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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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.

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.

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.

Conquering The Valley Of The Dustbunnies

From September to November, I spent a lot of time decluttering my flat, especially the bedroom. But once I made the deadline for the bulky trash collection, my enthusiasm and energy dwindled, and I did not get back at the task for the entire month of December. And now it was another deadline of sorts which got me moving again: my sister bought a new bed and I “inherited” the old one.
I had never before owned a bed big enough for two people to sleep in, and so my husband and I had no other choice but putting our mattresses on the floor – buying one of our own simply exceeded our budget. In the beginning, we joked about camping on the floor, but after a while it got really old, especially since our mattresses are of different heights. A friend offered us her bed when she gave up a rented studio, and at first I accepted – but the problem with the mismatching mattresses, the difficulty transporting it home (my car’s boot / trunk was already permanently locked then), lack of time due to uni projects, and rising depression spoilt the plan.
We spent two days emptying all bookshelves in the bedroom and dissembling the ones which were mounted on the wall above where my desk used to stand. We moved the freestanding shelves to that wall, cleaned them and put the books I want to keep back. Since there will be no replacement for the wall-mounted units, the archaeology, geosciences and geography books  will have their place in the living room from now on.

There is a sense of accomplishment which comes with having your books sitting neatly in clean shelves; especially if it has taken you years to get that far. My husband is a much faster worker, which is rather frustrating because it makes me feel so inferior, but I insist on handling certain things alone, even if that means it will take significantly longer to get everything done. I still have to sort through every single item and arrive at a decision whether to keep it or not, and where to store the pieces which do not end up in trash. Making that decision itself has become easier, though – it is not nearly as agonising anymore as it used to be just a few months ago. Partly that might be simply due to there being fewer and fewer possessions left which are still “unexamined” at this point, partly because I have experienced that discarding them only hurts temporarily.
My method may not be the most effective or stringent, but it is the only one that works for me, and I am almost done with the bedroom. I think from next weekend on, we can sleep in our new bed; my husband is really eager for this to happen and I certainly feel the same way. However, I want to make sure that I have gone through every last item before we move on, because I know from experience that stuff left for “later” will still be around after years. Then, I want to give the room a thorough cleaning, because once all the heavy furniture are up, certain areas will become as good as inaccessible. And, final reason, I have a therapy session on Thursday, which means that a) I am going to be out most of that day thanks to much longer commuting times without a car, and b) I will most likely want some time for reflection afterwards. But the weekend should be a realistic goal.

Fun Facts:
The most common finds in my bedroom were bobby pins (just how many can a single person lose over the years?), literally thousands of paper pieces – notes from class, drafts for letters or uni papers, transcribed poems, cash receipts etc. – and a wild assortment of pens and pencils.
The most unusual find so far was a kitchen knife in one of my handbags, the blade carefully wrapped in paper towel fixated with sticky tape – must be a leftover of some brunch we had at work, or a long-ago Christmas party or something in that direction.

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.