Psych Meds I Have Taken

Someone recently  blogged a full list, I thought it was kind of interesting, so once again, I’m bumping a substantial post down the ladder for this one. Here is my list; feel free to add your own:

  • Prozac (when it was new and pretty  much the only thing on the market)
  • Zoloft
  • Nortriptyline (my wonder drug, which I had to stop due to freak side effect, and if it were up to me, I’d keep taking it, consequences be damned)
  • Effexor (worst side effects)
  • Lithium
  • Cymbalta (most useless drug I have taken, horrible withdrawal)
  • Bupropion
  • Desipramine

This does not include the various benzos and sedatives tossed my way to shut me up from time to time when I was particularly obnoxious.

The absence of any other mood stabilizer is due to my stubborn refusal and fear of trying them and denial that I probably need one, not doctors’ ineptitude. I may have tossed back a few days worth of some new SSRIs but not in any significant amount.

I guess I’m lucky not to have (yet) been hit with anything harder.

Physical Versus Mental Illness

In an unpublished email, Milo wrote this comment to me:

Personally speaking, i passed a kidney stone last year, and being dead honest here, i’d  much rather the physical illness than having a paranoid episode… i really really do. i tell you one thing Sara, the pain was absolutely horrendous, but no one laughed at me. i felt much more dignified than i ever did when i was locked up in a psych ward… dead honest…

I think that almost anyone who has had a mental illness of any significance would agree with that statement. And the odd thing is that anyone who hasn’t would think just the opposite. Unless you’ve been there, there is a tremendous underestimation of how much mental illness impacts the quality of life. After all, there are very few physical illnesses – even ones involving extremes of physical suffering and death – that are associated with suicide in a way that even the “common cold” of mental illness, a simple depressive episode, is.

It seems to me that a lot of people who are writing journals like this one – experience journals – about their mental illnesses have a higher than average level of physical illness comorbidity, though I’m not sure that has been epidemiologically proven. There are probably cofounding factors – people plagued by crazy moods usually don’t take the best care of themselves (I am guilty here), destructive behaviors, substance abuse, being ignored by doctors.

But I’m also struck by how quickly physical illness is legitimatized by society, bringing with it what public health sociologists call the “sick role,” which is a social convention that is acceptable to society. Something about the whole construct and theory bothered me in medical school when it was touched upon briefly. I don’t like the blanket statements; I think people should be seen as essentially healthy, and by defining a sick role, you are encouraging sick behavior.  No alternative models are presented in medical school. But it does apply on a societal level as a descriptive model, if not the ideal one.

Yet it doesn’t apply for mental illness – the main two “rights” afforded the ill are not applicable – whether society says it or not, mental illness is seen as, maybe not quite active malingering, but something akin – not quite a “real” illness, not something that justifies the exemptions.  And the second right – that the sick person is not responsible for their illness – it is politically incorrect to disagree with this statement, but hell, if I, medically educated, liberal, and a victim myself, in short,  someone who should know better, insist on blaming myself, well, what can you expect from a society at large?

The “responsibilities” are also problematic. The idea that one should cooperate with a medical model which is infantalizing and patronizing and paternalistic, and often negates the core of one’s very experience with its drugs as well as its conception of pathology (something that does not happen, or at least not as much, in physical illnesses), is equally problematic. I do not agree with my physician – who, according to these same sociological principles, has the ultimate word and is considered the only “technically competent help” I can seek in order to conform with the sick role. Therefore, I in some way abdicate my rights to the sick role.

That’s ok with me on some level. I don’t want the sick role anyway, and, while I know it will probably make a lot of my readers angry, I am often against the institutional reward for the sick role. (Again, another disagreement I have with the basic premise of the theory.)  I think that by making it easier to get benefits for illness – and NOT just mental illness by any means, we infantalize people and encourage sick behaviors, define people as ill, create a permanent and all-encompassing sick role. We create patients who will never get better.

I am all for help, care, love, and rehabilitation – all things that Western countries tend not to give as easily as they give money (which they don’t give that easily either). But the welfare system writes people off, makes them dead long before they are, often encourages them to give up the fight.  It also exempts us as a society from working to improve their health, because they are maintained indefinitely as ill. It is relatively easy to cut someone a monthly check; it is quite difficult to encourage and help them find suitable work – and by work I do not mean employment, but rather “work” in the sense of “to work and to love” – something that gives life meaning. One can be a “healthy adult” with a mental illness. A physical one, too. But not while clinging to the sick role.

Back to Milo: whether we accept the “sick role” concept or not, physical illness is afforded a legitimacy that is regularly denied to mental illness. Here’s my example: I’m not proud of it, but during this last year, while taking one of the meds that made me insanely restless, suicidally depressed, argumentative, and, on top of it all, physically miserable due to akathisia, I landed at one shrink appointment and ended up begging him to do something – anything, just to make it stop. Stop this med. Find another one, one that would work quickly. That I wouldn’t argue, I’d do anything he said, take anything, just to make it stop.

And what happened? I got an annoyed reaction. “You of all people should know that psych drugs take 4-6 weeks to work, that it just doesn’t work like that…and anyway, it seems to be doing you some good.”

This is from a psychiatrist – the kind of doctor supposedly most educated and aware of mental illness, the one who chose to specialize in mental disorders, who presumably thinks they are a source of suffering significant enough to devote his life to treating. If he can’t be sympathetic, how can we expect society at large to be?

I’m not blaming him. I am sure I was annoying and demanding and all that, and there was no easy solution that would have satisfied me. I have certainly lost patience with patients with unreasonable expectations and demands, which mine was. It happens. He also redeemed himself a few minutes later, saying something like, “I know you feel awful,” which was probably what I needed to hear in the first place.

My point: contrast this with the recent very physical side effects of some med or other he gave me, or, what it is looking most likely to be – a peptic ulcer. After all the misery of this last year, the depressions, the irritability, the instability, I hardly cared about the stomach pain and vomiting, which were occuring daily, often during 30 hour call nights. My mood had improved, and the physical shit, while not insignificant and certainly distressing, relative to what I had been through, was almost nothing.

And yet, when I reported these symptoms (which I did at first because I thought they were due to one or another of the psych meds), I was told to rush to a doctor on the same day, if not the emergency room. That got me the sick role, and pretty damn fast.

* * *

Stay tuned for the next post – this one went in a different direction than I intended. I intended to discuss Milo’s point more directly, the way psychiatric illness is seen in the emergency room, by the medical system, and instead ended up here, on a more theoretical note. Later I’ll try to write on comparative suffering – physical pain versus mental pain and whether they are the same or somehow qualitatively different – whether mental illness really is just another type of illness, legitimate suffering, and how doctors really see psych patients.

On mental illness and stigma in medicine

Today I saw a patient for a pre-operative evaluation. This is a consultation for a patient that needs surgery, but who has other medical problems that make the surgeon nervous, and the surgeon basically wants someone like me to sign that I evaluated the person so that I can be blamed if something goes wrong. At least that’s my semi-cynical version of it. My fully-cynical version of it is that surgeons make relatively little money seeing a patient in clinic (though a lot more than a family doc or internist does), and they don’t want to waste time evaluating a patient when they could be operating and billing for the real benjamins.

Of course, I’m messing with the details of the story, but it went something like this: this woman was elderly, but under 80, and had the usual medical problems that go with that age, but not more – mild diabetes, mild high blood pressure, a few other things like that, but no history of smoking, no lung disease and no significant heart disease.
I think that over time I’ve collected a few doctor readers, so I’ll add this list of meds, more or less: some vitamins, a beta blocker, metformin, maybe there was an ACE inhibitor in there, can’t remember, a statin, a laxative, a bisphosphonate and some ranitidine, and a few other drugs, which I will get to in a minute.

She also had a recently discovered cancer, which was the occasion for the operation. The operation is a large one, but not “heroic” or the kind of thing they call people to come sit in the balcony to observe. It’s not a Whipple or anything close, but it’s not a lumpectomy either. It probably will not lead to a cure, but will almost certainly lengthen her life considerably, and will definitely prevent at least some of the uglier complications in the future. It is the standard of care.

Now, the rub: one of her diagnoses was “Depression.” No further explanation. In addition to the above, she also receives lithium at a healthy dose as well as paroxetine. This was the first time I saw her and she is an immigrant who does not speak any language I speak, so we had to speak through her son translating. But she was perfectly pleasant, totally coherent (able to give full medical and surgical history since childhood) as far as I could tell without speaking her language. To my shame, I didn’t ask what her profession had been. (I just didn’t think to while trying to sort out a complicated medical history.) I had never seen her before, and she came with almost no written medical information other than the recent imaging and investigations that were directly related to this cancer. I have no idea how her depression presented, why lithium was added, how long she had been stable or ill, or anything about that particular illness other than what I saw. To be fair, I also had no information about the history and control of her diabetes or blood pressure, though all three issues were controlled during my examination – blood pressure was good, sugars fine as well as HBA1C.

And then this: among all of her documents, I come across a paper that is a statement by a consultant psychiatrist that she is competent and able to both consent to and undergo the operation.

The surgeon and anesthesiologist had both refused to treat her without this evaluation. The surgeon’s referral put the demand for a full psychiatric evaluation (at the family’s expense) above cardiac, geriatric, oncologic, or functional evaluation, and refused to proceed or even make a tentative statement on her suitability for operation without this.

The surgeon, for that matter, does not speak her language either. But I assume he saw a similar patient to the one I did, as he had seen her less than 3 weeks before.

Just the fact that she came in taking certain medications, with a psychiatric diagnosis, one that, for that matter, has no bearing on her ability to decide how to live her life or to comprehend information, could have caused life-prolonging, standard-of-care treatment for cancer to have been withheld, to have been considered “inappropriate” or “unnecessary” or “unsuitable.”

In her case, fortunately, the psychiatrist did not write a full three page summary of her personal flaws (as I have seen sometimes in these types of evaluations), but rather summed it up with a line something like, “Patient understands implications of illness and treatment options and is competent to make any and all judgments blah blah blah.” But how many of these cases never make it that far? How many times, when surgery is an option, do surgeons see a diagnosis like that, or a drug like lithium and decide that the patient simply isn’t a candidate for surgery, or decide not to present all of the options?

I also wonder, if it had been an older man with “depression,” whether he would have been put through this humiliating evaluation, or whether only hysterical women need to be qualified as competent. Or if it had only been the paroxetine and not the lithium? What was it that pushed her into questionable incompetence? Does the referring doctor understand the implications of demanding an evaluation like that – that they are essentially calling into question a person’s sovereignty over their own body? I am hard-pressed to think of any kind of mental disability, including those conditions that include intellectual disability, in which a person cannot be presented with options in a manner fitting their understanding.

I don’t know whether to be angry, or to want to cry, or what. But I think mostly I’m afraid that someday I will be that little old lady with an ugly diagnosis on my chart, whose life is seen as only questionably worth saving.

My Answer to the Commenters

I started to put this in the comments and then just decided to post it as a regular post, because it was turning into one in length.

Thanks for writing, everyone. Thank you especially 5150 for reminding me that it will fade. I kept telling myself that during the worst of it…that it wouldn’t be forever like this.

I have zero benefits or anything. The one private disability insurance I bought probably wouldn’t cover this as a pre-existing condition and it only replaces about $700 a month of income anyway (a percent of what I am paid by the hospital and not the government – and the government pays most of my salary). Jjunior docs have no benefits at all – we are almost hourly wage employees – do not even have personnel benefits at the hospital that the cleaning staff has.

The option would be another job. I constantly remind myself that approximately 99.999999% of the jobs in the world are something other than “physician.” But it seems like such a shame, when I am so close to finishing training not to just suck it up and pull through.

On the other hand, when I find myself on the roof again and again, I keep telling myself, just walk away. You have a choice. You do not need to do this.

And the worst part of it is that it isn’t the practicing medicine that is killing me. It’s the bickering with the nurses who walk all over me, the paperwork, the phone hassles to get tests done. It’s not the essence of the job itself. Sometimes I even think that being decent to people and helping ease their way through something is what is keeping me going.

Another thing is that I quit taking the Wellbutrin and the lithium a few days ago and feel immensely better. One of them was doing something bad to me. I’m not sure which one…but I could feel it physically – shaking, throwing up, feeling drugged and surreal. You’d think that that was a creeping up lithium level, right? But it also came with a terrible agitation and that unreal feeling was never something I got from lithium. It felt like that first time I took the Wellbutrin and flipped out. Lithium, even at its worst, always chilled me out. I semi-wanted to call the shrink and ask what he thought but never managed to have a free moment to do that while it was a decent hour. And don’t even think about getting to a lab to have lithium levels done during business hours. I’ll probably slowly restart the lithium today.

The other thing I am slowly coming to accept are some limitations. While the idea of leave scares me, I realize that I just can’t keep up with my peers with the no sleep thing. They consider a day after call a day off. I can’t even move, and if I don’t sleep through until the next work day morning, I’m crazy. This saddens me. I used to be unstoppable, so ambitious, wanting to take care of everything, be the best at everything.

And I’m also coming to accept the idea that since my good cocktail is gone, I just may never feel totally well again. It’s been a year now, or almost a year…and nothing is any better than when I first started. That’s what sort of fucks up the idea of taking leave to fix the meds – the meds may never get fixed. I may never be what I was.

I think I could be okay with that if I could do a few things that are really important to me. First is to write – which I can’t really do in this state. Others are a creative habit that I can no longer do because my hands shake too badly, and flying, which I can’t do because I’m always on the edge of vomiting anyway. My three passions in life have been stripped away, which is hard. Maybe I just need to throw myself into medicine, which is something I can still do well, and find a real life in it, which is something I never have been able to do. Satisfaction, sometimes. Purpose, yes. Pleasure at using a skill for the good of others, yeah, I guess.

But passion…never.

Yes, I am a tremendous whiner, compared to so many people whose lives have been much more devastated than mine, I’m bitching about having a job as a physician. But still, a dream lost hurts, no matter how grand or small, and I dreamed of something so very different than this squalid sleepwalking broken-down life I am left with.

In which I fall back into my life

I know, I know, terrible to tempt fate. But it seems that the lithium + Wellbutrin combo is working. I’m not 100%, not even 50%. But I am not bat-shit crazy right now, and that brings both tremendous relief and tremendous horror at how I have acted over the past year. All the flying into rages, the inability to sit still, the impatience, the hating everything and everyone – all the stuff the shrink blamed on personality flaws and not mood – it has all just faded away. Now that I am not in the middle of it, I can fully appreciate how awful it was. How awful I was.

And now I have to put my life back together. I missed almost every opportunity this last year to learn something, to enjoy my work, to live my life. I’ve been horrible to everyone who cares about me, either from the irritability or being so sunk in my own misery that I couldn’t extend myself to them at all. By being so irritable and angry and short-fused, I’ve ruined my reputation in almost every department I’ve dealt with. Not the brilliance reputation, which might have even been enhanced (I aced the medical boards while in a similar manic-irritable state – in half the alloted test time), but the idea of being someone that anyone would ever want to work with.

I haven’t been to the shrink in about 3 weeks and honestly, that feels good too. I have a lot of work ahead of me, mending fences or bridges or however that expression goes. I am not sure if I owe him an apology for being so crazy and difficult and aggressive, or if he owes me one for not identifying that more clearly as a fairly severe mood state. Maybe both of us do.

I think I might need slightly more Wellbutrin and soon I need prescriptions for both things (I am still trying to hold fast to the principle of not messing with this stuff myself, getting prescriptions from a treating doc). And the Wellbutrin seems to be making me something of a worrier – every wound I close, I can’t sleep at night wondering if it will open, if it is bleeding inside. This is causing me considerable distress, and maybe I need a whiff of serotonin to tone that down.

I left a message with him last week, never got a call back (he is usually good about calling on the same day) and I’m hesitant to call again because, well, I’m always so ambivalent about dealing with him. In the meantime, I’m assuming he’s out of the country or something, though there is that nagging question about whether he possibly snapped himself and jumped off a roof somewhere. Occupational hazard.

But I don’t really want to go back to any kind of therapy. Not now. Not with him. It has felt good to have that weight and dread of appointments off me during these three weeks. Right now, I need to work on rebuilding my life, making amends, starting to function again. I know how to do that, more or less. Unfortunately, I’ve had to do it many times. A few of them, I’ve picked up and moved and started my life all over, so hard it was to face what I was during the episode, to face the people who saw it.  Sometimes, it’s easier to just start over than to try to fix what is broken.

I think a comment I left over at Secret Life of a Manic Depressive was sort of hurtful, though I didn’t mean it to be. It’s so strange, you learn as a doctor, how sometimes something that you say and mean in a totally different way is interpreted as insulting or hurtful. It’s happened to me. I guess the lesson is, once again, be gentle, for everyone around you is engaged in a great struggle. I’m sorry.

Why oh why can I not fire this shrink?

Thanks so much to everyone who commented supportively. It means a lot.

I was going to cancel the shrink, having hit such a low that I knew that I’m beyond help by anything human. But then I thought, “That’s ridiculous, to not go to the doctor because you feel too bad.”

I went today and laid out how I just can’t take much anymore and to please help me. That I am terribly independent and stubborn and all that, but I’m really reaching my breaking point, that a year of mood episodes almost non-stop is breaking me down. I had no idea how hard it would be to admit this.

His answer: “You can’t be that bad off. You’re wearing makeup.”

Never mind that I had just come from work at a new site rather than coming in after a call night, or that makeup is often my last defense. I subscribe to the “at least you looked good” school, which says that when everything else goes to shit, at least try to look professional.

This provoked a moderately angry response, which earned me a lecture on how bad a person I am, how if only I weren’t so angry all the time I wouldn’t have a mood disorder, how I’m too negative, that I need to just grow up. I’m an adult and a doctor now, I can’t allow myself to slip into manic episodes because they are fun (this was in response to the complaint that lithium is making me an idiot).

I have a  bad temper, but I don’t think I have anger issues – I never have exploded at someone in an inappropriate way. Yes, I am angry at this guy, but fucking up a year of my life and then blaming me for not wanting to help myself – when I have not taken ONE sick day or anything – seems like I have a right to be a little angry.

Anyway. I don’t know why I can’t quit. Part of it is that he’s convenient – conveniently located, flexible about seeing me at the freak hours I can actually make it, and not affiliated with any hospital or clinic I work at. And at least he’s seen my actual episodes. And honestly, most shrinks are idiots – incidentally today I had to call for a consult from the psychopharmacologist he wanted to refer me to and that guy was a complete idiot as well.

It seems I need to just stop going. That’s the odd thing about it all; when I actually seek help, I seem to get worse fast. (One of my complaints today was that over the past year, I’ve turned into a full blown psych patient.) When I am forced to get by on my own, as hard and lonely and scary as it may be, I do.

I guess I need to remember that psychiatry isn’t the answer, isn’t even much of an answer.

It’s the time of year to be thinking about repentance, being better, making amends. I think that might be contributing to my guilt-drenched nightmares. If I am that horrible of a person, which I certainly might be, though not for the reasons he thinks, then I pray for forgiveness from everyone who has ever had to deal with me. I’m sorry. I didn’t mean it. This is all I can think of lately, when my brain manages to function at all: how very very sorry I am for everything, for poisoning this sorry world further, for all the people I have hurt and will hurt. I am so sorry.

Soon it will be signed. I’ll do the best I can in these seven days that are left. I wish it would just be signed and sealed, come what may. I hope for a better year, though I don’t think I deserve one.  And I’m too drugged to even have enough feeling to repent. Still, may the God that lithium erased have mercy on my soul.

Sinking into a depression

It started really two weeks ago, was progressively getting worse. The last time I saw the (useless) shrink I mentioned it, to which his answer was, “The things that are bothering you are things that medication doesn’t treat anyway.” I am not sure what to say to something so unhelpful. Mostly because I know that when the medication is right, I wouldn’t set foot in a shrink’s office. Unfortunately, it isn’t right, and hasn’t been for a long time, and they are pretty much the only game in town.

Something about that comment really irked me. Medication doesn’t treat early waking? Pervasive guilt? Suicidal thoughts? Anhedonia? It’s not like I’m complaining of interpersonal difficulties or relationship conflict. I’m not under any particular stress elsewhere.

I guess it is belittling. When I say I’m depressed, slowed down, I really am. I could go on and on and spell it out for him, but I just am not that type.

Can someone explain to me why I can’t just fire this guy?

Tomorrow I go back to work after a few days off. No, they weren’t health days. I haven’t taken a sick day ever, not even at my most crazy. Sometimes I wonder what some of my locked-away evaluations say, the ones from when I was fully manic. I worry about that sometimes too, at least when I’m not medicated.

I’m supposed to see the shrink again tomorrow – why, I have no idea. So he can tell me I’m fine or even improved, I suppose, because all the energy to get irritated has run out of me.

I tried to read all day today, yesterday, this whole time off, and I can’t. I can’t focus, I can’t remember what I read five minutes before.

I guess I just need to get through the day tomorrow. Maybe even cancel the appointment, as it will almost certainly make me feel worse. Stop this fucking soul-draining lithium too.

I hate this person I’ve become, the true “mentally-ill” type, focused and closed in my own private misery, eating to swollen proportions I’ve never reached before, oblivious to others around me, to the amazing colorful magical world. I used to be a person, a good one even, one who was lively and alive and capable and funny. And I don’t even think it’s really the illness that has shipwrecked me – I think it is the treatment. I’m starting to hate this blog, because while it once was maybe interesting or insightful, now all it is is shit, which is oddly like my life.

Lithium has eaten my hope for a better day. The suicidality that I thought was gone is creeping back over me. It’s a cumulative thing. This has been going on for a year and a half, for I don’t know how many drug trials. Everyone has their limit, and that isn’t a judgmental statement. Everyone just does. I am reaching mine. I can’t take the self-doubt, the guilt, the dreams in which I sob and beg forgiveness of patients who have died.

People say, “Why not take some time off?” But time off isn’t time off from myself. It doesn’t matter if I go to work or not; sometimes I think it was vaguely better when I was working so much harder – at least I was busy. Now, the whole future seems insurmountable, and not worth surmounting at that.

And I can’t help thinking that all this psychiatric care is somewhat to blame. When I was on my own, forced to get by, I did. But with all this encouragement to get treatment, somehow I end up worse off than before. Maybe I am unhelpable; maybe we all are, ultimately left to save ourselves. “We’re all alone, until the day we die.”

So this will be my last random med trial. If this doesn’t work, that’s it. I quit, stretch me no longer on this rough world, whatever. All of this freaky talent, the freak IQ, the whatever it is that I’m supposed to have, well, fuck it, I didn’t ask for it, and I am tired of feeling like I owe the world something.