothing else lifts the psychomotor retardation as effectively. None of the blog posts of the last months was written without either a glass of cola standing next to me or having been consumed prior to typing.
I try limiting myself to two glasses a day, one in the early and one in the late afternoon, sometimes coupled with a cup of coffee. The results are about six hours of clarity. But there is no denying that occasionally, I drink more, and that on some days, I already crave cola before breakfast.

As I was going to wrap up this post and googled “cola depression”, I came across another fascinating blog post at Evolutionary Psychiatry, discussing the case study of a woman addicted to coca cola. Until very recently, I was much more worried about the physical consequences of my cola-consumption, and while my own intake is far lower than the quantities mentioned, it does make me wonder about possible influences on my mental health.
There is something of a dilemma: Either I give up Coca Cola and experience even more psychomotor retardation, accepting that the lowered intellectual capacities will depress me even more, and deal with the coke cravings on top of it. Or I will continue drinking soda, but risk possible negative effects for my physical and mental health, in the latter case even increasing the damage my brain has already taken in twenty years of major depression.
Maybe I’m fooling myself into a false sense of security by thinking that two glasses per day are permissible. Maybe I’m fooling myself by thinking that eventually I will get rid of the fatigue and brain fog for good, consequently not needing the cola-boost anymore. Maybe I’m a fool for thinking I will be able to quit the soda eventually. All I know is, right now I will take uncertain and abstract health risks over the certainty of daily psychomotor retardation.

Being A Guest Speaker Again

Last week I was a guest at my therapist’s student class again. Unlike the first time in April, when he’d asked me weeks ahead of the event, this time it was on very short notice, less than 24 hours before the class. I gave a positive reply without hesitation. Appearances like that make me rather nervous, but I am a firm believer in doing something for the greater good. If my appearance helps students to see chronic depression as less abstract, if they can put a face on textbook knowledge, it makes me feel a little better about my own mental health history – one positive aspect among so many negative ones.

The class was about the same size and gender ratio as last time (women vastly outnumbering the men); very well-behaved and quiet. The April-group was maybe a little more engaging, but then, they had only seen one other in-patient before me. This month’s group had already met an elderly in-patient with treatment-refractory depression, a bipolar patient and a young woman with chronic depression in the very early stages of therapy. I was meant to be her counterpart, who could talk about the changes which happen when you go through psychotherapy in general and CBASP in particular.
I was with the students for 25 minutes only, so naturally we didn’t go into as much detail as last time, and focused less on my personal history and more on the importance of trust and the professional’s behaviour: that in the long run psychotherapy is more successful if time is allowed for establishing a trusting relationship between therapist and patient first. More often than not, patients battle anxiety in addition to the depression, and they are easily scared away for good if not handled carefully or not taken seriously by therapists and hospital staff.

It is rather ironic that despite my social anxiety, I am a somewhat capable public speaker. I know that you have to enunciate clearly and speak with moderate tempo, that you have to talk louder than in a normal conversation and that eye contact with the audience is important if you want to come across as competent. I have held a number of lectures in university in front of up to a hundred people, and have almost always been congratulated on my “professionalism” afterwards. But it is just a mask I wear and afterwards, I am terribly exhausted and crash, and it takes weeks to fully recover from this.
Generally speaking, I was not as worried this time around, even though there always is this phase a couple of minutes before actually getting started where I become somewhat panicky, cursing myself for saying yes and badly wishing I had avoided this situation. And I’m always afraid of “forgetting” crucial facts, of not being able to access the memories of the early treatment days properly. Fortunately for me, my therapist knows me so well by now that he can anticipate problematic situations and guide the conversation around them, or take the edge off by moderating.

The chart of my depression indices was shown again – I noticed that this time, it had the title of an article printed on the bottom, stating it was “in press”. (For those who are not familiar with the rules of scientific writing: an article being “in press” means it has been accepted by a journal for publication, but has not been printed yet at the time being.) From the very beginning I had known that my anonymised data would get published sooner or later, and in the beginning I was itching with curiosity. Now that I had stopped thinking about it altogether, that silent announcement took me somewhat by surprise.
I can’t help but wonder whether this obsession about the article in the early days had something to do with the urge to chronicle my own life, as mentioned in my last blog post. As if my own thoughts and ideas and feelings about the topic don’t count if I can’t back them up with written proof.

Just A Quick Update

I’m still alive, but very busy. Lectures at university started again – not that I had a lot of free time during the “break”. I attended an extracurricular class in zoology and passed the exam for that, and I didn’t pass the second attempt of physics because I was just too burned out and my brain didn’t cooperate at all. As a result, I opted out of taking maths again.
Currently, I’m writing a report on the field trip I took in February; the text is as good as done, but I still have to put in pictures and so on.

Then, of course, I got married and had a lot of family drama going down the day before the wedding, all of which deserves a dedicated post.

Finally, my therapist invited me to join a class for psychology students next week – as a “living exhibit”. They’ll present my data, including the clinical tests I took (the results of which I’ve never been told), and I’ll be there to answer questions. Bring the person to life, I guess, because according to my therapist, most of these students have no real idea of what it is like to be depressed and what it is like to undergo CBASP therapy. Besides the scientific data, I can provide insight into all of that. Strangely enough, I’m looking forward to this.

On Discomfort & Comforts

After the drama at the beginning of the week, I had to pull myself together for the crystallography exam – successfully enough for passing. The results were in after 24 hours and thus I know that despite waking up to my head spinning with vertigo and my dysfunctional memory, I put that class behind me for good. The results for physics and mathematics still haven’t been put online, so in that regard I’m still biting my nails.

Friday and Saturday I was on an excursion to local sites of geological interest. Since most of the geological outcrops didn’t offer enough space for huge crowds, we got divided into groups of twenty-something people, and each group had slightly different routes and sites to visit. Our guide was very nice, but unfortunately his tempo was so insanely fast that a few of us got close to a physical breakdown. My metabolism is very slow (as a result of both depression and Hashimoto’s) and soon my head started spinning with vertigo. Another girl had an asthma attack, and together with others we soon fell behind. After realizing the effect this had on us, our guide apologized and promised to slow down, but we still kept lagging behind, desperately panting uphill hour after hour. At one point, about ten minutes before reaching the highest peak of the day, I paused and stared into the forest stretching below me, thinking: “Why couldn’t you pick a different subject? Something where you do not have to go on field trips…”
The only thing which kept me going was that we were in the middle of a nature reserve and thus the only way “back to civilization” was to continue walking.
The second day saw us climbing up a mountain through vineyards; not nearly as long a walk as the day before, but so steep that we had to clutch onto the wires for the vines and descend sidewards to prevent falling down the cliff-like slope. In the early afternoon I had to admit defeat because of a black-and-blue toenail – I simply could not walk properly anymore due to the pain. I’ll have to wear open shoes for the next days – very inconvenient, since the weather is rather wet, but that is the only way I can walk without a severe limp – and somewhat embarrassing. I will be rather self-conscious about it tomorrow, but it is my only option.

The best aspect of those two days was coming home to someone. I got served dinner and could rest my legs on my boyfriend’s lap while he massaged my sore feet (and legs and back). Even though most of my body hurt, I actually felt pampered.
He helps me staying in the present, to not worry about the future or think about the past so much. He comforts me emotionally and mentally. I think I wrote in an earlier post already that my idea of happiness is spending an evening on the sofa with him – it might sound utterly boring, but I really enjoy this very dullness. There is enough drama in my life and I am grateful about every time I can just wind down and bask in the warmth of our shared life together.

Finances, Fear, Family, Frustration

I’ve been in financial trouble lately, culminating in a letter threatening to turn off my gas and electricity if I didn’t pay within the next few days. It came as a really unpleasant surprise, because I was under the impression that I had already paid all I owed last month, but apparently had been mistaken. My boyfriend was able to cover for that and so we’ll continue having warm water and heating, but it still weighs down on me. My mother barks at me that I have to quit university and get a job, my therapist tells me it’s of utmost importance that I finish university, as does my boyfriend… I’m tired of being stuck in the hamster wheel, tired of the perpetual financial strains.

And I feel guilty because I do not have the stamina for handling both a job and uni. I can’t even hold up university alone…

Last week I saw my therapist for a few minutes because he had to give me a doctor’s note so I’d get out of the second attempt of the chemistry exam. He puts a lot of emphasis on the fact that I learn to put up boundaries towards other people and learn to defend myself so I can actually do what I need to make myself feel good. Which is a lot easier said than done, especially since my brain just “empties” under stress and I become completely speechless, in the very sense of the word. It is a reaction to the cortisol surge one experiences under stress: long-term exposure to this stress hormone damages the brain cells in the hippocampus, which results in memory problems, and it also impairs retrieval of already stored information.
This morning, I was crying after receiving the letter from the energy supplier, and despite my boyfriend asking me to talk to him and say something, I just was not able to. I could not form a coherent sentence, neither in English nor in German. Even now, it is difficult to describe what is going on in me in these situations – one should assume that once the problem is taken care of, everything is alright. And my boyfriend echoed what my therapist tells me as well, that I have to stay in the present and not make this about everything that went wrong in my life, but I am not always able to do that immediately. The fear and despair can be faster than any rational thought.

Money is not the only source of stress – there also are the uni exams, of course, family situations, and the fact that the bureaucratic process for our marriage is very frustrating. I had to hand in a statement from my parents that they supported me financially, which got “lost” – even though I handed it in, it never arrived at its destination. Then I brought a second copy of the statement, only to be told that I had to re-write it. It is almost ridiculous that my boyfriend’s American documents are all fine, but my German documents create all kinds of problems…

Defeats & Successes

The week started really badly. I had a confrontation with my mother once again. Or rather, she confronted me, and I stood there, thinking, “Defend yourself! Say something! Don’t let her treat you this way!” But I opened and closed my mouth a couple of times and nothing came out of it. Just stood there like a deer in headlights.
The topics weren’t new either: that I should give up university and get a cleaning job, that I’m ruining the family, that it’s been thirteen years now since I left school and still had not finished university yet, etc. Same old accusations, but they still sting, and I literally cried at my boyfriend’s shoulder.
I have never uttered a word of blame towards my parents, because that is not going to change anything about the position I am in, but sometimes I just want to yell at her that I would not be where I am today if she had not contributed to it, and that her behaviour is very counterproductive. I am not going to become “less of a problem” for my parents if I have to constantly fight battles on the side – getting through university is difficult enough as it is.
Just hours before that, I had a therapy session and it was the first one after over a year in which I felt truly uncomfortable. Not because my therapist was displaying a negative attitude towards me; the negativity came from inside me, because I was projecting my mother’s attitude on him, but I only realized that later.

However, he will sign me sick for the upcoming second attempts in chemistry (and crystallography if I want that), because I still am having cognitive problems. I did sit the physics exams today and during the first half of it my brain was really slow and on the verge of going blank, but I didn’t freak out and just tried the best I could. Not so sure about the result, I would say the chances for passing equal those for failing, but at the very least I got an idea of the requirements now.
But, I did pass the palaeontology/micropalaeontology test and got a placement in the zoology class. They did not publish the grades, so I have no idea how I ranked relative to the other students, but at least it was high enough to get into the class.