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.

Suicide and Me: Part II

This is the second part of a three part series, so if you haven’t already you might want to read Part I first.

When the psychiatrist collected me from the hospital waiting room and led me into the Crisis assessment room, I was terrified – there were two other women seated in there (in addition to the doctor), waiting to listen and take notes. It hit me that this was being taken very seriously, and I mentally started telling myself off for being so honest with Dr T and my GP; this level of attention/interference was exactly what I didn’t want. Who were these people to tell me I couldn’t Exit, and threaten me with being sectioned? My right to life, my right to Exit.

But I sensed that now was the time to keep those views quiet, so I spent the next hour playing down my plans and what had happened. That hour was intensely frustrating; the psychiatrist kept talking about ‘things you can do to keep yourself safe’, and the other two women would vigorously nod their heads in agreement like these were great ideas, while I was sitting there thinking I don’t need this, this is a waste of all our time. I knew that the next time I wanted Out, I wouldn’t sit around trying to persuade myself not to. In the end my silence/vague nodding paid off, and I was allowed to leave the hospital with my first prescription for zopiclone. The first thing I did when I got home was look up how much zopiclone would be fatal, but unsurprisingly I hadn’t been given anywhere near enough. I spent weeks trying to research the ‘perfect’ suicide method (perfect for me = painless, and 100% success rate), but there were problems with pretty much everything I came across.

Things calmed down over the next few months because the Crisis team helpfully referred me to see a psychiatrist on a semi-regular basis, which meant I had access to new medications that I hoped might make a bit of a difference. On the strong advice of my GP to take a year out from uni I suspended my studies, and without work my life became appointment-centred. On a weekly or fortnightly basis I was seeing my GP and my therapist, and then a bit less often also the psychiatrist, who additionally assigned me a CPN (community psychiatric nurse) who saw me every six weeks or so. Having a CPN was a real novelty; she was essentially a problem solver, and I liked knowing that if things got tough I could just offload to her and she’d tell me how to fix everything.

But time wore on and I developed some low-grade frustration at the lack of progress in certain areas. My crisis had been around March, and by the following Autumn I’d tried numerous medications that had all been discontinued for one reason or another. The only med that I felt had made a difference, fluoxetine (Prozac), was stopped by my psychiatrist on the basis that ‘while it is working, it isn’t working enough‘. And one day my psychiatrist casually informed me that he was actually a junior doctor on rotation, and that it was time for him to move on so I wouldn’t see him again…whaaat? A little notice, anyone? I felt quite betrayed that I hadn’t been made aware of this from the start, and was further annoyed to learn that I would never have the same psychiatrist for more than six months.

At around this time I was experiencing some real eating-related issues: in brief, I’d enjoyed a period of time the year before when my anxiety had been bad enough that I rarely ate and lost lots of weight without trying, and I was trying to re-create that without the anxiety. My CPN didn’t know how to handle this, and signed me off without telling me (again, I was casually informed of this six months later by a doctor). My mood was deteriorating by the week…and then it occurred to me that I was staring the ‘perfect’ suicide method in the face…death by starvation. And as soon as that idea entered my head, I was sold, because I was haunted by the conviction that my mental illness would never end, unless I ended it. I would cut down my food intake over a few days, fast for two weeks, and then take a small overdose of OTC sleeping tablets. Job done.

Except, it didn’t work, because only three days into the total fast, I was scared out of it when I experienced some mental confusion. I remember standing up one evening, and suddenly I had absolutely no idea where I was (room/town/country). Since I had a week and a half left to go I was really worried about how much worse this was going to get, so I abandoned the attempt, and the following week Dr T gave me hell for even trying.

I started this blog in December, and the posts from that time into 2014 make it clear how my mood was almost consistently low from that time. Part III will outline how that led to my most recent suicide attempt.

Not downhill, more like underground

My depression is really taking over, and I haven’t felt this bad since just under a year ago when things escalated beyond suicide ideation. I also feel quite ill physically – my head hurts a lot, I feel kind of sick so I can’t eat, and occasionally I feel weak…but I wonder if that’s psychosomatics at work rather than genuine illness. I don’t know.

What I do know is that all I want to do is curl up. No activity – just lie there, and be numb. I’m back to the days of struggling to get out of bed because I don’t give a s**t what the day holds. I don’t remember very much about what I’ve done this week – there are so many hours I can’t account for. The ones I do remember mainly involve sourcing ‘exit’ materials. I make myself leave the house each day, and try not to cry. I go to bed as early as possible, but can’t sleep.

I don’t feel like I can adequately explain the source of my depression, and last night I read about ‘endogenous depression’  (for want of a better way of putting this, that means the source is within my head) which is essentially psychotic. I’m wondering if that’s me. And what the consequences are if that is me. It’s adding to my already strong suspicions that I’m going to be mentally ill (either constantly or on-and-off) for the rest of my life. Which is why I need to shorten that time span.

I had an appointment with my GP yesterday, and he upped my daily dose of sertraline (/Zoloft) to 150mg. I nervously asked him if I could go back on zopiclone, and to my huge relief he said yes as long as I promised not to take all the pills at once (an easy promise as that wouldn’t kill me anyway). My GP almost made me cry; he talked about prodding the psych hospital into action and I said there was no point because at my last appointment the psychiatrist told me if sertraline didn’t work we’d have to give up – to which my GP immediately said he wouldn’t let them give up, and that he wouldn’t give up on me either. I still doubt what anyone can do at this point, but it was lovely to hear that.

I just want this over. 

 

Spotlight: Zopiclone (Imovane/Zimovane)

ImageFor my next medication post I’m going to look at zopiclone (Imovane), a sleeping pill that I rate pretty highly. It actually does what it’s supposed to do! Standard warning: all the information given here comes from my personal experience of zopiclone. It may work differently for different people.

For as long as I can remember, I’ve had issues with falling asleep. With therapy I’ve come to realise that it’s because when I was young my Dad would pop his head round my bedroom door and check on me before he went to bed, and I couldn’t fall asleep until he’d done that; I didn’t like the idea of him judging/looking at me without me knowing. The upshot of that is that it usually takes me an hour or two to get to sleep, and if I’m particularly stressed or low it can take a lot longer.

When my depression/anxiety began to attract medical attention in the ‘crisis days’, my psychiatrist decided my safety could be improved short term by giving me something to help me sleep. I left my emergency assessment with a rather optimistic prescription for 6 half dose pills (3.75mg each), intended to last me at least three nights. 3.75mg didn’t really do anything for me so I took the standard dose of 7.5mg, and that was perfect. I was asleep within half an hour which was a real novelty, and I slept deeply for at least eight hours. After the first night of using it I felt mildly drowsy the following morning, but I haven’t had that problem since then.

Unfortunately zopiclone is thought to be quite addictive, so I’ve only ever been given a maximum of a weeks’ prescription at a time, and the longest period of continuous use I’ve been allowed was three weeks. When I stop taking it I immediately revert back to having my age-old difficulties with falling asleep, but I don’t find them to be any worse than they were before. I also haven’t found zopiclone to become less effective with continuous use which is a definite plus compared to Nytol (diphenhydramine), which is effectively useless to me after a day or two unless I seriously ramp up the dose.

Summary

Doses (nightly):  3.75mg, 7.5mg

Positive effects: Definitely helped me fall asleep significantly faster than usual, and almost guaranteed a deep, uninterrupted night’s sleep.

Negative effects: Left me a little drowsy the morning after I first used it.

Conclusion: I love zopiclone!! It’s just a shame it’s only prescribed as a temporary/short-term sleep aid.

Spotlight: Olanzapine (Zyprexa)

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You have no idea how much stress this piece of paper caused me

I know I’ve found it really interesting in the past to read what other people think about the medicines they’ve been prescribed, so I intend to go through some of my past pills in case it can be helpful.

**IMPORTANT: Please bear in mind this post details my personal experiences. Medicines can work in different ways for different people, so what works or doesn’t work for me may do the opposite for you**

I’m kicking off with olanzapine, alternatively known as Zyprexa. Up until this point, which was June 2013, my medications were either antidepressants or sleep aids, but since they hadn’t managed to raise my mood (which was considered dangerously low given my DSH frequency) my psychiatrist decided it was time to add on an antipsychotic.

And so we welcome olanzapine to the scene, initially prescribed at 5mg nightly alongside 60mg fluoxetine (Prozac). It certainly improved my sleep, but I’d been warned about potential weight gain (the psychiatrist said he’d heard of people gaining over 80kg on this med), and I quickly found out why.

I noticed two changes: my appetite increased, and I rarely felt full even when I knew my stomach must have been full to the point of bursting. I felt driven to eat all the time and began to binge frequently, which was particularly uncomfortable as weight has always been a sensitive issue for me. Initially I coped by upping my exercise regime and telling myself that the increased hunger wasn’t real (and so could be ignored), but it didn’t last. My appetite pushed beyond the limits of my control; I was eating at every opportunity I had, and I’m ashamed to say I experimented with purging. On top of that, despite feeling guilty about bingeing my drive to exercise waxed and waned with my mood, which was perhaps unsurprisingly travelling south. I talked to my GP and my dose was lowered to 2.5mg, but when this didn’t decrease my appetite and lowered my mood further it was bumped up to 7.5mg.

A few weeks later I decided to stop taking olanzapine, reasoning that the appetite change and associated stresses weren’t worth the improved sleep and non-existent mood lift. My GP and psychiatrist didn’t approve and were quick to point out that I was noticeably more ‘agitated’ and tired, but I felt such a strong sense of relief when I regained control of my appetite and although my sleep suffered, I’ve been pretty confident that I made the right call.

Summary

Doses (daily): 5mg, 2.5mg, 7.5mg

Positive effects: While taking olanzapine I slept like a log, which was a relief after months of getting very little sleep each night.

Negative effects: Significant potential for substantial weight gain given hugely increased appetite and reduced ability to feel full.

Conclusion: Olanzapine did not improve my mood, and arguably worsened it via the stresses it caused me through the appetite-related side effects. I won’t be taking it again, and although I miss the improved sleep, it makes a lot more sense to take something like zopiclone alongside an antidepressant.