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.

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.

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.

Panic Attack

Last night I suffered an anxiety/panic attack over the upcoming exam. I saw it coming in the afternoon already, but tried to ignore it – not that ignoring the early signs did much good. Around 1 o’ clock in the morning I started crying and woke up my boyfriend, who tried calming me down and get me to sleep. When I finally drifted off, I had very unpleasant dreams and woke rather early, being completely cramped – my left hand was so tightly clenched that I had to open my fingers with the other hand.
I’ve also had increasing cognitive problems over the last days, with the ability to memorize going downhill really fast, word-finding problems and slowed speech. All very familiar symptoms, but it is scary how fast they can come back once I am really stressed out. So I emailed my therapist about this and he wrote back that the panic attack is enough for him to give me a doctor’s note which will allow me to not participate in tomorrow’s exam, so that unlike on Tuesday I won’t lose one of the precious three attempts. I see him briefly tomorrow morning, and for Monday I had a regular appointment scheduled anyway.

I think I probably overestimated my mental capacities and, trying to cram as many facts into my head as possible, eventually buckled under the pressure. I guess I should only have registered for two exams in the first place…

The Year Of The Living Dead

Usually, I write here for two reasons: 1. to chronicle the progress of  therapy; 2. to purge my mind from thoughts I can’t let go. Today, I write to remind myself of how far I’ve already come, because my newly acquired stress-regulating abilities really get put to the test by a family crisis. I’m trying my best to not let it influence me any more than absolutely necessary, and to concentrate on doing what’s helping me, which takes a lot of effort: I’m still in the process of learning how NOT to worry constantly about problems.

On Monday, one of my former co-workers gave a farewell party where I saw a colleague who had not been part of the meeting two weeks ago. We had known each other since June last year, when I was at my lowest, and this had been the first contact since early March. She asked, “Have you been on holidays?” I shook my head. “Well, you look like someone put new batteries into you.”

Mentioning this might sound vain to some and trivial to others, but little moments like this are what keeps me going when everyday life is more difficult than usually. Especially since this is not my therapist, who is trained to pay attention to this, or a friend trying to encourage me (not that I don’t value their respective opinions), but a spontaneous compliment that tells me I REALLY must be going somewhere if it starts penetrating my appearance even.

This particular colleague has only known me at my worst, and while I can’t tell the difference since I see myself in the mirror every day and the change is too gradual to notice that way, I have a very good idea of what depression does to people’s looks. Every time I’m at the hospital, I see the in-patients dragging themselves through the hallway: sallow skin, dark circles under their eyes and dull hair; with faces so utterly devoid of joy as if they had never laughed in their life.

A year ago, I was very close to this. It didn’t quite get to the point where I stopped showering (even though taking a shower was very exhausting), but anything beyond that was too much effort. I didn’t care that my haircut grew out or what clothes I wore, and if I did, it was too much effort to change anything about it.
For a native German, I have a rather tanned complexion, so that I get mistaken for mediterranean somewhat regularly, but even my skin became grey and lifeless, not to mention that the psychomotor retardation had more or less petrified me, wiped the facial expressions away.
I must have resembled those people at the hospital considerably, and when I look into the mirror now, there is a person who appears to be a lot more alive and lively. A person who pays attention to her outfit, who started wearing jewellery again, who tries to make an effort with her hair. And I’m not going to let this person go down the drain again.

Help, Where’s The Manual On “Normal” Behaviour?

At 2.30 AM last night, I found myself on the phone with the psychiatric ambulance of the hospital where I’m getting treated as an out-patient, and I’m still struggling to put into words what exactly has happened.

As mentioned in my last entry, I already had a strange urge to move yesterday, and last night the psychomotor retardation suddenly fell away completely. I had gone to bed relatively early, but couldn’t sleep, yet the later it got, the stronger the urge to go outside for a walk became. First I rocked a bit back and forth in my bed, then I got up and started walking around in my flat. It wasn’t agitation, though, I just felt – for the first time in years – like I had more energy at my disposal than I was using. My brain suddenly felt like someone had flipped a switch and I went from stand-by into active mode, and with it a flood a memories washed over me that had not been on my mind for years, some of which made me cry.

It scared the living daylights out of me. I was completely clueless on how to behave, what to do. I have no idea at all what it is like to not be depressed, and facing terra incognita in the wee hours of the morning became a little too intense, so I called the hospital, got connected to the wrong doctor first, and then felt utterly foolish when talking to the psychiatrist on duty. What was I supposed to say? “I’m not feeling depressed, please help me” ?

There wasn’t much she could tell me – I have no sleeping medication in the house since for years the problem had been sleeping too much – but the assurance that what I felt was not out of the ordinary and in fact part of the process already helped. She suggested taking a shower for calming down, which actually relaxed me enough to fall asleep around 4 AM (the first birds were already singing outside), even though I kept tossing and turning and woke up several times. So most of today I was really tired and thus back in familiar territory, not scared anymore.

My therapist, whom I had emailed after the phone call, wrote back this morning with the reassurance that everything was just the way it’s supposed to be and that it’s normal to be scared when the brain switches over to proactive thinking.

This afternoon I had another spell where I just wanted to go outside and walk, so I did just that and it felt really good – like I would never tire if I just kept going. I went quite a bit further than I had originally planned to, but returned home after an hour.

What threw me off, I believe, is that for all of my adult life (and adolescence) I have always fought into a certain direction, always against the same enemy. Last night, I suddenly did not go into my default reaction as every single time before, and subsequently was rendered absolutely clueless, with no orientation at all. Like a stranger to myself.

Hugging Thin Air

Doing better again – the “beached whale” feeling is gone and my legs don’t hurt all the time either: I checked a book on meditation out of the library – something I wanted to try out for a long time, to learn disconnecting from the worrying thoughts. I haven’t actually managed to empty my mind yet, because every time I sit down, the urge to scratch fifteen different parts of my body at once arises, but I will hopefully get there eventually. The book also contains exercises on physical relaxation and they have been very helpful already, hence the improvement of the muscle pain.

I don’t believe sports or meditation or yoga and the likes can prevent or heal depression, else I wouldn’t have started one of the biggest crashs of my life when I was just going through the most extensive sports programme I’ve ever done. An episode of major depression is too forceful to come to a halt just because of that. However, I do believe that it can support you in dealing with side effects and soften the blow a little.

As I was walking outside today, I felt a sudden urge to wave my arms around in the wind. An urge to move. I didn’t really act on it out of fear the people looking at me flailing my arms would think I had lost my marbles, but it made me wonder whether my body is “waking up” from the petrification  of chronic depression, too.