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…

The Status Quo: March 2013

1.) Long dark winter: Germany experiences an average of 160 hours of sunshine in the period defined as the meteorological winter – December, January, February. This year, we stayed well below the statistical mean with only 96 hours of sunshine in those three months, and I certainly felt it. Day after day of dreary grey; snow and rain and drizzle and sleet. I can cope with periods of bad weather, but this winter does not seem to end.
All of a sudden, there was a spring intermezzo last week. The sun came out and we had a few nice days in a row – only to go back to freezing temperatures and snow.

2.) The welfare process still makes no progress: The only thing missing is my therapist’s statement, so I could go back and officially apply. The psychologist couldn’t tell how long it’s going to take; when I asked her, she said, “it’s difficult”. I feel awful for even having to bother him (and her) about this, but unless someone’s going to donate me money to tide over the months until he can work again, what am I supposed to do? I wish I didn’t have to ask for that and could just let him recover…

3.) I still miss having a car: The supermarket closest to home is about ten minutes away by foot, but is too expensive for me to shop there regularly. The one I used to like best and frequented the most is about 30 – 40 minutes away by foot – one trip. So just the physical act of getting there and back takes at least an hour. Not to mention the physical limitations of how much I can carry; a few times I had to call my husband to meet me halfway because I had underestimated the combined weight of all articles. Sometimes I take the shopping trolley, but that is tedious and brings its own problems, like when the tram was so full that I couldn’t enter it with the trolley, leaving me with no choice but to wait for the next tram in the cold.
Last week, I borrowed my sister’s old bike for shopping (I don’t have one of my own anymore since selling it for making some money), but discovered that while I could get to my destination in about half the time, it really did not make much of a difference regarding how much I could bring home. Also, for at least ten years prior to this, I had ridden a bike exclusively when on vacations at the North Sea – in a car-free environment. I got so scared on my way to the supermarket that I rode on the sidewalk for about half the distance… On top of everything else, the bike is actually too small for me, so that I cannot stretch my legs properly, and I found the whole process actually more exhausting than walking the distance.

4.) The insomnia is under control: I still have problems falling asleep, but at least it’s restful slumber once I dozed off. No more waking up every hour.

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.

Staying Up All Night

Last night I broke my personal record for insomnia by falling asleep at 7.15 AM only, after my husband had left for class. Needless to say that aside from being immensely tired, I was also extremely distraught emotionally. Fortunately, I did not post the blog entry I had started writing, because it connected only marginally with the reality of my everyday life and was otherwise observed through the lense of nighttime pessimism.
Unfortunately, that means I also missed the time-window for calling the psychiatrist. The practice had been closed over the last few days because of carnival, and today they were only open in the morning… Will have to try tomorrow again, when they also open in the afternoon.
After I had finally drifted off, I dreamt that my therapist had done a new assessment questionnaire with me, and my results exceeded 100% in some categories. “That’s great,” he exclaimed, “now we finally know which parts of your brain we can cut out!”

A Bad Day

And I do mean bad: not-sleeping-until-5-AM-and-crying-after-waking-up-bad. I have been talking to my therapist about starting antidepressants again; even though he is also a psychiatrist, he must not treat me as such because legally therapy is “aftercare” for the clinical trial I was part of, and he is only allowed to see me as a CBASP therapist. With the kind of health insurance I have, I cannot see him as a regular patient, and I don’t have the money to cross over to his regular patient pool.
He said the antidepressants will not be able to replace the psychotherapeutic work (which I did not mean to do anyway), but might be able to aid it. He also recommended a psychiatrist to me, which makes things a lot easier as I do not have to do research and worry about whether I made a good choice or not.

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.

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.