Nope. Not happening.

I had an appointment with my psychiatrist today, and it hasn’t resulted in any great change; we’re upping the mirtazapine to 45mg nightly to try and counteract recent struggles with lethargy, but that’s it. And that’s my choice – once again my doc was pushing for ECT, but I held firm on refusing it. I don’t think it’s unreasonable to be wary of the potential cognitive problems ECT can cause, and either way it would be more of an ordeal than the ketamine-infusion therapy was.

So far the holiday blues haven’t hit, and I’m very grateful for this. It has definitely helped being given a hospital appointment on Christmas Eve, suspending the feel of the holiday until a few hours before the 25th. Fingers crossed the current stability holds.

I wish all my readers a very Merry Christmas, and I sincerely hope it can be a happy time for as many of you as possible. It can hurt so much, knowing that you’re seemingly not able to enjoy it like the people around you. Knowing that you’re flat or low on the ‘happiest day of the year’. But also know that you’re not alone in this, in spirit at least. That’s what I’m going to do.

Merry Christmas

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Embrace the fire

I sit here poised to write this post not quite knowing what the contents will be. And yet at the same time, I know beyond a doubt that I need to write something. It’s like there’s a huge blob in front of me, jumping up and down while waving flashing signs, but the words are too blurry for me to make out.

Let’s start with how I feel. I feel…weird. I know I’m too drugged up; illness alone can’t account for how much time I need to spend asleep at the moment. It’s ridiculous, but probably not surprising when you combine mirtazapine (Remeron) and tramadol. I sleep in until late morning, need an afternoon nap, and then go to bed around 9pm. I’d go to bed earlier if I thought no one would notice.

Mentally I feel weird too. Very weird. I think that without lithium, I’d be angry, and ironically it’s frustrating that I can’t feel that. Like a blocked pipe; I’m just getting drips. But I have to keep reminding myself that lithium is also keeping me alive. Brain dead, but breathing.

Today I saw my old GP’s car parked outside the surgery (I notice these things), and it hurt. At least, I think it did. I do miss him, and I felt something unpleasant, but it was watered down enough that I can’t be sure. Or lithium-ed down, if that can be a word. Once someone I cared about/trusted leaves, I need them completely gone from my life. For some reason I’m very black and white about it, so once my GP retired he was GONE, in capitals. Forever. It’s uncomfortable when life doesn’t follow my absolutes.

I also realise I could walk away from therapy right now. I say that a lot, and it’s not often true, but today it really is. It’s a statement about trust. And a statement about giving up on ‘hope’. Finally. Now that my psychiatrist has mentioned ECT I feel like we’ve come to the end of the medical road, as I’ve always imagined that would be the last resort. That leaves therapy. And after 2.5 years, where are we? I’m more ‘fluent’ (I filter faster). I understand more about why I am the way I am. I value these changes, genuinely. I just don’t see a conversion to life-change, past, present or future.

Last time I lost all hope I tried to commit suicide for the second time. When all the doors are shut (because there’s nothing you want behind them) the logical thing to do is End. It’s annoying I can’t naturally die of it; I certainly feel like I should have by now. If I think about it, it’s quite tempting to stop taking my meds, or at least the lithium. It isn’t removing darkness; it’s just taking the fire out of my ability to act on it. Makes me think of machines making a heart pump and lungs breathe when the body is really already dead.

I could let depression reach it’s conclusion. By all means tell me that I’m not my illness, but this partner isn’t ever going to let go.

I can’t tell you how tempting this is. Stop meds, and embrace the fire.

The uneasy middleground

Despite my self-reminder yesterday, I was still surprised by how strong 7.5mg mirtazapine (Remeron) is. I swallowed, and about 10/15 minutes later I felt extremely tired. I then slept like the dead. This is with only half of a pill. I don’t feel terribly tired today, but I was able to sleep in until about 11am. Tomorrow I have to get up early to go and puppy-sit, so that’ll be a better test of how long the drowsiness lasts.

The extreme-sounding suggestions from the psychiatrist yesterday are continuing to play on my mind, and the more I hear about it, the more I come to think ECT is something I really don’t want to have. I’ll keep researching both ECT and ketamine-infusion, but I do wonder if they’re both a step too far.

If my regular GP hadn’t retired, I’d ask him. Sad times. I don’t feel like I can discuss this with Dr T, who’ll be back from his six week holiday in a fortnight. He’s pretty anti medicine, so I’ve been filtering out that side of my treatment for a long time. He has even phoned up my GP to suggest taking me off meds altogether (without telling me). I have no doubt he’d have a negative reaction to what my psychiatrist has said, but then again, I expect he’d react the same if she’d said I should have more vitamins or something minor like that! This is one of the reasons my GP was so valuable; he sat in a perfect middle ground between medicine and talking therapy – he could see and appreciate the merits of both, with no vested interest himself. Dr T didn’t believe that, but I’m pretty sure of Dr T’s bias from what I’ve heard from another of his patients. 

It is hard to find a balanced view, when most of the medical professionals sit pretty firmly in one camp or the other. Of course Dr T is going to largely disregard meds in favour of therapy given the focus of his training, and of course my psychiatrist is going to push meds over talking therapy given her background. And I would have expected my GP to push meds too, but he made it clear from the start he didn’t want me taking anything I didn’t absolutely need. We only started my medication regime after we’d established therapy alone wasn’t enough (as evidenced by a lack of progress in 10 sessions).

Sometimes it feels like the patient has to sit in an uneasy middle ground, where navigating the way forward is a real challenge. I have a feeling that most people who have a therapist and a psychiatrist see more of an alliance between them, or at least don’t see them in conflict/opposition to each other. 

ECT? Ketamine infusions??

I saw my psychiatrist this morning, and it turned out to be quite an…interesting…half an hour.

She realised the lithium dilemma without me having to explain it, and the upshot is that we’re reducing my dose from 800mg to 600mg nightly in order to reduce the side effects I’m experiencing. This means we definitely won’t be hitting our original target of a lithium level between 0.55-0.7, but she says that target is more relevant to bipolar patients than patients with depression. Hopefully 600mg will still be useful to me.

We’re also adding in another antidepressant to try and boost my serotonin levels: welcome back mirtazapine (/Remeron). I have to admit, I’m a bit nervous about this – I’ve taken it before to help me sleep (which is another reason my psychiatrist wants me to take it now), and in December I wrote myself a warning before discontinuing this med for being too strong. I’ve been told to cut the pills in half and see if a lower dose is tolerable, and then increase in a fortnight. 

The whole medication vs insomnia battle really sucks; the meds are either so strong that I’m barely conscious in the daylight hours, or so weak I might as well be swallowing chalk pills. The only med that hit the right spot in the middle was zopiclone (/Imovane/Zimovane), but I’m not trusted with it in case I overdose. Grrr.

With this all established, my psychiatrist sat back and said we should think about what the next step is. When I see her in two months time, if the mirtazapine hasn’t helped much she wants to add in aripriprazole (/Abilify), an antipsychotic. After my bad experiences of olanzapine (/Zyprexa), quetiapine (/Seroquel) and risperidone (Risperdal) I had sworn I never wanted to touch an antipsychotic again, so we’ll see how I feel if it is decided this med is necessary.

And then my psychiatrist said she wanted to say something that might horrify me…that I should consider ECT. I’ve read enough blogs on WordPress to know that for all the scary assumptions we hold about it, it can have it’s good points, and my doc was quite encouraged when I didn’t immediately say no. She reckons it’s really underused, especially with patients like me who are managing to function, but are having a miserable time of it. 

Apparently I should also consider ketamine infusion therapy, because a UK trial has just finished and found some patients respond really well, so it’s opening up to referrals. And yes, that’s ketamine as in the horse tranquilliser/Class B drug, but used at a much smaller dose. 

I was a bit shocked by these suggestions – I’d thought that ECT especially was for very severe cases of depression, but now I know that’s not true (..and I’ve been reminded that my diagnosis is ‘severe depression’). I’m not exactly shut against the suggestion of having ECT, but the memory loss bothers me. I’d also have to have it as an outpatient because the hospital is really short on beds, but I’d need to have someone to care for me for 24 hours, and that’s not an option. 

With the ketamine infusion idea, I was pretty skeptical, but having looked up the details of the study etc I’m actually kind of intrigued. But, hopefully none of this will be necessary because the mirtazapine will help. Or the aripriprazole if it comes to that.

All in all, it wasn’t a bad meeting. I really like this psychiatrist (and yes, I realise that means she’ll be next on the list to disappear off somewhere else), because she is nice, but not too nice, and she clearly knows her stuff (not surprising given she’s a consultant psychiatrist). The loss of Nurse L was mentioned in passing – as I suspected there will be no replacement, and I have no interest in asking for one. My GP won’t be happy because she specifically told me to ask about it because she thinks it makes me safer (true), but letting someone else in is also dangerous in it’s own way.

We’re already rocking the med boat, so lets leave the rest alone, at least for now.