The First Day On Venlafaxine

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

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

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

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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.

Pre-Treatment Diary

Since it’s been almost exactly a year since my first psychotherapeutic session (the anniversary will be on Tuesday), I added a new section to the blog, a “Pre-Treatment Diary“. Originally a collection of messages written for a group of friends, it gives some insight into the process of seeking help, the side-effects citalopram had on me, how my moods kept crashing time and again as well as various clinical tests, interviews and my first MRi-scan at the hospital… Unfortunately, I lacked the energy to describe those first CBASP sessions in greater detail –  something I rather regret now – but it helps giving a more complete picture of my recovery process prior to the existence of this blog.

Last Session Of The Year

Last therapy session of the year; the next one is on Friday the 13th (January 2012), to which my mum will accompany me. Apparently, my regular therapy is also coming to a close – I’ve had 31 sessions so far and if I recall correctly, that means only 4 more in the normal rhythm before drawing them out. Not sure about the time periods between them, but I do know that session 40 is definitely my last one. I’ll part with a laughing and a crying eye: laughing because my life improved so vastly, crying because I will be sorry to say goodbye to my therapist for good. The whole purpose of our relationship was that it would end again eventually, but I’ve grown fond of him… but, I guess that’s a bridge I’ll cross when I get to it.

We took a look at my uni schedule today, trying to find out what I can eliminate – all contact hours, homework and commuting time added up, I had a 50-hour-week and a BDI-II score of 20, with a tendency for the worse. Friday was crossed off the list completely and I’m supposed to figure out what I can do without until I reach a point where the work load does not push me into a depression anymore.
“We are pulling the emergency brake now,” my therapist said. “And if it gets too much,” he smiled, “just scratch another class off the list and go to the cinema instead.”
Eliminating classes wasn’t the problem, I didn’t need help for that. The huge difference is that if my therapist “allows” me to take it easier, I feel like I’m actually doing something pro-active and taking care of myself, whereas without discussing it in therapy, I’d have suffered from a bad conscience and felt like I was only procrastinating. That’s clearly something I still need to learn during our remaining time together: that I have a right to take care of myself and that I’m allowed to set limits.
A job is only possible in summer, because I’m going to have exams and an “en bloc” course and an excursion (probably followed by another protocol) during the upcoming semester break, and during the second semester my situation will hardly be any different…

Our roleplaying exercises were a little different today: not the usual dialogues acted out, but instead my therapist challenged me to defend my position. After I told him that I preferred learning at home over learning at the library, for example, he said: “Convince me! Why should I believe you are learning more effectively at home?” So I listed my reasons – that I felt more relaxed at home and could concentrate better because I wasn’t constantly aware of the people around me, that I didn’t have to watch my stuff if I walked out of sight of the desk, that I had more freedom on when I wanted to learn…
Later he made me stand up while he remained seated (a position I hate, because it causes me to feel vastly overweight – even though he doesn’t get that impression and it exists in my head only) and voice the effects the depression has on me as if talking to my mother: “I have troubles falling asleep and wake up in the night; the muscles in my arms and legs hurt, my joints too. I have headaches and backaches and stomachaches. My eyes are inflamed and hurt and I can’t always see properly because of that. I can’t concentrate very well either and doing my homework gets really difficult because of that. There are cognitive problems which make me forget words and sometimes I don’t even understand my homework anymore because of this.”
Only when looking back I realize I listed exclusively physical symptoms, but didn’t mention the sadness, crying and despair descending upon me. Had I spoken to my therapist directly instead of him acting as a proxy for my mother, I would probably have mentioned this, but since we hardly ever discuss intimate feelings in my family, I didn’t speak about this in therapy either.

One aspect I forgot about and which my therapist highlighted today was exercise. There is no room in my current schedule for any kind of physical activity. He described a scientific experiment to me, in which hamsters had been exposed to stress over a long time, leading to the hamsters becoming depressed. The source of stress was removed then and the hamsters got divided in three groups: group A had a nice cage, plenty of food and social contacts; group B a nice cage and plenty of food; group C a nice cage, plenty of food and an ergometer. Everyone suspected group A to show the fastest recovery rates, but in fact it was group C which was the most successful within the given time frame…
Exercise is supposed to be light and fun – no pressure to achieve any results, but regular periods of physical movement. I certainly remember how beneficial my Tae Bo classes were, even though I have nowhere near the energy for that now. But I’ll try to reserve a fixed time for swimming or cycling or something like that.

Physical Side-Effects of Depression

In the therapy sessions, we usually concentrate on the emotional and behavioural aspects of depression, since this is the area where we can work on change. The physical side-effects of depression, which used to even eclipse the emotional pain quite often, will go away too when the depression vanishes.
For a long time, however, I wasn’t aware that these two aspects – mental/emotional well-being and physical pain – were so closely related. I blamed my thyroid and the Hashimoto’s disease for feeling fatigued and for the memory problems I was experiencing, even if the lab results showed that my medication was perfectly adjusted. For all the other complaints, I saw three doctors in total who all diagnosed me with a variety of conditions which usually matched the most recent physical manifestations, but always ignored the full picture. Nobody suspected depression before I started having panic attacks, and even though I personally suspected a mental health problem earlier, all the symptom lists for depression I checked mentioned weight loss and sleeplessness, while I was (am) clearly overweight and slept much more than the average person: I always dismissed the self-diagnosis again on these grounds. Only at the hospital I learned that in chronic depression, weight gain and hypersomnia can occur too, as well as many other symptoms.

Today, I wanted to take inventory of the physical side-effects which one would not necessarily relate to depression and which I experienced over the course of the years.

Permanent or frequent complaints:

• Muscle pain in the limbs: I’m not entirely sure when this started, but by spring 2009, I very often had severe pains in the muscles and nerves of my arms and legs. Sometimes it would feel like a “tennis arm”, sometimes like the kind of muscle cramps you get when over-exercising. I combatted the pain with ibuprofen, paracetamol or aspirin, which brought relief for a few hours.
  My second general physician diagnosed me with multiple sclerosis because of it.
  When I was put on an antidepressant in summer 2011, the pain went away after only four days. It returned after I discontinued citalopram; my therapist was the first person who told me that it was stress-related and caused by an inability to relax. Ever since, I lie down and try to consciously relax all of my body whenever I feel the pain. With the progress in therapy, the days when my limbs hurt become fewer and fewer.

• Inflammation of the eyeballs: This symptom first occurred in spring 2009 too, when my eyes became red, dry and sensitive to light. In the beginning, the intensity would be sometimes less, sometimes worse, but last year, it was permanent.
  My first general practitioner diagnosed it as hay fever – never mind that weather or seasonal changes had no influence on it at all. My sister and niece both have hay fever, so I am rather familiar with its symptoms, and I was very certain that the inflammation of my eyes was not allergy-related. The next doctor saw it as a symptom of MS, together with the muscle pain.
  As with the muscle pain, the inflammation vanished when I started to take citalopram and returned afterwards. Recently, the inflammation had come back, but as I try to counteract the stress, it gets a little better every day.

• Headaches: I used to have headaches very frequently; up to four or five times a week during the most intense periods. The most common form was a consistent, one-sided pain directly behind the eye, as if someone was relentlessly poking me into the eyeball from behind. In 70% of all cases, the left side was concerned. Rarely (once every couple of years), I will also have a case of migraines, when I can’t tolerate light and sound and have to lie down in a dark, quiet room with a wet cloth on my face.
  The headaches started very early, during my teenage years already, and currently occur on about two or three days per month.

• Digestive problems: Another group of symptoms that I had since adolescence – stomach aches / cramps, diarrhoea, a couple of episodes when I couldn’t eat anything but apples and plain rice, one episode of histamine intolerance that vanished after two weeks. Now I experience those problems about 2 – 3 times per month, but during the worst of it, that would be 4 – 5 times per week, for months on end.

• Backaches: For about twenty years, I used to have “typical” complaints like tense muscles around the shoulder and back of my neck, but in recent years, there have also been intense phases of lower back pain. The latter first occured early in 2008, about two weeks after I had started a new job that pushed me to the limit in regards to social anxiety. I didn’t make the connection back then, but in retrospect, it seems very clear that the job and the new type of backaches were related.

Infrequent or singular complaints:

• Vertigo: One morning in 2007, I woke up with such a heavy case of vertigo that I literally couldn’t get out of bed. Lifting my head alone brought such waves of nausea that I had to vomit. It took three days until I could leave the house and see a doctor for it, who was clueless and referred me to a specialist. I had my ears and head checked, especially the sense of equilibrium, but everything was fine. They sent me home, “If it happens again, come back.” So far, there has been no second episode of unexplainable vertigo.

• Chest cramps: This is a strange one. The first experience was the night after I celebrated my 18^th birthday with a party; I woke up in the wee hours of the morning with a feeling as if my stomach was starting to petrify. Since then, I have spells when it happens a couple of days in a row, just to stop again just as suddenly for about half a year.
  Very often, the cramps come at night and I wake up from the pain, but sometimes they can also occur during the day: the muscles around my stomach become hard and cramp; a very intense ache that I feel under the sternum and in the middle of my back. Sometimes, I can sense the muscles there going tense a few hours before the actual cramping, but usually it happens within minutes only.
  Heat helps as it relaxes the muscles. At my most desperate, I had hot water bottles on both chest and back and was drinking hot water to relax the muscles from inside as well, because the pain can get so intense that I can hardly stand upright anymore and feel like opening my chest with a knife just so I can reach under the sternum and massage the muscle.
  Some people have suggested that it might be heartburn, but it feels completely different and is not inside the oesophagus or stomach, but very clearly outside of it.
  It appears that the chest cramps have become less intense and more infrequent, but is too early for making a definite call still: I had episodes of up to nine months without them and experienced some chest cramps this spring, so it will need at the very least a year without them before I consider them gone.

Painful Reminders

For the past two days, my eyes and legs hurt. There could be many reasons for it: the long stressful drive home on Thursday – I’m the only driver in my family and nobody can take over. The change of climate. Having my period. Or a symptom of my depression that comes and goes since I started therapy.

Beginning in spring 2008, I suffered from inflamed eyeballs and increasing muscle pain in the limbs. At first, it was moderate only, but grew more intense as the months went by, causing a doctor to (wrongly) diagnose me with multiple sclerosis.
Only after I had a few panic attacks in June 2010 and was put on citalopram by a different doctor, the ache and inflammation vanished when previously I had taken painkillers on five days out of a week to find relief for a couple of hours.

That is the main credit I will give to being on an antidepressant: that it took the pain away relatively quickly and (for the duration of being medicated) permanently. Mood-wise, it did not change a lot, and so I was not sad when I had to wean myself off before starting therapy in December.

I know that medication is very beneficial for a lot of people and am far from condemning it, but the popular stance of “it is only a chemical imbalance of the brain and a few pills will fix you” certainly does not hit the nail for me. Even if I get occasionally re-visited by the physical pain, the citalopram came with its own set of side-effects: nausea, vertigo, sleepiness, nightmares and something called “brain zaps”. If you’ve never experienced them, they probably are hard to imagine – basically, the sensation is like electrical impulses travelling over your brain, which for me felt like bubbles rising in carbonated water, trying to escape a bottle you just opened. They started at the bottom of my brain just behind the eyes and would crawl all the way up to the top of it, rising just under the highest point of my skull.
Brain zaps don’t hurt (well, at least to me they did not), but they do not feel like anything else I ever experienced and in the beginning they were really scary because I did not know what was happening. Each zap lasted about two to three seconds and during that time, I had to stop whatever I was doing, even if only walking, and wait until the sensation faded. Only when I started to look for online information on why my brain started shivering, I came across this term and understood that I was not alone with it.
If I recall correctly, I had the first brain zap on the third day after getting on medication and they lasted for a couple of weeks until I had reached the therapeutic dosage and gotten used to it. Rapid eye movement could trigger them, but they also came spontaneously. When I discontinued citalopram, the same happened again, but since late December I haven’t had any brain zap at all.

The brain zaps were curious rather than inconveniencing for me, though, but there were other side-effects that lasted far longer which I could not tolerate. The depression led to hypersomnia in me, excessive sleeping, but instead of giving me more energy, citalopram made me so tired that I needed several (sic) naps each day and still slept twelve hours at night. I would get so tired that I almost collapsed on my bed, and the extremely vivid dreams I experienced from the drug often turned into tormenting nightmares.

Another lasting side-effect that never went away during the half-year was that citalopram completely neutered me. It erased any physical, mental or emotional sexual response – in other words, it turned me completely asexual. The mental and emotional parts started to recover after about three months, but physically I remained completely unexcitable. It would have put a huge strain on a partnership had I not been single then, but even so it was hard to bear because I constantly wondered if I’d ever go back to “fully functional” afterwards. I did, but it reduced my willingness to take antidepressants a lot.

Of course, others might not experience the same. Chances are they wouldn’t. No two people are the same. A different drug might have worked better for me. But given the choice between drugs and therapy, I’d always go for therapy first after the good experiences I made with it: it takes a little longer to get started and in the beginning it might make you feel worse instead of better because you start “poking” a lot of sore spots, but even if I got out of a session without having experienced an epiphany, at some point during the following days there would come up a situation where the previous sessions suddenly allowed me to understand better and take a different approach.

So therapy has made me feel emotionally better and it even gave me a little more energy, though I’m still not on “normal” levels. Most of the time, I’m pain-free, but once in a while it comes back when I am going through a more difficult phase than usual. For example, if I argue with my mother, I will feel the stings radiating from my fingers into the arms as we are still speaking. Given that I still have a couple of problems without solutions in my life, the duller aches in my thighs and the dry, itching eyes are like a silent reminder that even though I’ve already come so far, I cannot lean back yet.