Reflections on 2017

rearview mirror

The blunt reality is that 2017 has not been a good year for me.  I have really struggled with my mental health, and treatment-resistant depression makes it hard to find hope.  But as 2017 draws to a close, I can acknowledge that looking back on the bad staff is less productive than trying to focus on the good.  So here goes.

  • I started blogging.  This has been by far the best thing that I’ve incorporated into my life this year.  It hasn’t always been easy, and there have definitely been times when I’ve felt completely overwhelmed by all things blog-related.  But overall, it has been a fantastic way to be able to express myself and feel like part of a community.
  • My grandma (who is 100 years old and amazing) has decided she would rather see me start to enjoy my inheritance while she’s still alive, so she gave me a very large amount of money for Christmas.  She’s thrilled that the first thing I’m going to do with it is go on a much-needed vacation.  I’ve booked a week at an all-inclusive vacation in Mexico in late January, and I think the getaway will be highly therapeutic.  Bring on the sunshine!
  • I have grown my guinea pig family from 2 to 5 members.  There’ve been quite a few days that they’ve been the only thing that kept me going, they’ve forced me to maintain a consistent routine, and because of them I never feel completely alone.  This is extra-important since I live by myself and spend quite a bit of time at home.
  • I have cut a lot of people out of my life over the last while because of my illness, but this year I did have one amazing new person enter my life that I feel really safe with.  It’s a good reminder that safety is still possible and not all people are out to harm me.
  • I have found a really good set of treatment providers (doctor, naturopath, and massage therapist) that I feel comfortable with.  Definitely a step up from last year when I fired three different doctors in quick succession.
  • I have survived.  It hasn’t been easy, and at times suicide has very much seemed like the best option, but I’ve made it through.

And there you have it.  Onwards and upwards in 2018.

 

Photo credit: Jake weirick on Unsplash

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Feeling like a stranger in my own family

woman standing alone in a crowd

I spent Christmas with my family this year.  It was a small gathering – just my parents, my brother, his fiancee, and me.  Except it didn’t feel small; it seemed like there were far too many people around.  I haven’t had a lot of contact with my family for some time now because of my depression-related self-imposed isolation.  In the last year and a half I had only seen my brother twice, and hadn’t seen my soon-to-be sister-in-law at all.  I was reluctant to head “home for the holidays”, but decided I should push myself and just go for it.

Everyone gave me a fairly wide berth.  Not in a mean way, but in recognition of my need for space when I’m not feeling well.  Despite the cozy little gathering, I felt like an outsider, a stranger.  Not because anyone excluded me, but because their little family circle just seemed so foreign to me.

Since I wasn’t engaging much in the conversation, I felt kind of like a fly on the wall, observing from a detached position.  Or maybe not so detached; regardless, I found that things grated on me.  My sister-in-law is a lovely girl, but it seemed like my parents were putting on a performance of sorts because of her presence, and it looked so contrived from my odd perspective.  Things that would normally be minor irritants, like my dad’s poor table manners, stirred up a feeling that was closer to disgust.  Much of the general conversation focused on meaningless minutiae (kind of like Jerry’s parents in the show Seinfeld but without the humorous element), and it struck me as such a waste of time.  I was mostly able to keep a lid on my irritability in term of external expression, but it maintained a slow simmer on the inside.

I’m back home now, and it feels like a relief to be alone with just my guinea pigs for company.  I’m left wondering, though, if this feeling of being a stranger in my own family will ever really go away.  Maybe if (when?) my illness goes into remission things will go back to normal, but that seems hard to imagine at this point.  It’ not their behaviour that would need to change, it’s my perspective, and it feels like the connections that well me used to value have been washed away in the storm of my depression.  Maybe I’ll find them again, or maybe I’ll forge new connections in the future, but at this point I don’t see that happening any time soon.

 

Photo credit: Mike Wilson on Unsplash

Rising from the ashes of depression

tattoo.jpg

Those of us waging a battle against mental illness need to find strength wherever we can.  I decided a few years back to display mine on my body.

I got my first tattoo when I was 19, a dolphin on my right hip because I admired those beautiful, intelligent creatures.  I didn’t give much thought to any further body art until 2012.  I’d had my first relapse of depression in 2011 and spent two months in hospital, and I was finally starting to feel better and had returned to work.  I decided it was time for my second tattoo, and decided to go with Chinese characters on my left hip.  I asked a Chinese colleague what characters he thought best represented resilience, and the ones he selected literally mean “return to spring”, in the sense of regeneration and renewal.  The tattooing process was quick and easy, and I was happy with the result.

Not long after I got the tattoo, things began to take a downturn, and kept spiralling downwards until I made a suicide attempt in late 2012.  Once I got established on the road to recovery I decided I needed a more significant depiction of my ability to recover, and the myth of the phoenix rising from the ashes seemed intensely appropriate.  I looked at it as sick me dying with the suicide attempt, and well me being reborn.

I found a tattoo artist I connected with and she turned my vague idea into an amazing drawing.  Then we began the long, painful process of tattooing.  It took probably around 10 hours to do, with regular breaks when I started shaking because it hurt so much.  I just tried to remind myself, though, that the only reason I was here experiencing this physical pain was that I had the strength to endure so much mental pain.  I was thrilled with the result, which covers my left side from hip to armpit.  When I am feeling weak, it’s an amazing reminder of what I can endure.

Celtic oak tree symbolI’ve been unwell for the last year and a half or so, and I think it’s time for another visual representation.  I’m thinking about a Celtic oak tree design, which symbolizes strength and endurance.  I would like to move forward a little more in my recovery journey before I get the tattoo done, but that gives me something to look forward to.  And even when depression makes my mind play tricks on me, my body can always remind me of the truth.

 

Book review: Birth of a new Brain – Healing from Postpartum Bipolar Disorder

Birth of a New Brain book cover

Birth of a New Brain – Healing from Postpartum Bipolar Disorder chronicles author Dyane Harwood’s journey with postpartum onset bipolar disorder.  The story’s rich, vivid descriptions draw the reader along on the intense roller coaster ride of the author’s illness experience.  Many elements of her story will be hauntingly familiar to those whose lives have been touched in some way by bipolar disorder, including mood symptoms whose true nature only became apparent with hindsight and well-meaning attempts to get off medication that result in disaster.

Mental illness was a part of Dyane’s life from the beginning, as her father had bipolar disorder.  When she first began to struggle with her own mental health, she was diagnosed with depression.  Glimmers of hypomania made occasional brief appearances, but as is so often the case with hypomania the symptoms were only recognizable as such upon later reflection.

Depression is the most recognized postpartum mental health problem, while postpartum hypomania may not raise red flags.  As Dyane began to recognize that her thoughts were problematic, she became concerned, as many mentally ill new mothers might, that disclosing the true nature of her thoughts would result in her being designated an unfit mother.

It was after the birth of her second daughter that mania openly reared its head, resulting in a diagnosis of bipolar disorder with the specifier of “postpartum onset”.  Dyane described the surreal experience of hypergraphia, an uncommon symptoms involving excessive writing, including the juggling act of franticly writing while at the same time tandem breastfeeding her infant and toddler.

Dyane was hospitalized multiple times for her illness, and she recounted the sorts of challenges that are all too commonly faced by those with mental illness.  On one occasion she was handcuffed by police and taken to hospital in the back of a police car.  She was reported to Child Protective Services by one hospital psychiatrist, and when she reacted angrily she was placed in a seclusion room.  Being on locked wards that prevented from going outside and kept her cut off from internet and cell phone use had a detrimental effect on her recovery, and her hospitalizations worsened her anxiety and raised concerns about post-traumatic stress.  Mental health services could certainly benefit from incorporating this type of feedback.

Birth of a New Brain captures the frustration and desperation of treatment-resistant mental illness.  Dyane was trialled on numerous medications that triggered horrible side effects rather than a therapeutic benefit.  One particularly harrowing experience was with the antidepressant amitriptyline; taking a single dose led to intense suicidal thoughts requiring hospitalization.  Electroconvulsive therapy (ECT) was helpful, but she struggled with the considerable logistical and financial barriers that often go along with outpatient ECT.  For therapies like ECT to be at their most effective, it is important that mental health services work to minimize these sorts of barriers.

Over the years Dyane went off medications multiple times.  Despite giving it careful thought, consulting books by credible sources, and incorporating alternative strategies, her illness relapsed.  Finally she found success with an MAOI antidepressant, an option that has strong evidence of efficacy but is seldom considered due to the need for dietary restrictions. Once she was finally stabilized on an effective medication combination, she accepted that for her the reality was that medication would be an essential part of her wellness.  The book also describes a host of holistic strategies that Dyane incorporates as key elements of her treatment plan.

Birth of a New Brain offers hope to those struggling with mood disorders, and raises awareness about the little-known postpartum onset specifier for bipolar disorder.  By the end of the book the reader is left feeling as though Dyane is a dear friend who has bravely shared all and held nothing back.  While mental illness plays a starring role in the story, as Dyane concludes her final chapter, “I’m so much more than bipolar.  And so are you.”  Her book reminds us that no matter how hard the illness journey may be, recovery is possible.

Birth of a New Brain – Healing from Postpartum Bipolar Disorder

Foreword by the perinatal psychiatrist and acclaimed author Dr. Carol Henshaw. Available on Amazon in paperback & Kindle versions!

You can also find Dyane Harwood on her blog, Birth of a New Brain, and on Twitter @DyaneHarwood.

 

You can find my other book reviews in my blog index,

The mental illness teeter totter

seesaw

I’ve spent much of this month trying to decide whether or not to spend Christmas with my family.  It’s a subject that has cause a lot of torment and a lot of tears.

I used to love Christmas.  It was always a small, cozy, stress-free family affair. When I’m depressed, though, Christmas just doesn’t matter.  I didn’t go home for Christmas last year because of of my illness, so I thought maybe I should push myself to go this year.

When I told my mom I was planning on going there for Christmas, her response felt lukewarm, which made me think that my parents didn’t actually want me there.  I began thinking maybe I wouldn’t go after all.  I asked if my parents would pay for me to fly home, since the highway there passes through the mountains and can be pretty treacherous in winter.  Mom responded that they would pay, since they had already paid for tickets for my brother and his fiancee.  My mind twisted that into evidence that what mattered most to them was having my brother come home.

Yesterday in a fleeting moment of thinking I’d probably just feel shittier spending Christmas alone, I booked a flight.  I emailed the flight itinerary to my mom, and again I got a response that felt lukewarm.  After much crying, I cancelled my airline tickets even though I knew I was probably being unreasonable.  This morning I got a voicemail from my mom sounding quite concerned, so I decided to rebook the tickets.

Depression twists my thoughts, and even though I sometimes realize that these thoughts are probably coming from my depression, it’s hard not to get swept up in them.  It’s like a constant teeter totter, with depression as the chubby kid and my healthy self as the runty little kid whose feet can’t reach the ground.  I guess that recognizing this is the first step, and I just need to keep working on finding healthy bits and pieces to help bolster my scrawny little self and turn the balance in my favour.

Liebster Award nomination

Liebster award logo

It’s so amazing to get another Liebster Award nomination, this time from Girl with the Paw Print Tattoo, who writes courageously about vaginismus, a topic that too often remains silenced in the shadows.  Her blog is a great example of the value of speaking up about taboo subjects.

I get easily overwhelmed by this kind of thing, so I’m going to try to keep it short and sweet.  What excites me most about these awards is the chance to spread the word about some cool blogs people may not have checked out before.

What is the Liebster Award?

From what I understand, and through a little research, the Liebster Award is a recognition award from one blogger to another. The word Liebster means “dearest” or “beloved.” Through these awards, we can learn more about our fellow bloggers. This helps us to discover and be discovered.

Rules of the Liebster Award:

  1. Acknowledge the blog that gave it to you and display the award.
  2. Answer 11 questions that the blogger gives you.
  3. Give 11 random facts about yourself.
  4. Nominate 11 blogs and notify them of their nominations.
  5. Give them 11 questions to answer.

Questions from Girl With the Paw Print Tattoo:

  1. Why did you start blogging?  It’s a great way to talk about important issues and share ideas with people.
  2. What is your favorite movie?  Dirty Dancing.  I’ve seen it so often I’ve pretty much got the lines memorized.
  3. If you could live anywhere, where would it be? Right here in Vancouver, Canada
  4. What is your favorite season?  Early fall
  5. What is your favorite holiday? It’s always been Christmas, although my illness has made me pretty indifferent to it the last couple of years.
  6. Dogs or cats?  Guinea pigs.
  7. Coffee or tea? Tea for relaxing at home, coffee for an energy boost when out and about
  8. What is your favorite book? A Tale of Two Cities by Charles Darwin.  The ending always makes me cry.
  9. If you were only given one meal to eat for the rest of your life, what would it be? I’d say Cheerios; it’s not exciting, but when I’m coming home from backpacking overseas, it’s always the food I look forward to the most.
  10. What is your favorite hobby? Blogging!
  11. Who is your favorite band? I don’t know if I have a favourite.  I’ve got quite a random assortment on my iPhone playlist.

Random facts about me: They’re all travel-related because I can’t think of anything else right now.

  1. I’ve travelled to 37 different countries.
  2. Australia and Antarctica are the only continents I haven’t visited.
  3.  I spent a couple of nights in a yurt in Kyrgyzstan
  4. I got groped by my guide while doing a semi-controlled fall/dismount off a horse on the way to the yurt
  5. The cheapest accommodation I’ve stayed in was $1 USD/night in Cambodia
  6. I’ve been to Auschwitz and the Killing Fields in Cambodia. Disturbing stuff.
  7. I ate snail soup for breakfast in Vietnam.
  8. I threw up multiple times while flying over the Nazca Lines in Peru.
  9. In France there were multiple occasions I was served wine with ice cubes.  If it’s good enough for them, it’s good enough for me.
  10. Egypt was the country where I’ve encountered the creepiest men.
  11. I would really like to go to Tibet for my next trip.

My nominees: There are so many amazing blogs out there, which makes it tough to narrow it down.  This time around I’m nominating some blogs that don’t have a lot of followers yet.

Questions for the nominees:  I don’t really have it in me to be creative right now, so I’m going to recycle the questions I got from Girl with the Paw Print Tattoo.

  1. Why did you start blogging?
  2. What is your favorite movie?
  3. If you could live anywhere, where would it be?
  4. What is your favorite season?
  5. What is your favorite holiday?
  6. Dogs or cats?
  7. Coffee or tea?
  8. What is your favorite book?
  9. If you were only given one meal to eat for the rest of your life, what would it be?
  10. What is your favorite hobby?
  11. Who is your favorite band?

Thanks again to Girl With the Paw Print Tattoo, and happy blogging and reading everybody 🙂

Looking for forgiveness (and not finding it)

forgiveness drawn in sand

I have had a lot of sh*tty things happen to me in the past year and a half, and it’s really shaken (probably more like shattered) the faith I used to have in the goodness of humanity.  In particular, I look at the behaviour of a couple of people who were in positions to exert considerable power over me.  This behaviour is probably best described as cruel, and it has significantly impacted both my current circumstances and my ability to move beyond those circumstances.  It profoundly disgusts me that people in positions of power can and do conduct themselves in such a manner, and I believe it reflects fundamental problems on a broader scale.  However that is beyond the scope of this post.

“When a deep injury is done to us we never heal until we forgive.” – Nelson Mandela

Throughout this current depressive episode, which has lasted more than a year and been resistant to treatment, I have given a lot of thought to what it might take for me to get well again.  People far wiser than I am have spoken about the importance of forgiveness, so occasionally I ponder this, and ask myself how, or if, I would be able to forgive.  And no matter how often I think about it, I keep drawing a blank.

“Forgiveness is how we put a stop to anger, ill-will and a desire for revenge” – His Holiness the Dalai Lama

In some of my darkest moments, I have contemplated a scenario where I was driving down the street, and a certain person happened to be crossing the road, and accidentally/on-purpose…  Well, let’s just leave it at that; I am not a violent person by any stretch of the imagination, but there is a nasty, vengeful part of me that wishes the people who directly contributed to so much suffering on my part could get a little payback.

“The weak can never forgive.  Forgiveness is the attribute of the strong.” – Mahatma Gandhi

Maybe the problem is that I am not strong enough to forgive.  I am not the bigger person; I’m the little person that my depression has made me.  This isn’t the person I used to be, but now I am easily irritated and really do not like most people.  It feels as though forgiveness would involve climbing to a new height, and I’m wearing flip flops rather than climbing shoes.

“Practicing forgiveness does not mean accepting wrong doing.” – His Holiness the Dalai Lama

The past and future are both painful directions to look in, so I try to just focus on one day at a time.  In some ways that’s a good thing, but it’s perhaps not the most useful as a coping mechanism to deal with  uncertainty or unwillingness around forgiveness.  If I’m truly honest with myself, probably less is uncertainty, and more is unwillingness.  It’s as if by forgiving that would somehow condones the behaviour.  As if in some twisted way I would be betraying myself by forgiving.  I know it’s not logical or reasonable, but there you have it.

hands clasped in prayer

There is another factor that has started bubbling up in my mind recently.  I grew up in an atheist household.  The only religious services I’ve ever attended have been in foreign languages while travelling overseas.  I have long had concerns over the unspeakable ills that have been done for many, many years supposedly in the name of organized religion.  And yet…  Religion makes a regular appearance in a number of the blogs that I read regularly, and this has provided some interesting food for thought.  I’ve been reminded of the deeply powerful and positive role that religion can play, as a source of strength, hope, and meaning.  Is faith a missing piece of the puzzle in the search for forgiveness?

And when you stand praying, if you hold anything against anyone, forgive them, so that your Father in heaven may forgive you your sins – Mark 11:25

I’m the first to admit I have spent very little time looking at the bible, and I found the above passage courtesy of Google, but I wonder, is it easier to find motivation to forgive if there’s something in it for you?  Of course that’s not the intended biblical meaning, and there’s something “in it for me” regardless of how I might find forgiveness, but sometimes a little extrinsic motivation can be useful when the intrinsic motivation just isn’t coming.

Perhaps faith in a higher power can act as a beacon to guide the way along difficult journeys.  I certainly feel like I could use at least a signpost some of the time.  While I’m unlikely to let go of my concerns with organized religion anytime soon, maybe it really is time for some soul-searching to see if there’s some sort of higher power/purpose/meaning, whatever that may be, that could allow me to move beyond whatever it is that’s holding me back, and find the strength to forgive.

 

There is a follow-up to this post here,

Photo  credits:

BenteBoe on Pixabay

Himsan on Pixabay

Psych meds 101: Anti-anxiety meds

anxiety written in Scrabble tiles

This is part of a psych meds 101 series written from my perspective as mental health nurse, ex-pharmacist, and psych med users.  Previous posts have covered antidepressants, antipsychotics, and mood stabilizers, and an upcoming post will touch on sleep meds.  Much of this post will focus on the benzodiazepine class of medications, but I’ll also cover other meds used for anxiety.

Benzodiazepines

Benzos bind to GABA-A receptors on neurons to boost the activity of the neurotransmitter GABA, which exerts a calming effect on the brain.  GABA counteracts the excitatory neurotransmitter glutamate.  Besides being used for anxiety, benzos are used for acute management of seizures and alcohol withdrawal.  Very rapid- and short-acting benzos like midazolam may be used for procedural sedation.  Despite their downsides, benzodiazepines (benzos for short) work for anxiety.  They work very well, and they work quickly.  And  that’s what makes them so darn problematic.

Duration of action

Drugs within the benzodiazepine class differ considerably in their half-lives, i.e. the time it takes for the body to clear half of the medication.  Half-lives are also affected by a given individual’s ability to metabolize the drug.  The half-life of lorazepam (aka Ativan) can range from 8-24 hours, and clonazepam’s half-life is 19-60 hours.  Time of onset tends to be between 20-60 minutes after administration.

Tolerance

Taking benzos regularly for an extended period will lead to tolerance.  Full stop.  How long it takes and the extent to which it happens may vary from person to person, but over time the same benzo dose will produce less of a therapeutic effect.  A general rule of thumb is that benzos work best the less you take them.  Ideally, this might look like finding another medication for sustained use and using a benzo as needed (prn) for breakthrough anxiety symptoms.  Of course, we don’t live in an ideal world and for some people benzos are the only thing that helps them get through the days.  Still, it’s the kind of thing you want to know about going in rather than finding out after you’ve already been on regular benzos for a year.

Withdrawal

That brings me to my next point: withdrawal.  Withdrawal can range from nasty (increased heart rate and blood pressure, cramps, anxiety, insomnia, impaired memory and consciousness) to downright dangerous (high fever, seizures, psychosis).  Withdrawal results from physiological dependence, where essentially your body chemistry changes to adapt to the regular presence of the drug.  We might think of addiction as involving both a physiological and a psychological dependence, but whether you consider yourself addicted or not if you have been on long-term high-dose benzos and you stop cold turkey, you will have withdrawal.  Getting off of benzos requires a gradual tapering down of the dose, and even then it can be a really tough experience.  That brings me back to my earlier point; it’s good to know going in that benzos work best the less you use them, if that’s something that’s feasible for you.

Antidepressants

Antidepressants that promote serotonin neurotransmission can help to settle down the amygdala, part of the primitive caveman brain that is associated with anxiety, fear, and panic.  SSRIs (selective serotonin reuptake inhibitors) or SNRIs (serotonin and norepinephrine reuptake inhibitors) are commonly used.  Older antidepressants from the TCA (tricyclic antidepressant) or MAOI (monoamine oxidase inhibitor) classes may also be used and are quite effective, but they are more likely to cause side effects.  Typically higher doses are required than for the treatment of depression, and it can take longer to see a therapeutic effect because of the complex signalling loops that are involved.  In OCD, it can take up to 10 weeks for SSRIs to be effective.  It can be a frustrating waiting game, and benzos can certainly be useful in getting through this.

Buspirone

This acts on 5HT1a serotonin receptors to suppress neuron firing in a portion of the brainstem known as the dorsal raphe nucleus.  It may take a few weeks to become effective.  It’s an older drug that’s not used all that commonly, but a psychiatrist that I used to work with often prescribed it and found it to be quite effective without a lot of side effects.  It’s not addictive and not sedating, so it’s a pretty low-risk medication to try out.

Gabapentin, pregabalin

These anti-seizure medications act on the transporter that moves calcium ions in and out of neurons.  This helps control the release of the excitatory neurotransmitter glutamate in the amygdala.  While these are not among the anti-seizure medications that have demonstrated mood stabilizing activity, they can be useful for anxiety.  They’re not addictive, although some people experience discontinuation symptoms if they’re taken off too quickly.  Both gabapentin and pregabalin are dosed three times a day.  Gabapentin has a wide dosing range, so it may take some tweaking to get the right dose.

Atypical antipsychotics

Atypical antipsychotics may also be useful.  It’s not entirely clear how they exert this effect, but it may be related to changes in norepinephrine and serotonin signalling via interaction with alpha-2 adrenergic receptors.  Quetiapine is commonly used for anxiety, and risperidone has demonstrated effectiveness in obsessive compulsive disorder.  Atypicals may be used as an add-on treatment for longer-term management or for prn (as needed) use.  Generally lower doses are required than for management of psychosis.

Clonidine

Clonidine acts on alpha-2 adrenergic receptors.  While it has shown some effectiveness, this doesn’t tend to be sustained, and it’s not considered a first-line treatment option.

Beta blockers

Beta blockers like propranolol can settle down some of the body’s fight-or-flight response, and can be useful for “performance anxiety”.  It tends to target the physical effects of anxiety rather than the mental experience.

 

This isn’t an exhaustive list by any means.  There are some other medications including mood stabilizers that may be used, and treatment of choice varies depending on the particular diagnosis.  In the recent DSM-5 PTSD has been moved out of the anxiety disorders category, so I haven’t touched on that at all here.

Next up in the psych meds 101 series will be sleep meds zzzzz……

 

Photo credit: Wokandapix on Pixabay

Pill Popper RN

horde of flying tablets and capsules

The title is a kind of weak ripoff from the Seinfeld-ian Pimple Popper MD, but still, it’s fairly apt.  I have major depressive disorder, and I take a boatload of pills.  Because my memory isn’t that great and I don’t want to forget to take them, I have them all laid out on a shelf in my bookcase.  If anyone comes into my living room chances are they’ll notice the mini pharmacy I’ve got going on, but I am so beyond caring about what people think about that.

In this post I’m going to break down the various things I’m putting into my body to try and stay afloat with my depression.  Medications will never be all of the picture, but for me they are an important part of my treatment plan.

Mirtazapine 30mg and venlafaxine 300mg: These are my two antidepressants.  I have always responded better to antidepressants with more activity related to norepinephrine than serotonin, so these two fit the bill.  The combo is sometimes referred to as “California rocket fuel” because of its potency.  Mirtazapine is actually most sedating at lower doses, so I’ve settled on the middle of the road 30mg dose because I didn’t sleep as well on higher doses.

Lithium 1200mg: I don’t have bipolar disorder, but lithium has actually been recognized for a long time as an effective augmentation strategy in major depressive disorder.  If I start feeling worse one of the first things my doctor and I consider is increasing my lithium, since I tend to respond fairly quickly to dose increases.  When my serum levels get higher, though, I tend to have increased problems with tremor and coordination, turning me into a complete klutz, complete with wipeouts on the sidewalk and falling down stairs.

Quetiapine 600mg: Atypical antipsychotics are also effective for treatment augmentation in depression.  Of the ones I have tried, quetiapine has been most effective for me.  It helps with my mood and is very reliable for getting to sleep.

Dextroamphetamine 15mg: I first tried dextroamphetamine a year and a half ago when I was really slowed down in both movement and thinking.  It helped, but I wasn’t keen on taking “speed” any longer than needed, so I only took it for about a month.  I restarted it earlier this year when I got really slowed down again.  It helped, but when I tried to decrease the dose my mood dropped.  Research has shown that it tends to be effective as an antidepressant augmentation strategy for only a couple of months or so, and then the effect tends to wear off; however, I’ve tried several times to decrease the dose and it makes me feel worse.  My doctor has a good attitude about it, and has no problem with me taking it on an ongoing basis when it’s clearly working.

Propranolol 10mg prn (as needed): Lithium gives me an intention tremor, which occurs with intentional movement as opposed to a resting tremor.  It’s worse if my lithium level is higher or if I’m worn out, and probably the dextroamphetamine doesn’t help either.  Propranolol helps keep it in check, and I tend to use it mostly for days that I’m working, since patients generally aren’t reassured about getting an injection if the nurse drawing it up has shaky hands.

nurse administering intramuscular injection

Lorazepam 0.5-1mg prn: Anxiety is generally not a prominent feature of my illness, so I’ve never needed to use lorazepam (Ativan) on a regular basis.  I find for me it’s most effective to get a bit of a numbing effect when I’m going into particularly stressful situations.  Since I use it so seldom, I’m able to get away with a small dose.

Min-Ovral: I have spent much of my adult life on birth control, but decided a couple of years ago to take a break.  When I got depressed last year, my hormones went crazy.  I was getting my period every 3 weeks and PMS was having a big impact on my mood.  Now I’m back on birth control and my hormones are steady and happy.  The estrogen in the Min-Ovral may also give my neurotransmitters a bit of a boost.

Omega-3 fatty acid plus vitamin D supplement: There have been research studies that have shown that omega-3’s have some beneficial effect on depression.  Vitamin D may also play a role in depression, and since I live on the Wet Coast of Canada where it rains for a good chunk of the year supplementation seems like a good way to go.

Multivitamin/mineral/antioxidant supplement: Besides helping my overall health, the goal with this is to have some effect on decreasing oxidative stress, which may play a role in depression.

L-methyfolate and vitamin B12 supplementation: I get these in an intramuscular injection every 2 weeks from my naturopath.  Both play a role in the methylation cycle that’s involved in neurotransmitter synthesis, and L-methylfolate in particular has been shown to be useful in depression.

So that’s me, Pill Popper RN.  What’s in your medicine cabinet?

 

Photo credits:

Qimono on Pixabay

huntlh on Pixabay

Getting back on the self-care horse

girl standing in front of sunrise

I’ve been letting my self-care slip over the last month or two.  A few factors have contributed to this, including work schedule and being distracted by other things, but a lot of it is depression-induced apathy.  I’m not feeling very well mentally these days, and my body is starting to become unhappy with me.  My gut is a pretty good barometer for my mind-body relationship, and it has not been a happy camper for the last week or so.  Yesterday evening I was feeling nauseated (due I think to a combination of sleep deprivation and far too much caffeine) and ended up having to pull over to the side of the road to vomit.  I’m definitely taking that as a sign that i need to push through the don’t-give-a-crap feeling and recommit to self-care.  Hopefully writing about it will help with turning thoughts into action.

Meditation

I’ve gotten erratic with my meditation practice, and recently broke a months-long daily meditation streak on the Simple Habit app.  Even when I have meditated lately I haven’t really been interested enough to focus on it.  I’m not sure how to change that, but I would like to commit to doing 10 minutes every day and try to build up from there.

Aromatherapy

I have no idea how helpful aromatherapy actually is for mental illness, but if nothing else it’s still pleasant.  I’d used up my favourite essential oil blends and hadn’t gotten around to going to the store to replace them, but yesterday I went to my favourite aromatherapy shop and I’m now good to go.  At the moment I’m diffusing Mountain High from Saje.

Gratitude

For the last 6 months or so I’ve tried to keep a daily gratitude journal, but lately it had fallen by the wayside.  This week I’ve started getting back on track by using a great 30 days of gratitude graphic from The Asylum blog.  Having that structure has definitely been helpful, and I want to finish the 30-day plan and then repeat it again.

Brushing my teeth

When I’m feeling apathetic one of the places it tends to show up is in dental care.  Brushing my teeth doesn’t happen regularly and flossing goes right out the window.  The more I do this, the less I think about how gross it is, but it’s time to break the pattern.

SAD light

My mood tends to dip during the dark, wet Vancouver winter days.  I have a SAD light, and while I’m not sure how much it helps, it’s probably worth the 15 seconds of effort to set it up next to me once a day while I’m reading blogs.  If nothing else it will help get me in the self-care mindset.

Walking

There’s a grocery story near my house, and I should walk there but sometimes I get lazy and stop in when I’m driving home from doing something else.  Getting back into walking should be an easy change to make.

 

None of these things are earth-shattering, but I think if I can manage to cover these bases it will get me back on the right track.  It’s all doable without too much effort; I just have to push through and do it whether I feel like I give a crap or not.

 

Photo credit: Xan Griffin on Unsplash

Postcards from the loony bin

bed in an abandoned asylum

Okay, so perhaps the photo is rather overdramatic.  Still, it does a lot to capture what can be a horrific experience of hospitalization.

I look at this issue from 2 quite different perspectives; I’m a mental health nurse and have worked on an inpatient psychiatric ward, but I also have major depressive disorder and have been hospitalized 4 times.  The first two each lasted 2 months, and the others were each for 3 weeks.  Only one was voluntary; the other three I was committed involuntarily.  I still feel traumatized by many of my experiences in hospital, and the years that have passed since my last inpatient stay have made me even more certain that it should never have had to be that way.  Because of what I have experienced I highly doubt I will ever again go to hospital voluntarily, and on multiple occasions I have resorted to lying to my doctors to avoid being committed.  I doubt I’m the only one who feels this way, and this points to problems in the way that inpatient psychiatric care is being provided.

My first hospitalization seemed like one long fight with the treatment team.  This earned me a diagnosis of borderline personality traits, an inaccurate label that is sadly reflective of the tendency of some health professionals to view patients who are “difficult” as having a personality disorder.  I developed a romantic connection with another patient on the ward, and while I can see why they didn’t react well to walking in on us getting it on in the bathroom (hey, desperate times call for desperate measures), it just kept getting ratcheted up to new levels of ridiculousness.  There was the “5-foot-rule”, that we were not allowed within 5 feet of each other in common areas.  Sometimes that was expanded to a rule of not being allowed in the same room together.  It really should not be surprising to staff that when you treat someone like a child, they will react by behaving like a child, yet I continue to see this sort of thing on a disappointingly regular basis in the context of my work.  In my case, the childish behaviour manifested as hostility, swearing, screaming, and temper tantrums.

During my last hospitalization, when I was first transferred from the medical emergency to the psych emergency ward, the doctor had ordered my regular meds to be held for a day to give time for the pills I overdosed on to clear from my system.  Except no one told me this, so I had a complete sh*t fit at the night nurse: “how the f*** am I supposed to get better if you don’t give me my f***ing meds?”  The next day I applied for a review panel to challenge my involuntary committal.  When it was held a couple of weeks later I lost, and I remember afterwards leaving an angry message for my community psychiatrist: “I’m stuck in this hellhole until whenever the f*** they decide to let me go.”  How very therapeutic.  There I was, locked on a ward, being treated by a psychiatrist that I didn’t trust and nurses whose competence I questioned (like the one who thought I was depressed because I was single, or the one who was annoyed I wouldn’t tell her what I was angry about, since if I attempted suicide I must be angry about something).  I wasn’t allowed to have my cellphone, which would have been a lifeline to my social support network, and I was regularly chided for not attending groups, as if baking muffins with my co-patients would be some great panacea.  The screaming, temper tantrums, and other childish behaviours continued to pop up as over and over again I was treated like a child.

fingers clawing through paper

The nurse side of me gets that sometimes involuntary treatment is the only way to keep people safe, and on rare occasion practices like seclusion and restraint are also necessary for safety.  I’ve seen people respond very, very well to treatment they never would have gotten voluntarily.  However, I think that all too often a shift in perspective is called for so that these restrictive types of interventions used only when absolutely necessarily rather than as a first-line approach to care.

An important ethical issue at play here is the conflicting principles of paternalism and autonomy.  The importance placed on each varies depending on many factors, including the situation and cultural norms.  In general, autonomy is seen as quite important in Western cultures, with some notable exceptions. Medicine has traditionally been a field in which a paternalistic doctor-knows-best point of view has been considered acceptable.  This is something that has started to change as it’s become easier for patients to inform themselves rather than relying solely on a doctor for information.  The field of psychiatry has been slower to come around, and there are a number or reasons for that. Mental illness may cause”anosognosia”, or lack of insight into one’s own condition.  Mental illness may also impact judgment, making it harder to make reasoned, informed decisions about treatment.  This is part of why there are laws that allow for involuntary committal to hospital.

hands holding onto a chain-link fence

That’s fine.  But the ethical reasoning process should not stop there.  By stripping away  a patient’s autonomy and forcing the treatment provider’s choices upon them, the treatment team is undercutting what many would consider to be a basic human right.  This can cause harm, and it can cause trauma.  When I screamed and swore and fought (figuratively, not literally) against the hospital treatment providers, it was because I felt like my dignity was being stripped away.  I did not feel helped, supported, or understood; I felt degraded.  How is that conducive to effective treatment?

Two more ethical issues that are relevant here are beneficence (do good) and nonmaleficence  (do no harm).  I honestly think that most treatment providers believe they are doing good by imposing clinical interventions, but again, the ethical reasoning process should not stop there.  How often is that next step happening, to consider what harm might be done by practices such as involuntary treatment, seclusion, and restraint?  Did any of the health professionals who treated me in hospital even for a moment consider how traumatizing the experience was for me?  I may be biased, but I doubt it.  What I have seen in my own professional practice tends to back that up.  There is too often a sort of arrogant righteousness in those who believe they know what’s best for their patients.

There are ways to impose desperately needed treatment and still promote patient autonomy.  Treating people with respect, compassion, and empathy and valuing their dignity can go a long way.  Making sure that patients feel heard, and that they have at least some input into their treatment plan.  If I could have sent a postcard from the loony bin to those who treated me, it would say “imagine how you would feel if you were the patient”.  It is only by speaking up and sharing our experiences of mental illness and its treatment that the tide can slowly start to shift.

 

Photo credits:

Jon Butterworth on Unsplash

WenPhotos on Pixabay

Fifaliana on Pixabay

Mystery Blogger Award

Mystery blogger award logo

Wahoo, this is exciting!  I’m loving this whole blogging thing, and it’s really great to be able to share ideas with all of you wonderful people in the blogosphere.  I was nominated for this award by Shannon Diana, who mixes raw honesty, passionate advocacy, and fun lifestyle ideas all in one place.

The Rules of the award:

1. Put the award logo/image on your blog

2. List the rules.

3. Thank whoever nominated you and provide a link to their blog.

4. Tell your readers 3 things about yourself

5. Answer the questions you were asked

6. Nominate 10 – 20 people & notify

7. Ask your nominees any 5 questions of your choice; with one weird or funny question (specify)

8. Share a link to your best post(s)

My Nominations:  All of these blogs have amazing stories about mental health and I’ve learned a lot from them.  I’ve tried to nominate people who haven’t previously been nominated for the award, but I’m not all that on the ball so I’ve probably made some mistakes.  And I would love to nominate more blogs but am feeling a bit worn out.  Such is life.  Anyway, definitely have a look at these blogs.

  1. The Bipolar Writer
  2. Mental Health Diary
  3. A Journey With You
  4. Beckie’s Mental Mess
  5. Convolute Me
  6. Deanna’s Dark Diary
  7. Letters of Hope From the Soul
  8. Mentally Un(qualified)
  9. My Battle – the Struggles of Depression
  10. The Daily Struggle
  11. Let’s Talk Depression
  12. Be Your Own Light

 

3 Things about me:

  1. I don’t keep normal human being hours.  I usually go to bed at 8pm and wake up around 3am.
  2. When I was 14 I did a school exchange to Japan and my host family fed me a fish head for breakfast.  Um, thank you?
  3. I still remember from that same trip how to say “please sit here” in Japanese: “koko ni suwatte kudasai”.  At least my memory isn’t entirely shot to shit.

My answers to Shannon’s 5 questions:

  1. What is your best achievement in your life so far?  Probably completing a Master of Psychiatric Nursing degree, especially since based on my thesis work I ended up getting a couple of papers published in peer-reviewed journals examining my own experience of mental illness.
  2.  Where do you see yourself in 10 years time?  I have no idea.  I’m not really in a headspace right now to look much beyond tomorrow.  Whatever I’m doing, I’ll be surrounded by a big herd of guinea pigs.
  3. What advice would you give your younger self?  Reach out for help.  Sooner rather than later.
  4. Why did you start blogging?  I wanted to engage in conversation about mental health issues.
  5. What is your funniest moment? This wasn’t funny at the time, but I was at a train station in India in the middle of the night.  I’d gotten confused about where to catch my train, and staff told me I’d missed it.  I cried like a 5-year-old, and it worked.  Turned out the train was still pulling out of the station.  They radioed to the engineer, and an employee picks up my backpack and starts sprinting down the platform, with me huffing and puffing behind him.  I was then able to leap onto the moving train.  No kidding.

5 questions for my nominees:

  1. What would you want as a one-line eulogy?
  2. What has been your most funny (or frightening) toilet-related experience?  Come on, it’s gross but you know you want to share!
  3. What is your favourite farm animal?
  4. What country would you most like to visit?
  5. What is the strangest food item anyone has ever offered you? (i.e. can you beat fish head for breakfast?)

Link to my best post:

couple kissing

I have no idea what my best post is, but the one that has gotten the most views by far is Let’s Talk About Sex (and Mental Illness).  I’m not that into Pinterest, but I do create a pin with a link for all of my blog posts.  Almost every day I’m getting a click-through from Pinterest to this post.  Go figure.

 

Thanks again to Shannon for nominating me.  This whole spreading the love award business is a lot of fun.

Ashley

 

 

 

Psych meds 101: Mood stabilizers

pill_bottle

This is the 3rd in a series of primers on how psychiatric meds work.  The previous posts were on antidepressants and antipsychotics, and upcoming are anti-anxiety meds and sleep meds.  These are based on my professional knowledge as a mental health nurse and former pharmacist as well as my own experiencing taking these medications (although with a diagnosis of major depressive disorder I’ve never taken any of the anticonvulsant mood stabilizers).

Mood stabilizers work in a number of different ways to control signalling between nerve cells.  They are used to treat and prevent both mania and depression, although some drugs are more effective for one than the other.  They fall into 3 broad categories: lithium, anticonvulsants, and atypical antipsychotics.

Lithium

Lithium has been around for many years.  It works via a number of different mechanisms, including regulating genetic expression of various neuron-related factors, and boosting activity of the calming neurotransmitter GABA.  GABA counterbalances the excitatory neurotransmitter glutamate.  Lithium is effective for both mania and depression, and has been shown to decrease the risk of suicide.

Lithium is a type of salt, so blood levels are affected by kidney function and hydration status.  In the past, some people developed kidney damage from long-term lithium use, but that is rare now as we have a better understanding of what levels are safe.  People taking lithium need periodic bloodwork to check their lithium and creatinine levels (an indicator of kidney function).  Target levels are 0.6-1.2 mmol/L, with higher levels being needed in acute mania.  It takes 5 days after a dose change for blood levels to restabilize.

Lithium can potentially cause a lot of side effects: nausea/vomiting/diarrhea, tremor, weight gain,  hair loss, acne, frequent thirst, frequent urination, hypothyroidism, and effects on the heart.  And if that wasn’t enough, lithium toxicity (levels over 1.5) can cause confusion or even seizures and coma.  Yikes.  Except lithium works very well, and some people may have no side effects at all.

Lithium has definitely been effective for me.  I’m using it for depression, so I aim for levels between 0.65-0.8 depending on how I’m doing.  I have side effects, but for me the benefit outweighs the negatives.  I have a tremor, which is worse when I’m fatigued or if I’ve had to increase my dose.  Taking propranolol (a beta-blocker) helps with this.  I’ve gained weight on meds, but I’m on 2 other meds that cause weight gain so it’s hard to tell what’s causing what.

Anticonvulsants

These medications were initially developed as anti-seizure medications, but have since come to be used as mood stabilizers.  They affect signalling between nerve cells by acting at voltage-sensitive ion channels that allow sodium/calcium to flow in and out of neurons, and they also boost GABA neurotransmission.

Valproic acid/divalproex

These are essentially the same molecule, but divalproex can be formulated into an enteric-coated tablet that decreases stomach upset.  Valproic acid is effective for mania, but it is less clear how effective it is for bipolar depression.  Dosing is targeted to reach a blood level of 350-700 µmol/L.

Side effects include nausea, sedation, weight gain,  hair loss, tremor, negative effects on the liver, cessation of menstrual periods, and polycystic ovarian syndrome.  It is also teratogenic (causes harm to a developing fetus).  I talk more about this in my post on mental illness and childbearing.

Carbamazepine

Carbamazepine is most clearly effective for mania.  It affects the liver’s cytochrome P450 system, leading to interactions with a number of different medications.  It can also decrease the reliability of oral contraceptives.

Side effects include gastrointestinal upset, sedation, dizziness, impaired coordination, and negative effects on the liver, white blood cells, and platelets.

Lamotrigine

Lamotrigine is not effective for bipolar mania, and works best for the prevention of bipolar depression.  It interacts with both valproic acid and carbamazepine, requiring adjustments in dose.  It must be initiated slowly to decrease the risk of Stevens-Johnson syndrome, a type of severe rash.

Other side effects include dizziness, headache, double vision, drowsiness, impaired coordination, nausea, and weight gain.

Others

There are other anticonvulsants that have been tried in bipolar disorder but don’t necessarily have strong evidence to support their use.  These include levatiracetam and topiramate.  Gabapentin does not appear to be effective.

Atypical antipsychotics

The mechanism by which atypical antipsychotics have a mood stabilizing effect is not entirely clear, but may be related to their action at the 5HT2a serotonin receptor and resultant effects on glutamate, dopamine, norepinephrine, and serotonin signalling.  They are useful for both bipolar mania and depression.  Examples include lurasidone, aripiprazole, quetiapine, and olanzapine (which can be combined with the SSRI antidepressant fluoxetine for bipolar depression).

For more detail on atypical antipsychotics, please have a look at my post Psych Meds 101: Antipsychotics.

Role of antidepressants

There are two key problems with antidepressants in bipolar disorder: they don’t work particularly well, and there is a risk of triggering mania.  The International Society for Bipolar Disorder task force on antidepressant use found that evidence for antidepressant use is limited and weak, and as a result they could not broadly endorse the use of antidepressants in bipolar disorder.  An exception is fluoxetine, which is effective when used in tandem with olanzapine.

For more on antidepressants, you can read my post Psych Meds 101: Antidepressants

In conclusion…

I hope that this has all made sense and shone some new light on mood stabilizers.  If you have any questions please feel free to shoot them my way!

 

Photo credit: nosheep on Pixabay

Organizing my way through the darkness

day planner book

I will freely admit that I’m a bit of an organization nut.  It’s a trait that has served me very well in terms of maintaining functioning while bogged down in an episode of depression.  I’ve been doing this depression thing long enough that I know what my deficits tend to be when I’m unwell, and I draw on that knack for organization to create a sort of safety net for myself.

Mental illness can wreak havoc on memory.  When I’m ill, my brain feels like a strange hybrid of Swiss cheese and mashed potatoes.  Since I am aware of this, I can try to plan ahead for it.  I do this by setting up an organizational system that can compensate for some of my deficits.  When it comes to important things, my backup plan needs its own backup plan, since I know that I might not always remember to put things in my calendar, for instance.  This has come to the rescue a few times, including saving me from being a no-show for visits I’d booked with my patients for my home care nursing job.

I rely heavily on my Google calendar.  Everything goes in there as soon as it’s arranged (unless I’m really scattered and forget this crucial part of my system).  I use color-coding to separate work and personal, and have recurring reminders set up for things like bill payments.  I’m also a great lover of lists, and use Google Keep along with Apple Notes.  I’ve got checklists breaking more complex tasks into individual components for those days when I’m feeling too overwhelmed to know how to do anything.  The goal is to rely as little as possible on my brain to remember things.  Working on getting/staying well is hard enough, and any brainpower I can free up is a good thing.

2017 calendar displayed on a smartphone

When depression muddles my thinking, making simple decisions can seem overwhelming and impossible.  If I haven’t decided ahead of time what kind of yogurt I’m going to buy, I might stand in front of the yogurt section at the grocery store for 10 minutes with a blank stare on my face and absolutely no idea how to make a decision about what to buy.  It’s not a matter of anxiety over what the right decision is, but more like that part of the brain that knows how to make decisions has decided to close up shop and take a siesta.  There has been many a time that I have simply left a store empty-handed, because the default decision is do/buy nothing.  I’ve learned that when I’m feeling like this, I need to decide exactly what I’m going to get ahead of time, when I’m not faced with an array of options.  It feels a bit silly to be so rigid, but it’s a lot less silly than staring stupidly at a sea of yogurt containers.

Mental illness can warp how we see the present in relation to both past and future.  It can be very hard to see a pattern in our symptoms and what might be triggering them.  Technology can be a powerful tool to gain insight into what is happening both inside and outside the mind and body.  I use apps to track almost everything I do: sleep, mood, diet, activity, menstrual cycle, medication changes, alcohol, stressful events, work, etc, etc.  Again, it feels kind of silly to be this rigid, but it helps me understand how I’m doing, and makes it s lot easier to answer questions that my health care providers might ask.  When my depression leaves me feeling totally powerless, tracking things on my apps can help me feel a little bit more in control.

cup of coffee, cell phone, and book sitting on a tableHaving a routine is very important to me, especially when I’m not well.  It gives me a sense of peace, and makes it easier to turn down the volume on my thoughts.  Most important is my morning routine.  I drink tea, tea, and more tea, read the discussion forums on a mental health app I use, meditate, and do crossword puzzles.  Even my pet guinea pigs support me in sticking to the ritual – they know that their veggies come at the same time as mama’s first and second cups of tea, and if I happen to forget, they will give me loud squeaky reminders.

We all have our little tricks to help us cope with the day to day experience of mental illness.  These are some things that have worked for me, but it’s always great to learn new strategies from other people who are dealing with the same sorts of issues.  Together we can be stronger, and our bags of tricks can help us make it through.

 

Photo credits:

stevepb on Pixabay

geralt on Pixabay

Juja Han on Unsplash

Sometime the wheels just fall off

Partly shadowed woman crying

It’s been kind of a tough week.  I’ve been working night shifts the last couple of weeks, so my sleep pattern has been wonky and that certainly makes me more vulnerable.  December has brought on a lot of conflicted feelings related to Christmas.  I had originally planned to spend Christmas in Cuba with my best friend, but then something happened that made it abundantly clear that she really knew nothing about me, and we haven’t spoken since.  I have had a difficult relationship with my parents over the last year and a half; when I’m depressed, I push them away, and I think that’s been very hard for them.  They didn’t invite me to come for Christmas this year, and when I let them know I was thinking about coming, the response was lukewarm.  They’re probably just struggling in their own way to cope with my illness, but it felt really shitty.

I spent most of my hour-long drive home from work yesterday morning crying.  Being sleep-deprived tends to break down the walls I try to build to help me keep a lid on things.  To try and cheer myself up a bit I went out and bought some silly little toys for me and the colleague I’ve been working with the last couple weeks, a lovely man who is actually the only person I feel safe with these days.  Anyway, instead of acting cheerful about it he gave me a bit of a lecture on how I shouldn’t be spending money on stuff for him.  I know he was well-intentioned and not in any way trying to be hurtful, but it unleashed all the other stuff I had been barely holding in.  I spent about 2 hours crying at work last night (luckily the clients were asleep so none of them saw me), and then cried some more on my drive home this morning.

I feel pathetic.  I usually try not to beat myself up too much about my depression unleashing itself on the world around me, but I hate crying at work.  It’s the one setting where I feel like I really should be able to hold it together.  Except realistically that’s not always going to be the case.  So I guess I need to let it go and accept that sometimes the wheels are just going to fall off, but tonight I will get some sleep and tomorrow will be a new day.

 

Photo credit: Pexels on Pixabay

Liebster Award nomination

Liebster Award nomination badge

This is my 2nd Liebster Award nomination (my 1st was here).  I was nominated by the fabulous Shannon Diana, a passionate crusader in the fight against mental health-related stigma.

What is the Liebster Award?

The Liebster Award serves to bring new bloggers some recognition as well as some well-needed motivation. This blogging community is brought closer each year through this award which enables us to support each other.

Here are the rules If you have been nominated for The Liebster Award and you choose to accept it, write a blog post about the Liebster award in which you:

  1. Thank the person who nominated you, and post a link to their blog on your blog.
  2. Display the award on your blog — by including it in your post and/or displaying it using a “widget” or a “gadget”.
  3. Provide 10 random facts about yourself.
  4. Nominate 5 – 12 blogs that you feel deserve the award, who have a less than 200 followers.
  5. List these rules in your post. Once you have written and published it, you then have to: Inform the people/blogs that you nominated that they have been nominated for the Liebster award and provide a link for them to your post.

Now the most exciting part of all of this is to make some nominations of my own and share with you some of blogs I’m loving right now that have less than 200 followers.  You should definitely check them out.  My nominations are (in no particular order):

  1. Letters of Hope From the Soul
  2. Happy Mentality
  3. Nourish My Life
  4. Mental Illness: It Does Not Define You
  5. Convolute Me
  6. My Battle: The Struggles of Depression
  7. Reclaiming My Sanity
  8. The Asylum
  9. Confessions of a Borderline
  10. Stigma Unraveled
  11. This Bipolar Brat
  12. Living With Bipolar II

 

I’m going to skip the 10 facts about me because I’m just coming off a week of night shifts and my brain is working rather slowly, and instead I’ll move on to answering the 10 questions posed by Shannon.  Oh, and nominees, I’m passing the same 10 questions on to you (again, creativity is just not happening in my brain right now, so can’t come up with 10 questions of my own).

  1. Why did you start blogging and where were you when you started your blog? I started my blog 2 months ago.  I wasn’t working much, and wanted to do something useful with my time. 
  2. Do you ever fall out of love with blogging? I haven’t been at it long enough to get bored yet.
  3. What’s your favourite movie? Dirty Dancing – “no one puts Baby in a corner”
  4. Favourite make up (or hair/body care) product? Eye shadow – it’s fun to experiment with colours.
  5. What app do you use the most to promote your blog? I don’t do anything blog-related on my smartphone, so no apps, but I have started using Twitter.
  6. What’s your favourite memory do you have while you have been blogging? I usually write my posts a couple of days before I publish them, but it’s been great to throw in some spontaneity once in a while.
  7. Are you glad you started blogging? definitely
  8. What advice would you give to newbie bloggers? Try not to worry about follows and likes and all of that business.  Just enjoy writing and reading!
  9. How often do you post? 2-3 times per week usually
  10. What would you want to happen in a year time for you and your blog? Mostly I just want to keep feeling good about the experience of blogging.
  11. What make up or (hair/body care) product is your least favourite and why? I don’t like foundation, because I don’t like to feel like I’m wearing makeup.

 

Thanks again Shannon for the nomination, and thanks also to my nominees for sharing your words on the important topic of mental health.

xo

When taking a shower is like climbing a mountain

silhouette of a mountain climber

 

We’re supposed to dream big, aim high, reach for the sky, and all that crap.  But what about those days when your mental illness is kicking your butt and you barely have the energy, motivation, interest, or presence of mind to haul your a** out of bed, much less hold yourself up for the duration of a shower?

Let me be clear, setting goals is a good thing.  Pushing yourself to do more than you think you’re capable can allow you to do things you thought you could only dream of.  However, the goals you set should be realistic, and what’s realistic is going to change based on how your illness is currently affecting you.  If you’re setting yourself up for failure, how is that doing you any favours?

When my depression is severe, just getting out of bed can be a gargantuan effort.  If I were to try to go outside for a walk because that’s what you “should” do when you’re depressed, I probably wouldn’t make it beyond the front door.  That would make me feel even more negative about myself, and reinforce the thoughts that I’m useless, pathetic, etc., etc.  I find that I don’t tend to devote a lot of energy to comparing myself to others (perhaps because I hate people when I’m depressed), but I do compare myself to my level of functioning when I’m well.  Realistically, though, that’s not a fair comparison.

The way I try to look at it is that goals should be proportionate to the amount of energy you have and the amount of energy it would take to complete a task.  If depression is sucking the life out of you and your energy level is so low that if it were a gas tank you’d be running on fumes, is it reasonable to plan on going for a 4-hour drive on that empty tank?  Hmm, not so much.

triumphant_silhouette.jpg

So I say, if taking a shower when you’re severely depressed takes about the same amount of energy that it would take you to climb Mount Kilimanjaro when you’re well, then taking a shower is a huge goal and an accomplishment worth celebrating.  The fact that showering when you’re well is easy is totally irrelevant.  It’s not an apples to apples comparison or even an apples to watermelons comparison; it’s more of an apples to mountains comparison.

As I nurse I try to tell both myself and my patients to aim low and dream small when feeling really unwell.  Achieving a “small” goal will serve you better than failing at a bigger goal.  And don’t forget to congratulate yourself for that mountain-summit-equivalent shower that you didn’t think you could do.  You absolutely earned it.

 

Photo credits:

Sam Mgrdichian on Unsplash

Catherine McMahon on Unsplash

Psych meds 101: Antipsychotics

neural_network

Welcome to the second post of my psych meds 101 series on how psychiatric medications work, this time focusing on antipsychotics.  In these posts I’m bringing together my knowledge as a mental health nurse, ex-pharmacist, and gal with depression who’s tried a boatload of meds, and hopefully putting out something that will make it easier to understand the nuts and bolts underlying the meds that so many of us take.  Knowledge is power, after all.

**note: I will exclusively use generic drug names, since brand names vary from country to country

**the other posts in this series are on antidepressantsmood stabilizers, and anti-anxiety meds.

Therapeutic uses

Needless to say the primary use of antipsychotic medications is in the treatment of psychosis.  There are a number of other uses, though, and the atypicals (I’ll get to that soon) are more versatile than the older drugs.  Atypical antipsychotics have an important role to play as mood stabilizers in bipolar disorder and to augment antidepressant regimens in major depressive disorder.  They may also be used for anxiety, and quetiapine is a common example of this.  Sedating antipsychotics such as quetiapine and methotrimeprazine may be used for sleep.  Haloperidol, a typical antipsychotic, is used in the treatment of delirium, a rapid-onset disturbance in cognition and orientation.

Mechanism of action

Antipsychotics work by blocking D2 dopamine receptors.  This impacts four major dopamine pathways in the brain, producing the therapeutic effect as well as side effects:

  • mesolimbic: dopamine overactivity in this pathway is associated with psychotic symptoms
  • mesocortical: this affects areas of the prefrontal cortex (the most evolutionarily advanced part of the brain) associated with cognition and mood
  • nigrostriatal: this pathway is associated with movement
  • tuberoinfundibular: this pathway regulates the hormone prolactin

There are two broad classes of antipsychotics: the “typicals” (older) and “atypicals“.  The key difference between these classes is that atypicals also block 5HT2a serotonin receptors.  This actually boosts dopamine signalling in the pathways other than the mesolimbic, which decreases the risk of side effects related to those 3 pathways.  Additionally, the effect on 5HT2a receptors contributes to a therapeutic effect on mood.  Another difference is that the atypicals are thought to move more rapidly on and off the D2 receptors, which is thought to allow for the full therapeutic effect without as much potential for side effects (this effect is referred to as “hit-and-run”).

To complicate matters, most antipsychotics aren’t very “clean”, in that they affect a number of other receptors aside from D2 and 5HT2a.  And that means side effects.

Side effects

While there is no way to predict which specific person is going to experience which particular side effects, in general medication side effect profiles are based on the types of receptors they interact with.

Movement-related symptoms

Extrapyramidal symptoms (EPS) occur most commonly with typical antipsychotics.  These are named for an area of the brain that is part of the nigrostriatal dopamine-signalling.  Excessively blocking dopamine in this region produces movement-related side effects, including tremor, rigidity, and akathisia (restlessness).  Anticholinergic medications such as benztropine can help to reverse these symptoms, due to an inverse relationship between the neurotransmitters acetylcholine and dopamine in this part of the brain.

Tardive dyskinesia (TD) is a slow onset, potentially reversible involuntary movement disorder that may affect the mouth, hands, and trunk.  It is caused by enduring changes in dopamine receptors in the basal ganglia as a result of long-term use of high-potency typical antipsychotics.  The risk of TD with atypicals is very low, and clozapine may actually improve TD symptoms.

Neuroleptic-induced deficit syndrome

This is a fancy name for causing apathy and related symptoms similar to negative symptoms of schizophrenia.  This can result from blocking dopamine receptors in the mesocortical pathway, and primarily occurs with typical antipsychotics.

Prolactin-related effects

Dopamine blockade in the tongue-twisting tuberoinfundibular pathway can increase levels of the hormone prolactin, which can result in some distressing side effects.  It can affect both sex drive and sexual function, and can also cause gynecomastia (development of breast tissue in men).  In general atypicals are less likely to cause this, although risperidone tends to carry a higher risk than other atypicals.

Metabolic effects

The atypicals win out over the typicals in many senses, but a major downside is that they do carry a risk for metabolic syndrome, including weight gain, increased cholesterol, and increased risk of diabetes.  This may be related to activity at histamine and 5HT2c serotonin receptors.  The big three are clozapine, olanzapine, and (to a lesser extent) quetiapine.  Aripiprazole and ziprasidone do not tend to be associated with weight gain.

Sedation

This can be related to effects on histamine, muscarinic, and alpha adrenergic receptors.  Individual medications vary in terms of which of these receptors they do or don’t effect, so there is a lot of variability in sedating effect.

Anticholinergic effects

The cholinergic signalling system is responsible for resting and digesting activities.  When antipsychotics disrupt this, the result can be things like dry mouth and constipation.  On a more positive note, this can decrease the likelihood of experiencing EPS.  Again, there is a lot of variation from medication to medication as to anticholinergic activity.

Drug-specific details

Quetiapine (atypical)

Quetipine affects serotonin and norepinephrine signalling in addition to its action on dopamine, and this likely contributes to its beneficial effects on mood.  The dose range varies widely, and for good antipsychotic effect the dose needs to be at the higher end of the range, approaching 1000mg/day.

Olanzapine (atypical)

Olanzapine is beneficial for mood.  It has a low risk of EPS.

Risperidone (atypical)

Of the atypicals, risperidone is the most likely to cause EPS and prolactin-related side effects.  Risperidone is metabolized by the body into paliperidone, which carries a somewhat lower risk of side effects.

Aripiprazole (atypical)

Aripiprazole has a unique mechanism of action.  It’s a partial agonist at D2 receptors, meaning it tries to create something along the lines of the Goldilocks just-right bowl of porridge.  It’s not sedating, and can actually help boost people’s energy.  It’s not associated with weight gain.  For all that it sounds like a pretty good drug, when I tried it several years ago I found my mood actually got worse.

Clozapine (atypical)

Clozapine can be a wonder drug for people whose psychotic symptoms are resistant to other medications.  It is the only antipsychotic that has been shown to decrease the risk of suicide in schizophrenia.  However, it can be problematic in terms of side effects.  It can increase the risk of seizures.  It can cause drooling, which can be quite bothersome for some people.  It can cause a dangerous drop in white blood cells, so bloodwork is required every 1-4 weeks.  When starting clozapine, there is a small risk of an inflammatory reaction in the heart called myocarditis.  It’s definitely not a first line medication, but sometimes you really do need to bring out the big guns.

Typical antipsychotics

Examples include loxapine, haloperidol, zuclopenthixol, and flupenthixol.  The latter three are often given as long-acting injections, although there are more alternatives now as a number of atypicals have become available for injection.

Long-acting injections

injectable medication

There are a a number of typical and antitypical medications available as long-acting (“depot”) injections.  These are generally given every 2-4 weeks.  They are given intramuscularly into the shoulder (deltoid), hip (ventrogluteal) or upper buttocks (dorsogluteal) sites.

There are a number of benefits to long-acting injections.  For some people it’s just easier to get an injection every few weeks than to take pills every day.  Long-acting injections produce very steady levels of medication in the blood, and it can be hard to replicate this even if someone is fairly consistent with taking oral medications.  Injections may be the treatment of choice for someone who is on some sort of community treatment order (the terminology and details around this vary depending on jurisdiction), particularly if they’re not keen on taking meds because they don’t have insight into their psychosis.

The downside to long-acting injections is that if people have side effects, they have to wait a while for the medication to clear out of their system.  This can be avoided by trialling someone on the oral version and then switching to the injectable.

In conclusion…

I hope that I haven’t confused you or totally turned you off of antipsychotics.  Personally I’ve taken quetiapine for years and will continue to take it for many more.  Antipsychotics can do a world of good, and I would say the most important thing is to work with your treatment provider to find what works best for you.

I’ll close with a brief anecdote.  I once had a client who had been extremely psychotic when I first started working with him.  We stabilized him on risperidone, and he responded beautifully except he was having sexual side effects.  We lowered his risperidone and added some olanzapine, and now several years later he is an amazing peer leader and advocate.  Meds gave this client his life back, and that’s priceless.

 

Image credit: Geralt on Pixabay

The depression Grinch who stole Christmas

Christmas lights through a rainy window

Growing up, I absolutely loved Christmas.  The tree, the traditional Christmas baking and other yummy treats, Christmas carols, the excitement of Christmas morning, turkey dinner… the list went on and on.  As I grew into adulthood, some of the sparkle faded to more of a soft happy glow, but there was a new form of sparkle in things like rum and eggnog and ice wine.

My first non-Christmas, or Christmas that wasn’t, happened in 2008, when my partner at the time was in ICU following a suicide attempt.  My Christmas dinner that year was a hotdog from 7-Eleven, because nothing else was open near the hospital.  My next non-Christmas was in 2012, when I was locked up in the psych ward.  My family chose to have Christmas at my parents’ place in another city, which I understood but couldn’t help but feel some resentment over.

Depression next stole Christmas away from me last year.  I was completely indifferent, and joined a friend for turkey dinner more because I thought it would satisfy her than out of any desire on my own part to celebrate Christmas.  This year seems to be headed toward another indifferent Christmas.  The large collection of Christmas tree ornaments that are a mix of childhood favourites and new additions is tucked away in my closet, and I haven’t felt any desire to fire up my old ritual of Christmas tree decorating accompanied by carols and eggnog.

While I don’t feel much of anything about Christmas itself, I do feel a sense of loss that something I used to care about and enjoy so much now means nothing.  Maybe if I forced myself to follow the rituals anyway the Christmas spirit would sneak back into my life.  Or maybe it would all just feel like a farce and remind me that I am broken.

I have a small family, and our Christmases have always been intimate affairs rather than a chaotic bustle.  My parents almost always host Christmas, and they live 4 hours away, so I have the options of just not going.  They haven’t said anything about it yet, and I know they’re worried that if I feel pressured it will scare me off.  I probably “should” go home for Christmas, but shoulds just don’t really hold water with me these days.

I suppose what I have to accept is that my depression makes it almost impossible for me to enjoy anything at this point.  Whether I put up a tree or not that isn’t going to change.  But that doesn’t mean some rum and eggnog and butter tarts can’t lighten things up a little bit.

blurry Christmas tree lights

Photo credits:

Guillaime Jaillet on Unsplash

Clem Onojeghuo on Unsplash

Confessions of an introvert

girl sitting alone on a mountaintop

I have always been an introvert.  I am at my most comfortable when I am alone, and being in group social situations is something I find to be very tiring.  As I have gotten older I have not only accepted but embraced my introversion, yet there is always an underlying awareness that being introverted is not necessarily socially acceptable.

I experienced a boost in social activity while I was doing my first university degree, from about age 18-23.  This was fuelled in large part by alcohol, but also by a desire to explore and have fun while figuring out who I was as an adult.  Even at that time, though, I had my small core group of friends that I had strong connections with.

As I moved through my 20’s, I continued to have a reasonably active social life, although it became increasingly clear to me that it felt like work to be in group social situations.  I wasn’t anxious; it was more that it just didn’t feel natural.  I hated making small talk just for the sake of talking, so when I was interacting with people I didn’t feel close to it seemed to take a lot of effort to come up with something to say.  I used to push myself to be sociable even though I didn’t want to be, since I thought I should conform to normal social expectations.  As I moved into my thirties, though, I began to adopt more of a “f*** it” mentality; if I hate parties, I’m not going to go to them just to try to please other people.

I’ve been a mental health nurse since age 25, and that has proved to be the curious exception to my introversion.  I thrive off of interactions with my clients.  In part that’s because the nurse-client relationship is the rare situation where highly personal topics are seldom out of bounds.  I also feel like there’s less spontaneity required; I’ve been a nurse for 13 years, and it’s very much second nature by this point.  My nurse persona is a well-oiled machine that takes little effort to set in motion.

I was diagnosed with depression at age 27.  When I’m depressed, my natural introversion  is amplified exponentially.  As time has gone by, my depressive illness has pushed this introversion to extremes, and I become extremely isolative, as described in my earlier post My Hermitification.  I have pushed all of my former friends out of my life, and while I know in theory that’s probably not a good thing, I am mostly at ease when I am alone.

woman walking alone on a

One misconception about introversion is that it is the same as social anxiety.  Let me put that myth to bed right now; they are two very different creatures.  There are some good reads about social anxiety on James Edgar Skye’s The Bipolar Writer blog, but that’s not what I’m talking about here.  While I may occasionally feel slightly anxious in social situations, social anxiety has never been a major issue for me.  I think a key difference introversion and social anxiety is that being an introvert can feel very comfortable if you accept that it’s the way you are, whereas there is no comfort to be found in social anxiety disorder.

Where introverts may experience the most discomfort is in the dissonance between who they are and the prevalent sociocultural expectations of extroversion.  In many cultures, people are expected to be social creatures.  Parties are supposed to be a good thing, and having a large group of friends is valued; one need look no further than social media to see this.  One good thing (maybe?) that has come of my depression is that I don’t give a fat flying f*** what other people want or expect of me.  My depression makes me hate people, which allows me to wallow in my introversion like a pig in mud.

Maybe, just maybe, if my depression goes into remission again, I will find a happier medium somewhere between my natural introversion and my depression-fuelled dislike of the world.  Then again, maybe I won’t, and my social connections will consist of my pet guinea pigs.  Either way, I fully accept that I am and always will be an introvert.

 

Photo credits:

Denys Nevozhai on Unsplash

StockSnap on Pixabay