More on meds & psychiatry

Well, time for another unusual type of post.  Several people left some really interesting comments on my last entry that got me thinking, and I wanted to respond to them.  I started off writing a reply in the comments, but it became obvious that it was going to be too long for that.  So, instead, here they are in a post all of their own.  (You can see the complete comments over on the other post.)

DeeDee Ramona: Holy crap Aethelred – that psychiatrist sounds like a complete plonker.

That’s the confusing thing, though, he wasn’t.  I actually quite liked him – as MH professionals go, he’s one of the most “human” I’ve ever encountered.  Those of you who’ve had the pleasure of being on the receiving end of psychological/ psychiatric consultations will know what I mean when I say that those who work in mental health often give the impression of having recently arrived from another planet.  (“This session will last fifty of your Earth-minutes.”…)  He managed not to.

DD R:  It took 6 – yes 6! – antidepressants before one was found for me that a) worked and b) did not give me a hypomanic episode.

Well, I’ve actually been tried on 7 ADs – Citalopram, Trazodone, Fluoxetine, Lofepramine, Mirtazapine (I forgot to include this one in my original run-down), Duloxetine and Escitalopram.  I’m by no means an expert on meds, but that seems to include at least one representative from several classes of drug – SSRI, SNRI, TCAs, and tetracyclics – which would seem to suggest that the various doctors and psychiatrist I’ve seen have tried quite a lot of the options.  In fact, the only ones that seem obviously missing are the “old-school” tricyclics, and MAOIs, and I think they are almost never prescribed these days.

I had the best response to the TCA (Lofepramine), which to me would make it logical if I were to have been tried on other meds from the same class, rather than switiching classes altogether.  But I’m not a doctor – there may be all kinds of reasons why that wasn’t a good idea.

DD R:  Did he ask you about how you felt about ECT?

No, he didn’t, although, if he had done, my reponse would have been, “You’ll have to section me and strap me down so I can’t fight back before you’ll get to try that one on me, sunshine.”  I think my depression would be unlikely to be considered serious enough for ECT in any case.

This is actually, I think, one of the problems I face.  To most people my MH problems don’t seem all that severe.  I’m not inclined to break down in public.  Even when I’m struggling really quite horrendously, I manage to hold it together.  If I can’t hold it together, I just don’t go out.  Nobody – not even my ex, who I was with for nearly 8 years – has seen me at my worst.

Because I’ve become so good, over the years, at hiding what’s really going on inside me it’s hard to see that there’s anything going on.  Combine that with the fact that I have a built-in reticence to tell people about what I’m dealing with, and that I have a tendency always to minimise it (the “mustn’t grumble” approach), I think it’s probably quite hard for people to know what’s going on.  No-one in the “real world” (as opposed to the people who read this blog) knows that I have made detailed plans to kill myself.  No-one in the real world knows that I have periods of intense paranoia, or that I have psychotic symptoms either.

Obviously, I ought to make all this known to the people treating me.  Partly I don’t want to – specifically with the case of suicide, I want to reserve the right to kill myself without interference if I choose to.  But the other part of it comes down, essentially, to shame – whether there should be or not, there is an enormous stigma attached to mental ill-health.  Also, from a personal point of view, I would tend to see laying out my problems in detail as essentially pleading or begging for help.  My illness has left very little in the way of personal attributes unaffected, but one thing I do still have left is a certain amount of dignity and self-respect.  I won’t lightly give that up.

One might, of course, hope that an experienced psychiatrist would be aware of the possibility of these kinds of feelings and motivations in one of their patients, and so would ask questions accordingly.  With the exception of suicide, I would never flat-out lie.

DD R:  I would suggest you go to your GP and say you’re not happy with what the psychiatrist did, that not all avenues were explored, and you want a second opinion / to see someone else.

Good advice, but not, I’m afraid, advice I’m likely to follow.  I am truly lousy at standing up for myself in situations like this.  I will always follow the path of least resistance, and in this case, that is to do nothing.  I did try briefly it to Yvonne (the nurse specialist I’m seeing), but faster than you could say “transference” she started giving me a little lecture about how sometimes we can project feelings that are to do with one person onto someone else entirely, and that I should explore my feelings of being let down or diasppointed by my psychiatrist in that light.  Oooh, helpful.

DD R:  it_is_ possible to recover even after years of depression (and mania) – I did.

I’m pleased things have worked out well for you.  I try to keep telling myself it’ll work out ok for me too.

 

Rich:  Duloxetine wasn’t bad for me […]  I did have “inappropriate” moments too. Your moments seem just a little more inappropriate than mine.

Sometimes I think my whole life has been nothing but a series of inappropriate moments….

R:  Have you tried combining drugs? I think it’s called augmentation or something e.g. mirtazapine + another etc.

That’s never been suggested to me, although it is something I’ve wondered about.  I’ve come across quite a few people on the web who’ve said that combining drugs is the only thing that’s really helped them, but most of them seemed to live in America.  I don’t know if it’s common practice to do that sort of thing over here.  I’m also not sure how I’d cope with two sets of side-effects at the same time.

R:  I’ve just started the mirtazapine, and it’s giving me nightmares and hallucinations during the evening.  Curiously, this might stop if I up the dose.

Mmmm, sounds like fun.  I hope they clear up one way or the other, anyway.

R:  It’s disappointing to hear how rubbish your Psychiatrist is. Mine is pretty similar […]  I had a care plan meeting with him a while back and made sure the others present understood the situation. […] never underestimate the power of shaming him by making him look bad in front of his colleagues…

Whenever I see anyone in MH it’s always a one-on-one session, so the opportunity of shaming him in front of his colleagues isn’t really an option for me.  As I mentioned above, when I did try discussing it with Yvonne, it was dealt with in a way that made it clear that my feelings were inappropriate or misplaced.

To be honest, this is the way I would expect any complaint or criticism I made to be handled.  In the field of MH there are almost endless ways to dismiss the validity of anything and everything said by a patient, after all.  I’m also not certain of the wisdom of antagonising people I may be reliant on in the future – it’s always a good idea to be damn certain you’re on the right side of the river before you start firebombing bridges….

 

Mandy:  My experiences of meds are similar to yours. Most made me feel horrendous. Some made me feel okay for while…one actually lifted me for a while but like you, I am dubious as to whether that was the drug or more a personal state of being. A natural lifting.

I know exactly where you’re coming from.  Although I’m reasonably certain that Lofepramine did actually work, it’s very hard to know for certain.  It’s made more difficult for me to be certain because, although I coped with some bad things well when I was taking it, I know I am sometimes able to deal with negative events positively, even with no treatment at all.  I guess the most definite thing I can say is that my longest period of comparitive wellness (that’s a horrible word – “wellness”…yuck – but I can’t think of a better one) coincided with my taking it.  It’s why I wasn’t ready to give up on the possibility of medication helping me, even though my psychiatrist apparently was.

On the other hand, I have been “med-free” for several months now, and it seems to be working out ok.  I know I could feel quite a bit better than I do right now.  In particular, I’m going through a real yo-yo phase, where I’m up one day, down the next, and wandering round in weird, brain-on-fire mode just about any old time.  I would think there’s a good chance medication would help things along a little.  But things aren’t disastrous, and every day of coping at the moment is a victory for me rather than a victory for the meds, and that’s quite a nice feeling.

Of course, all of this is only going to apply only so long as I don’t behave in ridiculously stupid ways that are pretty much guaranteed to sabotage everything I’m trying to achieve – but that’s the topic for my next post…..

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4 Responses to More on meds & psychiatry

  1. J. Wibble says:

    When I was on combined drugs my psych said the ideal situation was for me to be on just one drug. This sounds like a sensible proposition, but in practice I wasn’t sure how well it was going to work. It didn’t. The problem with medication is, if you’re on just one drug but it’s the wrong drug then it won’t help, if you’re on some drugs that do work and some drugs that don’t then you don’t know which it is that’s causing the problem, and if none of your cacophony of drugs work then you’re probably even worse off than if you were on nothing at all.

    Combinations do seem more common in America than in the UK – it would be cynical of me to say this is because the NHS is trying desperately to save money at the expense of providing treatments that might actually work for people, but then it would also be cynical of me to say that polypharmacology is more common in America because the drug companies make more profit from it. So I haven’t just said any of that. ;)

    MH drug treatment isn’t as straightforward as ‘paracetamol cures headaches, chemotherapy cures cancer’ etc. (I understand that these are both gross overgeneralisations, but at least a lot of physical medicine has a starting point. With psych drugs, 9 times out of 10 it really is shooting in the dark) and I think often it doesn’t come to the point where the doctor feels there are no more options as the patient usually gets fed up long before that and either puts up with semi-effective treatment or walks away altogether. People who try to insist on actually recieving decent MH treatment, and that as many drugs as possible are tried and all possible combinations exhausted, seem to be quite heavily frowned upon. As you said, there is always some way in MH to say it is your fault, and if you think it’s your fault you’re less likely to sue them for being crap.

    Excuse my rampant cynicism and general irritability but I’m tired and not having a good day.

  2. Kalian says:

    Combining ADs in the UK does happen, at least, it’s happened with me. From 2003 onwards I’ve been settled on Venlafaxine. While taking it I’ve also been prescribed Amitriptyline, and when that didn’t work, it was switched to Mirtazapine by a psychiatrist I’d (finally, in the last year) been referred to. She then decided that ultimately I’d be better off on lithium permanently. I was put on that, and about 4 months after I was able to come off the Mirtazapine. I’m now waiting for my psychiatrist to decide that I can start to come off the Venlafaxine.

    The Mirtazapine was horrible. Although it ultimately helped, it left me very lethargic, and in a bit of a foggy state. Coming off it was like waking up after being in a dream for months.

    I’m looking forward to eventually getting off the Venlafaxine, mainly thanks to the side effects. I sweat almost constantly, especially from my head. It makes me dread summer each year. The sexual disfunction should really be described as ‘lack of sexual appetite’, one of the symptoms of depression that you’d hope ADs would sort out, and very frustrating in itself. The withdrawal effects from missing a dose are disorientating, and seem to manifest when i have a cold too.

    So far, the only side effect from lithium are tremors, which so far have been manageable.

    Ah, the joy of chemicals!

  3. You might find it interesting to take a look at the NICE Guidelines for depression (you can download them from http://www.nice.org.uk/CG023NICEguideline).

    The section on treatment resistant depression specifically mentions augmenting anti-depressants with lithium, using multiple anti-depressants, and various other things. “In general, doctors, nurses and other healthcare professionals in the NHS are expected to follow NICE’s clinical guidelines.” So these are the kinds of treatment options that you should be offered.

    If you’re uncomfortable directly asking your GP for another referral, would it be easier to ask your GP about these kinds of treatments? In general GP’s aren’t comfortable initiating these kinds of treatments, so your GP might suggest referring you back to a psychiatrist, or provide you with the opportunity to suggest it without having to be assertive or demanding.

  4. aethelreadtheunread says:

    Thanks for the link to NICE guidlines – it looks as though it’ll be an interesting read, and a useful source of information. I’ve only really glanced at it so far, but it certainly seems as though my experiences and what should have happened seem quite different in a number of ways.

    Thanks for the other comments too!

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