Probably a slightly misleading title, but this post is about medications, and my feelings about a particular psychiatrist. And, anyway, it’s not every day you get to pay tribute to Placebo, and the title track of their slightly disappointing 5th album. Ah well, I still love them. And not just because I have a crush on one of the band.
Ahem. Sorry, I seemed to distract myself for a moment there….. Back to the point of this post – medication, and the reason I’m not being prescribed any.
When I was first diagnosed with depression, I was prescribed Citalopram. I was started on a low dose, and then this was fairly rapidly increased. Within a couple of weeks I started to develop some mild side-effects. If I concentrated, I could keep my legs and feet still by pressing them hard against the floor, but as soon as I forgot about them, they started to twitch and shake. Then, when I was at work one day (I was still working in those days), I briefly passed out.
Personally, I think I fainted. The air conditioning had broken in the office, it was really hot weather, and I was recovering from a mild tummy bug, so I hadn’t eaten properly for a couple of days. My colleagues called an ambulance, and the upshot of the various investigations at A&E was that I might have had a seizure, and that the seizure might have been caused by the Citalopram.
Because of this, and the twitching legs thing, my GP didn’t think it would be a good idea to put me back on the same medication, and so she switched me to Trazodone. In some ways this was the best medication I’ve ever been on, as for about four hours a day I felt absolutely fantastic, almost euphoric, in fact. In other ways it was less ideal. In the rest of a 24 hour period I spent about four hours throwing up and feeling intensely nauseous, and the remaining sixteen either sleeping, or wandering around in zombie mode. I also developed large and fairly painful red blotches across my torso and legs.
I persevered with this one for about 12 weeks in the hopes that the side-effects would start to subside, but when they didn’t my doctor decided to take a risk, and put me back on another SSRI – Fluoxetine. I didn’t have any more possible seizures, and, in fact, didn’t really notice any side-effects at all. I didn’t notice a huge improvement in my mood at the beginning, but it did seem to have a mildly beneficial effect. How much of that was just a natural lift as a result of not suffering the Trazodone side-effects any more I don’t know.
I was on a low dose of Fluoxetine for about six months, and noticed a gradual deterioration in my mood over that time. My doctor agreed, and increased the dosage. I didn’t really notice a particular improvement in my mood with the increased dose, but I did start to encounter side effects again, especially trembling in my arms and legs, which was worst in the morning.
So it was back to my GP, who by this time was beginning to make it plain how frustrating my inability to get better was. Because of the increasing side effects (or “perceived side effects”, as it was ostentatiously written into my notes in front of me) and the lack of any response, another new type of anti-depressant was put on the menu: Lofepramine. The side effects with this were noticeable but manageable – I sweated like a pig and I had an incredibly dry mouth. There were other things that were listed as side effects but that I personally found beneficial. The constipation acted as an antidote to my usual IBS symptoms, and the urinary retention came in very handy on long coach journeys.
In terms of its impact on my mood, Lofepramine initially seemed like another dud, but my GP kept upping the dose over several months, from an initial 70mg a day, through 140mg/day and 210mg/day, to a final 280mg/day. Every other doctor I’ve seen has always looked slightly concerned by that final dose, on one occasion looking it up in his BNF Handbook, and saying “But that’s far too much!”, which leads me to assume it was above the recommended dose. Whatever the precise details, I’m pleased I was put on that high dose as it worked well for me for over two years.
Eventually, however, I noticed my mood starting to spiral downwards again (I’ve written about it here), and eventually saw a psychiatrist who decided, reasonably enough, to change my medication. First of all he tried me on Duloxetine, which is part of a relatively new class of drugs called SNRIs, and seems to be generally regarded as the “Newest Bestest Thing” by psychiatrists.
I didn’t get on all that well with Duloxetine. To begin with, it hurts to take – it’s contained in a gastric resistant coating that causes really painful stomach cramps. I’ve mentioned already that I suffer from IBS, so I’m no stranger to the idea of painful stomach cramps, but these really were exceptional. Other things being equal, I daresay I could have learned to cope with them, and they would probably have improved after a while anyway, but other things really weren’t equal.
The pills seemed to trigger a bizarre mental state, and did so from the very first one that I took. I burst out laughing for no reason. I spent most of the night pacing up and down my hall, then left the flat early in the morning to walk in the outside world. When I needed a pint of milk I decided to walk several miles to buy it rather than going to the local newsagent because I seemed to have so much energy to burn. I felt keyed up and on edge all the time. It’s without doubt the most unpleasant experience I’ve ever had with any medication.
What I should have done, of course, was to go and see my GP, explain the side-effects, and agree a plan for dealing with them. In my defence, it was Saturday morning on a bank holiday weekend when I decided I had to stop taking them, and seeking medical advice would have meant waiting until Tuesday. Anyway, I stopped taking them, without anyone’s advice. Having done so, there didn’t seem much point in telling my GP about it, so I waited three weeks or so until my next psychiatric appointment, and told him.
This was the first time I had ever stopped taking medication by myself, so I didn’t know exactly what to expect, but I assumed I was due a bit of a telling off. I also assumed the psychiatrist would have at least some interest in knowing why I’d done it, but he didn’t. As soon as he knew I’d stopped taking them, he didn’t want to know anymore – he actually said, “I’m not interested in that.” He cut me off mid-sentence, told me to come back in six weeks, and showed me the door. I was walking out of the hospital gate exactly five minutes after my appointment had been due to start (his clinic always ran bang to time). It felt, to be honest, like I was being sent to the naughty-step for refusing to obey orders. I do understand that people not taking their medication is a serious problem, but I’m also certain that this wasn’t the best way of dealing with it.
At the next appointment he indicated that he might be prepared to give me another chance, so long as I promised to be a good boy. When I swore blind that I would be, he said that he would prescribe (or rather, instruct my GP to prescribe) Escitalopram, which he explained was a version of Citalopram that had been tweaked to reduce its side effect profile. This surprised me a bit, as, side effects aside, I hadn’t really responded to either of the previous SSRIs I’d been prescribed. Normally I might have asked about that, but, since I was supposed to be on my best behaviour, I chose not to.
Well, for the most part, I had no side effects at all with Escitalopram, but I also had no discernable improvement in my depression either. Over the same period there was a marked increase in my levels of anxiety – by the end of it I was experiencing two or three panic attacks a day. The psychiatrist’s response, as I told him all this in several follow-up appointments, was to nod his head and increase the dosage. Once I was at the maximum, he just nodded his head.
This was an exercise in acute frustration for me. My anxiety was getting demonstrably worse, and my depression wasn’t improving, and his only suggestion was to keep taking pills that seemed to have no effect whatsoever. If I told him my anxiety wasn’t helped by Escitalopram he would tell me that might well be, but it was helping with the depression. If I told him my depression wasn’t helped by Escitalopram he would tell me that might well be, but it was helping with the anxiety. Sometimes he would tell me both things in the same consultation, apparently hoping I wouldn’t realise they were contradictory.
I told him I wanted to stop taking Escitalopram as I couldn’t see any benefit in it. I explained I was not saying no because I didn’t like the side effects – I wasn’t having any, apart from mild nausea, and some trembling in my fingers early in the morning – and I was happy to try anything else he wanted to prescribe. He told me no, so I kept taking the tablets. This pattern was repeated in appointment after appointment until, eventually, I snapped, and stopped taking it for myself. I weaned myself off over a period of a couple of weeks. As I expected, my depression got no worse. I was surprised to find there was a marked improvement in my anxiety, with the frequency of my panic attacks significantly reduced.
I discussed all of this with him at the next appointment, and his response was to grin hugely, as though I’d finally done what he wanted all along. “Well,” he said, “that’s it. You’ve reached the end of medical psychiatry. There’s nothing more I can do for you.” He explained he was discharging me, and that he would write to my GP and the psychoanalysis team to let them know. His parting shot as he walked me to the door was this: “Go back to your GP if any of this is worrying you. You’ve responded well to medication in the past, and there are other ones that can be tried.”
I have really struggled to understand why, if he thought medication might still help, he would tell me that I had reached the end of psychiatry. I’ve also struggled to understand why, if he knew of medication that might help me, he would refuse to prescribe it. I’ve come up with three possible explanations. I suppose he might have felt that the therapeutic relationship had completely broken down, and that it was therefore in my best interests to bring it to a close. I didn’t feel that was the case, but I guess he might have done. Another possibility is that he genuinely didn’t believe anti-depressants would ever help me, and his closing comment was just intended to maximise any possible placebo effect if I ever happened to be prescribed them again. My innate pessimism makes me think there may be quite a lot of truth in this explanation.
But in the end I don’t think that’s the most likely reason. The first time I stopped taking the meds he had prescribed, his instinctive reaction was to punish me. Not to investigate why I’d stopped taking the pills, or think about alternative strategies, but to exclude me from all treatment for a period of six weeks. With the second offence, of course, the punishment is always greater, so this time I had to be discharged from treatment altogether. It seems like it was more important to this particular psychiatrist to maintain his position of authority than it was to ensure that I got the help I needed, which, if it’s true, is rather a shame.