Suspended in Air

This is another guest post by Dorothy Donald.

Imipramine

I was twelve years old. Dr B said she didn’t like to prescribe antidepressants for someone so young, but I was such a classic case that she felt she had to. My mother kept my meds in a high cupboard so that I couldn’t… you know. I didn’t get better.

Fluoxetine

I was a teenager. It made me feel like I was looking at the world from the bottom of a swimming pool. I did things without deciding to do them. I had never harmed myself before…

Citalopram

Early 20s. I just didn’t think it was helping. I thought I was just getting worse. I wanted to know if there was an alternative. Dr R wrote ‘patient refused to continue treatment’ on my medical notes and dismissed me from his office.

Sertraline

I didn’t want another SSRI. I remember citing some meta-analysis or another on the success rate of SSRIs. I remember saying that I’d tried them before. I remember saying I was not in the least convinced that they would do me any good. Dr S gently asked if maybe doing something that might work was preferable to doing nothing. What did I have to lose, from where I was?

I agreed to give the damn pills a try. I agreed to stick out the first few weeks of dizziness, nausea, acid reflux, and general big weird feelings. I even agreed to up my dosage last summer when I had ‘a bit of a wobble’. Since then I’ve been different.

I still get low mood, but it kicks around for a day or so, rather than weeks or months.

I still have times when I struggle to get out of bed, but the thought process goes “oh, I need more sleep” rather than “I am useless”.

I still think about offing myself, but it’s a thought that drifts into my head and then just drifts right out again, rather than some abominable earworm.

I’m not happy all the time – that would be odd. I get grumpy, furious, sad, excited, tired, TIRED, lost in the flow state, bored, amused, content… all the stuff.

I just looked through my diary for 2017. It shows a bereavement, a house move, a couple of other fairly serious upheavals, and only one thing that felt like a depressive episode. Which seems to have lasted only three or four weeks. I think this is pretty good going, considering.

It would be premature to conclude anything about the efficacy of these tablets (my memory is not infallible and I’m not good enough a girl to keep a really comprehensive diary). It would be unwise to draw comparisons with the other drugs (oh, the confounding variables!).

18 months and counting.

Vignette: My head is screaming

And my feet are slowing down.

Tonight ended with an anxiety attack. I had been fighting internally to stay sane and not go to pieces for a few hours, sometimes successfully, sometimes losing the battle. For whatever reason I ended up wanting to get myself sane rather than actually talk to someone (say my wife, right next to me) about what I was feeling.

Towards the end of the evening, it felt like the inside of my head was screaming with the pressure of an anxiety attack that wanted to take over everything, to the point where it was getting hard to hear anything outside. Hard to hear my wife's conversation.

And then I started slowing down. I kept putting one foot in front of the other. I was even able to guide our path. But it was getting harder and harder, and my steps kept getting shorter and shorter. After outpacing me three-four times and not noticing for a while, my wife decided to walk behind me instead, to make sure she wouldn't leave me behind.

Now we're home. I've grabbed one of my anti-anxiety pills, for when I can't quite handle things on my own even if I try. One of the last-resort shouldn't-really-be-taking pills. Getting hold of water to swallow with was a struggle. Calming down my grimacing facial rictus to the point where I could put things in my mouth was a struggle.

And then things got better. I swallowed. I took care of our laundry. My wife unpacked our shopping. So of course, now that I can move again, the feelings of guilt are creeping back in. Guilt for making such a fuss. Guilt for not being able to control my feelings better. Guilt for all the sadness and upset this brings my wife when she has to see me suffering.

Guilt that doesn't help anyone with anything in any way whatsoever.

So THAT's what they meant?!

When I first got treated, years back, I was issued Lamotrigin, an anti-epileptic, and told that its role was to «give me space and a respite from my emotions enough for therapy to work». At that time I'm not sure I understood what my psychiatrist meant by it.

Right now, on the other hand, I spend some time being amazed by how well my current medication is working. I am noticing control over my own emotions for the first time I can remember. I am noticing how I can learn — more or less on my own — not to overreact.

For an example: I have a fear of heights. This means among other things that glass or lattice floors high up are genuinely disturbing to me. It is irrational, and more of an emotional overload than anything else.

The conference I'm at this week is at a conference center in a hotel that has a glass staircase leading up from the lobby to the conference center. First time I walked the stairway I swore over the stupid architects making my life bad.

And then something amazing happened.

Over the course of the 3 conference days here, I have grown to accept the glass floor. I no longer need to look up to keep the transparency out of my field of view. I no longer feel pangs of panic as I walk up or down the stairs.

This was inconceivable back in the day. Utterly unthinkable. But now? I am able to learn to deal with emotional and affective issues I have. Something has unlocked in my brain that makes new information actually take hold and stick around.

Adjusting medication routines

My psychiatrist suggested I try changing my routines to deal with the drowsiness I get from combining Fluoxetin and Wellbutrin. Thus, since Thursday I have been taking Wellbutrin in the morning and Fluoxetin in the evening instead of both in the morning.

And as of yesterday, my brain chemistry is hitting back against the change in routine.

Yesterday and today both I have during early evening gone through approximately the same progression. I lose focus on the things I am involved in and grow detached. After a little bit the detachment grows into boredom and then into inexplicable sadness. After some time, or with sufficient distraction, it dies down again; but a return back to daily sadness bouts is not something I welcome particularly.

As for now, I'm going to assume it's a result of changing my medication routines. If this continues beyond a week or so, I'll get in touch with my psychiatrist.

Vignette: I think I am getting a baseline…

You know the saying about how when a noise suddenly stops is the first time you can perceive how loud it was?

That.

I have been now on a combination of fluoxetin and voxra/wellbutrin for about 2 months. And I realize thinking back on the recent weeks that I have been feeling… normal. Or at least what I imagine normal might be like.

Gone is the constant work trying to figure out whether there were any subtexts I should have picked up on.
Gone is the constant worry someone, somewhere might not like me and what I do as much as I hope they do.
Gone is the constant conviction that nobody, nowhere, actually likes me particularly much.

I feel now that what I observe is far more in harmony with how I represent it internally. People's emotional states match up better with what I think that they are.

Effects and side-effects — an update

After about 2 months on Fluoxetin, we adjusted my medication.
Since mid-March, I have been taking Fluoxetin and Voxra (Wellbutrin) together.

I am now getting to the point where observations can be written down; where I have more than a few days worth of a sample.

First off, the really good: my mood is much more normal now. On Fluoxetin alone, I turned flat; I kept being sad for much of the time, but the crashes went away. I just was bored, dull, apathetic instead of having daily anxiety attacks. Improvement, sure, but not up at good just yet.

With the combination, my dull flatness has gone away. I have my ups and downs — I had a fullblown classic breakdown a few days ago, but it's once in 2 weeks, not several times a week. And I'm happy and energetic far more often than earlier in the past year.

So as for the primary effects, the combination seems pretty much spot on. Sure, it would be nice to get more stable than this, but it is already an incredible improvement on Before.

Now for the side-effects. I have gotten rid of some, retained some, and gained a couple of new ones.
My grinding and chattering teeth are remaining. Last night, it was apparently bad enough it helped keep Susanne awake at night.
I am far more sensitive to alcohol than I was before. On the other hand, I have always tried to pay attention to my body signals when it comes to alcohol consumption, so this doesn't really worry me.
I wake up several times each night. This is new.
I am tired. A lot. I grow almost uncontrollably tired around 9pm; we used to have a family diurnal rhythm with bedtime at midnight. Now, I go to bed between 10pm and 11pm instead. This, too, is new.

Stepping it up

As of today I am adding Wellbutrin to my Fluoxetin.

Fluoxetin alone did quite an alright job in reducing the severity of my bad moods; but did not so much in decreasing their frequency. Instead of crashing and burning daily, I have been apathetically dull daily.

To medicate or not to medicate

I woke up this morning to find the following exchange waiting for me on twitter:

1. 
   
   
   

   7hMeredith L Patterson ‏@maradydd

   RT @Sheeeela People say meds are a crutch. So is a crutch, but you wouldn't take it away from someone with a broken leg#depression #stigma

   Expand
2. 2hDieter Schuldt ‏@LeSabot

   @maradydd @Sheeeela I am seriously concerned that meds will stop me from being productive. Successful research is all I have to hope for.

   Expand

2hMeredith L Patterson ‏@maradydd

@LeSabot @Sheeeela This is a concern I've heard many researchers express. @michiexile, you want to help field this one?

I started medicating early January. I was worried when I started whether medicating would remain sensible, what with my intense reliance on my brain and my creativity for my work, exactly like LeSabot here worries.

For me, with a history of manic-spectrum issues in addition to my depression, there is the additional worry that SSRIs may actually trigger manias if you are unlucky enough.

So I went into medication with a pretty vigilant mind. On the lookout for Things That Might Change Me. I figured that in the worst case scenario — drugs are actively counter-productive — it's worth losing, say, 3-4 months to find out whether they could have worked or not. And the best case scenario removes so much sadness, anguish, and problems that investing in this test is worthwhile doing.

I have been at it for a bit over a month now, and finally the side-effects are starting to wane. First month on meds was kinda shitty — I still had bad moods, but I ended up having a very flat, apathetic approach to both my moods and everything else. I have not had any significant mania-spectrum events. 

And what's most likely important to this discussion: so far, about a month into daily medication with fluoxetin, I have not noticed any change in my intellectual prowess. I pushed out two papers since medication started — one SIGGRAPH submission (which honestly was pretty punishing in stress levels and workloads) and one arXiv preprint — and more than anything, the medication frees up parts of my brain that were working on keeping my emotions in check.

I'm not sure whether I end up more productive now. But at the very least, I can say with confidence, SSRIs have certainly not made me less productive.

SSRI: a few weeks in

It's been a bit over 3 weeks now. I got started on SSRIs on January 7, and had an immediate and forceful placebo help.

Just enough time has passed that now I can start collect some first impressions.
First off, side effects. I have them. Common ones? In spades.

• My joints are aching. Usually, it's been my elbow joints, but today I have a shoulder ache that annoys me and throws me off my productivity significantly.
• I've had a touch of my manic side. Just one, very early on, and nowhere near where I would ask for help for it — just enough to remind me it exists.
• I have some slight eczema. Just enough to redden the skin and make me wonder why. Doesn't itch, just discolors.
• I am exhausted in the evenings. Utterly and completely. Leaning on doors and walls, just waiting for it to be late enough that we can go to bed.
• Muscular tension — oh boy! I have chattering teeth, grinding teeth, bouncy knees, and tense up pretty much all over.
• Several different instances of autonomous systems going weird on me. I won't talk about bodily fluids here, but have gained a bit of awareness over the past few weeks.

On the other hand, there are the actual effects of taking the pills.

• Before I started, I had daily crying jags. After I started, not once.
• Before I started, I had daily episodes where I was terrified of things. In these three weeks, twice.
• Before I started, my bad moods would be these chasms swallowing me up, leaving me powerless, anxious, afraid and inconsolable. After I started, it's much more of a gray dull sadness. Still not good necessarily, but far more livable and endurable than the explosive mood swings I had earlier.

Of course, life. During these three weeks I have submitted a major paper to a high-prestige conference. The last weeks running up to that submission, I pushed myself hard. As a result, I am still reeling from the sudden relief of the stress; I have yet to get back to marching speed with any of my regular activities. And it is hard to see what parts of my sadness, inactivity, and lack of impetus comes from my illness, and what parts simply come from my body trying to recuperate after the paper crunch.

But for today: my shoulder joint hurts.

Hiding from strangers

My depression and my anxieties hide when I am out with strangers. In fact, me crashing with you around me is a token of trust and friendship, as weird as it sounds and as hard it makes your life.

I was reminded, again, of how much this is a part of my illness today. Y'see, I was lunching with my mother — who used to trigger a fair number of emotional crashes herself. I mentioned to her that I started with anti-depressants, and that they have been mostly working well for me.

“I didn't even know you were having problems again.”

That, apparently, is how far my independence has gone: my parents no longer cause my emotional crashes, they are among the people I hide my emotions from.
Instead, it is my wife who had to bear me crying inconsolably because I thought my dad might be annoyed at us coming late for the christmas party.

I wonder how wide-spread this is; the gradation of your affective problems by your context, the tendency to only ever be noticeably ill when among your very closest. It means that work takes a very small, if any, hit from my mood swings. But on the flip side, it means that my mood swings are utterly brutal on my closest and most intimate friends and family.
My wife has had to carry an incredible load through the years, and only through forming her own coping strategies have we been able to carry on even as I grow randomly sad, angry, irritated, afraid, and more often than not blame her because I cannot find anything else to blame for my mood.

As much of a hell as your depression is on you, it is hard on those who care about you.
Being unable to perceive their caring only makes a bad situation even worse.

…

I wish I could find a way to articulate these thoughts without fueling the guilt and anxiety some of you already feel. I do not think that I can. Try to remember that the ones you feel guilty about subjecting to your mood swings most likely care deeply about you and will help if they can only figure out how.

I can feel the emotional crash

It hovers just outside my peripheral vision. It taps on the door, wants me to let it inside.

Two weeks ago, I would have already crashed by now. I can recognize the signs. The pressure in my head, the urge to just cry, to hide, the apathy, the anhedonia.

SSRIs must be working, because I don't seem to be crashing. I haven't gotten all that much done tonight — but after almost a week of solid all-evening work, working through the weekend, pushing for our paper deadline, it's probably just good that I drop off the grid for tonight.

But this here, this is a novel feeling. Almost crashing, but never quite. Feeling the lead-in to an emotional breakdown without it going all the way.

I can live with this.