Meds that can make you crazy (literally)

bottle labelled poison

We work so hard on our mental health, but sometimes we can get knocked down by an unexpected source: prescription medication.  Sure, we all know that some street drugs can adversely affect mental health, but there are also a number of prescription medications for conditions totally unrelated to mental health that can trigger symptoms of depression, mania, and psychosis.  The actual degree of risk varies depending on the specific medication and the patient context, and it’s always a question of risk versus benefit when deciding whether or not to take something.

Antibiotics: There have been a small number of reports of depression associated with norfloxacin and sulfa antibiotics.

Antiparasitics: Chloroquine and mefloquine, which are used in the prevention and treatment of malaria, can cause psychosis and mania.  My opinion is that there’s no reason for a person with a psych history to take either of these drugs, as there are other safe and effective alternatives.  If I’m visiting a malaria risk area, I always take Malarone, which is pricey but I can live with that to avoid psychosis; my second choice would be doxycycline.

Antivirals:  High-dose acyclovir, which can be used in the management or herpes or shingles, can trigger psychosis or depression.  Amantadine, which is used both as an antiviral to manage influenza and as an anti-Parkinsonian agent, can cause psychosis or mania, most frequently in the elderly.  Interferon is not technically an antiviral, but it is used in the treatment of viral hepatitis C; it can cause psychosis, mania, depression, and suicidal thoughts.  Luckily there are other treatment options available now, which is certainly more desirable for people living with mental illness.

Blood pressure and heart medications: Beta blockers have been linked with depression and mania.  Digoxin can trigger psychosis and depression.  The calcium channel blockers diltiazem and nifedipine have been associated with depression.  Diuretics in the same class as hydrochlorothiazide have been linked to depression and suicidal ideation.

Gastrointestinal: High doses of medications from the H2 receptor blocker class for acid reflux, such as ranitidine and cimetidine, can trigger psychosis, depression, and mania, particularly in the elderly or those with renal dysfunction.  Metoclopramide, which is used to boost GI motility, has been linked to mania and depression.

Analgesics and muscle relaxants: Abrupt discontinuation of the muscle relaxant baclofen can bring on depression, psychosis, or mania.  Cyclobenzaprine can also trigger mania and psychosis.  Some NSAIDs have been linked with psychosis and depression.

Hormonal agents:  Oral contraceptives can trigger depression; one study found that this happened in up to 15% of users.  The initial doses of thyroid hormones like levothyroxine in vulnerable patients can trigger mania, depression, and psychosis.  Steroids, including anabolic steroids and corticosteroids such as prednisone, can cause mania, depression, or psychosis, particularly when used at high dose or in withdrawal.  Topical or inhaled steroids have much lower systemic absorption and thus carry far less risk.

This is by no means an exhaustive list, and it’s not intended as a “do not take” list.  For most of these medications, the incidence of psychiatric side effects is low, and most people can take them without any problems.  I take the beta blocker propranolol on a fairly regular basis to manage my lithium-related tremor, and I’ve never noticed it impacting my mood.  I also take birth control and in my case it boosts my mood rather than making me depressed.  I’d say the important thing is to be aware that meds for physical health problems can impact your mental health, and listen to what your mind and body are telling you.

As a final word of caution, I would say be careful with steroids that are taken orally; in my experience they’re the top culprit for medication-related psychiatric symptoms.  Generally with something like prednisone it’s the kind of thing that if you need it, you need it, but there should always be a discussion with your doctor on how to do it most safely and make sure you’re monitored appropriately.

As always, knowledge is power!

 

Image credit: qimono on Pixabay

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Adjusting expectations

steering.jpg

I have a volunteer gig with a local community services agency doing presentations to high school students on suicide awareness.  There’s a pretty standardized format for these workshops, and they are usually done for various grade 9 classes a few times a semester.  I started doing this about a year ago to try to give myself more of a sense of purpose and hopefully aid in my recovery from depression.  I’ve done public speaking about mental health in the past related to my work as a nurse, and it was something that I typically enjoyed and didn’t get overly nervous about.  I’m not sure why I thought that ease of public speaking when well would translate into some degree of ease when depressed, because that has definitely not been the case.

Luckily anxiety hasn’t been too much of an issue; it helps that I know the subject matter well and it’s essentially the same spiel each time.  My feelings leading up to these presentations have been a strange mix of antipathy and forced pseudo-excitement.  I want to feel good about speaking to youth on suicide prevention.  It’s certainly a topic that matters to me and that fits with my desire to combat stigma, but wanting to care and wanting to be excited aren’t translating into actually caring and being excited, no matter how hard I try to convince myself.  I post about it on Twitter in an attempt to stir up some advocative fire, but it only fuels my apathy.  That in and of itself bothers me; I want to be able to feel corresponding emotions to things that are important to me in a cognitive sense.  It’s just not working out that way, though.

I did a presentation yesterday morning to a class of grade 9’s, and the kids were ok; not great about participating, but not terrible.  Once again I disappointed myself with my own performance; it was ok, but not what I would have expected of myself under normal circumstances.  My thinking is slow, and it’s hard to be spontaneous.  There were times when I lost my train of thought or stopped to search for words that I just weren’t coming.  I’ve noticed for some time now that in many situations when I’m having to think hard about what I’m saying, I look up at the ceiling as I speak.  This isn’t something I do consciously, and I’m guessing I do it to minimize visual stimulation in order to focus better.  Normally it’s just a quirk of depressed Ashley, but while speaking in front of a class of kids it certainly doesn’t add to my effectiveness as a presenter.

I’ve had to come to terms with having my level of functioning impaired by depression across multiple contexts, but it seems just a little bit harder when it comes to something like this that I want to be passionate about.  I feel like in a sense I’m letting down my values and ideals.  I’m fully aware that this idea is ridiculous, but there you have it.

I was able to give myself some credit, though, for an email I received yesterday morning from the editor-in-chief at the Journal of Psychiatric and Mental Health Nursing.  The email invited me to apply to be a member of their editorial board.  I’m fairly certain that this was a form letter sent out to anyone that has had a paper published in journal over the last while, but I still thought it was pretty cool.  That’s not to say I’m actually going to apply; without a PhD I’m not properly qualified, plus the workload would be more than I’d be prepared to take on.  Still, I have to remind myself not to discount the positive when I find it.  The email triggered a glimmer of an idea for a new research project looking at mental health blogging; I’ll have to give it some more thought and evaluate whether I have the energy for it or if I’d just be setting myself up for failure, but if I decide to go ahead with I’ll be asking fellow bloggers to get involved.

No matter what it is I’m doing I try to adjust my expectations based on what my illness will or will not allow at the time.  Sometimes I’m able to do that without too much difficulty, and in other situations it can be a real struggle. I guess what’s most important, though, is that I’m attributing my limitations to my illness rather than a fundamental flaw in myself, so it’s a dynamic work in progress.  And as Marsha Linehan would remind me in her DBT assumptions, I’m doing the best I can.

 

Image credit: Maximilian Weisbecker on Unsplash

 

You always remember where you were when…

Sandy Hook elementary never forget sidewalk

There are certain moments in time that become etched in our memories, and we remember exactly where we were and what we were doing when an event happened.  Sometimes that’s because of the significance of the event itself.  For my parents’ generation, that might have been the assassination of John F Kennedy or the moon landing.  I remember that on the morning of September 11, 2001, I was in university but for some reason didn’t have classes that morning.  When I got up my roommates had the tv on, and we watched in stunned, horrified silence as the 2nd tower collapsed.

Then there are the moments we remember not so much because of the event itself but because of our own circumstances at the time.  For me, the Sandy Hook elementary school shooting was one of those moments in time.  Don’t get me wrong, it was a terrible event, but sadly these types of events occur with disturbing regularity.  I remember Sandy Hook, though, because it is burned in my mind what was going on for me at the time.  I was in the small psychiatric emergency ward in a suburban hospital near the city where I lived.  It was a single large room with curtained off beds and a small seating area with a tv.  There was nothing else to do, so I watched tv and picked at the rats nest that my hair had become during the delirious days prior to my admission.  The tv was tuned to CBC Newsworld, the 24 hour news channel of Canada’s public broadcaster.  As I watched the story unfold, I felt a curious sense of indifference.  The only thing that really struck me was that I wished Adam Lanza could have shot me rather than those innocent kids.  Why did they get to escape this world while I was stuck rotting on the psych ward? Aside from that thought, I just kept mindlessly picking away at my hair.

I don’t like the heartlessness that depression brings about in me.  I previously blogged about my own non-reaction to the Las Vegas mass shooting; I was disturbed more by my lack of reaction than by the event itself.  Indifference was not a “normal” way to look at such a horrific tragedy.

I find it interesting that my life’s chronology has come to be defined very little by external significant events and much more by illness events.  Hospitalizations and relapses form the major milestones as I look back at my life over the past 10 years.  Everything else is situated in relation to those milestones; either that, or it just blurs into a fog of meaninglessness.  I regularly watch the news and so am aware of major world events, but unless things somehow relate to my depression journey my brain relegates them to the discard bin.

Mental illness changes how we interact with the world around us, and that can be distressing and even frightening.  It can be hard to separate how much of our reactions are truly our own and how much are the illness.  Why are both 9/11 and Sandy Hook burned in my mind when so many other events have gone into the dusty filing cabinet of my brain?  Why did 9/11 trigger stunned horror while Sandy Hook triggered nothing?  It’s not something I try to beat myself up over, but I do find it curious.  As in so many other situations, I’m not really sure where I end and the illness begins.  On this journey of self-discovery I don’t think I’ll ever find concrete answers, and maybe there will always just be more questions.  Still, it’s important to keep asking those questions – and maybe that’s what I really need to take away from all of this.

 

I am actually getting stupider

THINC-it test results

Despite what the title might suggest, this post isn’t about me being self-critical.  I have been struggling for months with cognitive symptoms of depression, and on a daily basis I notice that it impairs my functioning.  But it’s not something I’ve ever had much of an objective sense of.

Until yesterday.  As a nurse working in psychiatry, I need to keep up my knowledge base, and my preferred way to do that is by watching webinars.  I decided I would get going right away for 2018, and watched a presentation on depression and cognition by Dr. Roger McIntyre, a professor of psychiatry at the University of Toronto who does some really interesting research.  So much of what he said resonated that I felt like he was talking about me.  He mentioned one study that found that people in their mid-thirties experiencing performed about the same on cognitive testing tasks as people with a blood alcohol content of 0.08 (legally impaired to drive).  Hmm, sounds about right.

Dr. McIntyre and his colleagues recently developed a tool called THINC-it to objectively evaluate cognitive performance in people with depression.  There are 5 elements: a short patient self-report, and then 4 different computer-based cognitive tasks.  As soon as I finished the webinar, I downloaded the THINC-it tool and gave it a go.

My results are in the picture above.  The ball on the left is my self-report of cognitive symptoms, and the next four balls represent the four different tests.  Green is good, and red is bad.  I performed abysmally.

It’s interesting to see an objective reflection of what I have been feeling for some time now.  It’s hard to be confident in my perspective of my own impairment when I’m stuck in the middle of it.  I do recognize, though, that I’m much lower functioning than I used to be, and the difficulties I have with basic tasks don’t match up with my high IQ and graduate degree.

One thing that Dr McIntyre mentioned that I’d heard before in other webinars is that vortioxetine is the only antidepressants that’s been show to improve cognitive functioning across multiple domains independent of its effect on mood.  I was actually saying to my doctor just the other day that maybe I should consider vortioxetine, but I’m not keen on rocking the boat by switching up my antidepressants.

Having the confirmation of this test, though, makes me think a little more strongly about making a change.  Depression is bad for the brain; there are cumulative neurodegenerative effects, and outcomes are worse for people who don’t achieve full remission between episodes.  For me right now the most prominent symptoms I’m having are cognitive, and while my current meds help somewhat, it just doesn’t look like they’re going to fully treat these symptoms.

So maybe it is time to try vortioxetine.  Yet the idea of a major med change terrifies me, because it was so hard to hit on this particular combo when I was really sick 5 years ago. This is perhaps the only time I have regretted that I’m seeing a family doctor rather than a psychiatrist.  I’m really happy with my doctor, and for the most part I’ve liked that I tell him what I’m considering and he gives me feedback on what he thinks is the best choice. When it’s something as big as this, though, a part of me wishes for someone who’s up on the latest knowledge in the field to take the lead.  Then again, I don’t trust very easily, and I trust my current doctor.

I’m not sure what I’ll decide, but I think I should make sure that I’m not just accepting the status quo by default.

Sometimes my body rebels

trees spinning dizzily

It seems like every so often my depression decides to remind me that I’m not the only one steering the ship that is my body.  For the last three days I’ve felt quite dizzy for no obvious reason; I’m well hydrated, and I’m not doing anything differently.  Also, I’m headachy and my intestinal tract seems to have slowed down to a crawl despite plenty of fiber.  I don’t seem to be fighting off a cold or anything like that.

I haven’t been able to identify a pattern for when this happens, but it is the kind of thing that my body throws at me periodically.  The last time was maybe 6 weeks ago.  I was dizzy enough that shoulder-checking while driving was challenging.  I was sufficiently frustrated with the constipation that I decided to go for the big guns and take some CitroMag, the kind of thing that might be used for pre-procedure bowel prep.  It made me feel horribly nauseated, but didn’t do what it was actually supposed to do.

I’m not feeling anxious or catastrophizing about it, and am not concerned there’s some underlying physical issue going on, but I’m just feeling yucky, and the dizziness in particular is quite unpleasant.  I’m hoping that in the next few days my depression decides to move to the back seat and let me have my body back under my control again.  Funny how mental illness doesn’t seem too interested in staying “mental”.

 

Image credit: Felix_Hu on Pixabay

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 downtown, 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.

 

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.

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