“What are you taking?” Once you’ve identified someone as a fellow traveler, that’s how you usually break the ice. Before you ask what they do for a living, whether they’re in a committed relationship, have children, or root for the Red Sox or Yankees (correct answer revealed later), you want to know what drugs they’re on. It’s a bonding thing.
Once they answer, the proper response is a thoughtful, “Huh.” followed by a few pleasant stories about anyone you know who has ever taken that drug successfully.
There are some people who respond by telling stories of people they know who took that drug and broke out in hives, had brain-crushing headaches, and/or ended up in an Inpatient Psychiatric Unit.
I consider this to be in extremely bad form.
Despite my uncertainty, if not total ignorance, about these things, when I used to hear what drug someone was taking, I thought I had something useful to contribute to the discussion. After all, I did much better with Lamictal than Depakote. Celexa made me crazy (literally) this time around after working for years. Wellbutrin helped even out my moods in the late 1990s; this time, it did little more than blunt the occasional edge—just enough so that when I told folks I felt a little better, I didn’t feel I was perjuring myself. Seroquel left me uncomfortably numb. When combined with Depakote I felt drugged (a delineation that might seem meaningless in my case). Lorazepam made me feel just weird. Buspirone has a short half life and allegedly doesn’t cause cognitive or memory impairment. I took it two or three times a day and it made me feel stupid. Valium was addictive for me. But, for whatever reason, I can take Klonopin on and off with no problem.
The point is that my experience is irrelevant. All my opinions and attitudes are based on the assumption (delusion) that how something affected me might affect you.
I’m not trying to show off here. (Well I am, kind of.) It’s just that understanding the dysfunctional categorizing and fairly irrelevant nomenclature of drugs helps me understand what the ones I take are supposed to do, how they relate to each other, and how they relate to other ones I’ve taken in the past. Call it idle curiosity. Call it an obsessive thirst for knowledge. Call it empowering. When I learn this stuff, it makes me feel better.
For example, I’ve always wondered why there are so many different SSRIs. Seemed to me that a drug inhibits serotonin reuptake or it doesn’t. It turns out that there are a whole lot of different molecules that can inhibit serotonin uptake. And they all do it a little differently. In particular, they all influence different combinations of receptors and metabolize at different speeds.
The speed of metabolism is particularly important for anyone who wants to understand what’s happening in their brain when they take a psychotropic medication. Because it explains a drug’s average “half-life.” (Average because of everyone’s different size, shape, metabolism, etc.) A half-life defines how long it takes for half of the drug to get out of your system. Which helps explain:
• Why you might be told to take one drug, say, three times a and another once per day;
• Why they make ER (extended release) and/or SR (sustained release) versions for some drugs and not others;
• Why it takes different lengths of time to get up to a therapeutic dose … in other words, for all those overlapping half-lives to stabilize into a fairly steady amount in your bloodstream;
• Why they usually tell you not to double-up after missing a dose;
• Why some drugs are more addictive than others;
• And why, since we all metabolize drugs differently, you should tell your psychiatrist everything you can about your health history and daily habits. She or he might not be pleased that you smoke, drink, and never exercise, but it’s better to fess up, rather than be given the wrong amount of the wrong drug.
You can have a basic understanding of all these things just from knowing the half-life of the drug you’re taking. Because, unlike the Strontium 90 they just found in the soil near my friendly neighborhood nuclear plant—which has a half-life of about 30 years—the half-life of most medications can be measured in minutes, hours, or days. Obviously, the longer the half-life, the less problematic it is to miss one dose. Again, we’re talking average half-lives. And none of us is average.
Here’s a case in point. One morning, well after I’d stabilized, I realized I was running out of Lamictal. I called for a refill, but, having no other excuse to go downtown, I decided to split my two doses that day (i.e., 50 mg twice a day instead of 100 mg twice day).
The next morning, I took a whole 100 mg pill because I was sure I’d get downtown sometime that day. But I didn’t. Maybe it was snowing or something. So, I took 50 mg that night and 50 mg the next morning. I can’t remember why I didn’t go to the pharmacy that day. In any event, I took my last 50 mg that night. I knew had had to go downtown the next morning. No matter what.
The writers of those tiny-type prescription inserts whip themselves into a frenzy about how you can break into weird rashes, send your blood pressure soaring, and/or die if you lose at medication roulette. But, at least with the antidepressants I’ve taken, they’re rather la-di-da about missing one dose: don’t double up, just take your next regular dose and get on with your life.
They do not, unfortunately, include the warning, “Hey, Dave … yeah you, the guy in Vermont … we’re assuming you’re not an idiot. In other words, that you’ll go downtown and get a refill ASAP after you realize you’re out.”
The half-life of Lamictal is particularly variable, ±25 hours seems to be the accepted average for someone taking it on a regular basis. So, on the day after a given dose, you have about 50% of that dose left in your system; 25% the next; 12.5% the next, and so on. Since, in this case, over the previous three days I’d taken about half as much as usual … well, you do the math. (I get really confused when I try.) Bottom line, I was reducing my blood levels way faster than I would have if going off intentionally.
As I said, half-lives depend on a lot of subjective factors, e.g., how much you weigh, other drugs you’re taking, and whether your kidneys and/or liver are operating at full power. For example, if you’re also taking valproate acid (Depakote), the half life of Lamictal is considerably longer; i.e., you need significantly less. That’s why, when I segued from Depakote to Lamictal, my psychiatrist gave me a special pack that dispensed exactly the correct amount to take of each, every day over a five-week period.
Statistics aside, when I woke up around 6 a.m. the fourth morning, I was seriously agitated. But the pharmacy wouldn’t open for a few hours. I took a Klonopin, which calmed my mind a little but didn’t do much for the shakes. By the time I was in the car, my heart was racing, I was beginning to cold-sweat, and it took all my powers of persuasion to convince myself I wasn’t having a heart attack. At one point, I almost pulled over and called 911.
I got downtown and managed to feign some measure of calm while picking up my prescription. I started sucking on one before I was even out the door. I felt better almost immediately—maybe a placebo effect, although Lamictal is absorbed pretty quickly (reaching peak concentration in 1.4–4.8 hours). Most of my symptoms were gone within an hour, leaving me with that feeling of shaky relief you have after narrowly escaping a car crash.
When you first go on a medication, you might feel shaky, lose your appetite, get headaches and/or nausea, and/or dizziness, and/or insomnia—the list goes on and on … even in 8 point type. You also might get more depressed, more anxious, more manic, and even more suicidal. All of which could also happen if you don’t take the drug.
Going off a med can be just as risky. And, with many of them, doing it suddenly can be downright dangerous. In fact, one of the best arguments for universal healthcare is that some patients stop taking medications too quickly because they can no longer afford them … sometimes with tragic results.
I always considered myself to be a well-informed patient but, reading the literature now, I’m amazed at how little research I did back then about specific drugs. Altho
ugh, in the midst of this kind of experience, it’s hard to know whether a little knowledge is a good or a dangerous thing.
Drugs can cause headaches, stomachaches, heart aches, flu-like symptoms, incontinence, impotence, indigestion, dizziness, blurriness, bloatedness, and any other malaise you can imagine. Of course, so can everyday life. But, if you happen to be taking a drug when one of these symptoms arise, there might be a cause-and-effect thing going on.
When you start taking an SSRI, it can take a little time for your body to adapt to having so many more successful serotonin synapses. And since, as I mentioned before, 90% of the serotonin in your body is in your gut, stomach problems are a common side effect. In extreme cases, it can feel like you just swallowed a vibrator—which was one of the symptoms of my “Serotonin Syndrome” episode in October 2005.
So if you feel extreme agitation in your stomach, it’s time to call your doctor. And make sure you tell him or her if you’re taking any supplement or herb that might also be affecting your serotonin levels.
While side effects like this usually occur when you start taking the drug, in some cases they appear down the road. Troubling as that may be, it’s a relief to know that your blurriness is probably due to medication and not brain cancer. Usually it’ll go away after you and your doctor change the dosage or wean you off that one and work you onto another. But, don’t let that stop you from dialing 911 if you get into a real panic.
The package inserts have a lot to say about side effects, but most of us only care about a few things:
Will I gain weight? Since I lost 25 pounds during my breakdown, this was not a huge concern for me. In fact, I’ve considered writing a book called, Psychotics Guide to Weight Loss & Lower Cholesterol. (The latter dropped about 50 points.) But it is a concern for many people and certain meds are more likely to cause weight gain than others.
Is it okay to drive? Since driving a car is kind of difficult if you feel groggy, have a splitting headache, and/or are throwing up, it’s a pretty good idea to be careful when you start taking a med or raising a dose. Feel weird? Pull over. Whoever’s waiting for you … they can wait.
Can I drink? I’ve never seen a pill bottle with a warning that says: “For maximum effectiveness, get smashed daily while taking this drug.” Pharmaceutical companies and most medical professionals err on the side of caution and often say outright that you should not drink. Others will use the famously subjective: “in moderation” phrase. There’s also the argument that, since alcohol is a depressant, you’re kind of defeating the purpose to drink while taking an antidepressant. (Although, they’re actually depressing different systems.) You can work those fine points out with your doctor.
However, I hasten to point out that, as hopefully everyone knows, combining alcohol with anti-anxiety drugs that depress your system (like Valium or Lorazepam) is a seriously high-risk behavior.
Can I have sex? If you and your partner are consenting adults, why not? Sure, you may find you’re not as interested, or might not be able to, uh, perform to your, uh, satisfaction, if at all. And, that might throw your partner for a loop—although she or he might cut you some slack since she or he is so relieved that you’re not curled up on the floor with a blanket over your head. That’s not particularly sexy. There are also, in some cases, changes in weight and body image that, let’s face it, can affect both partners.
On the other hand, you might find your orgasms last longer and are more intense. Or, if your drug-taking partner is a guy, maybe he’ll last longer—if he gets there in the first place … which can’t hurt—within reason. And, like sex itself, it’s certainly different for men and women and from person to person, couple to couple, and I imagine—but only imagine—threesome to threesome.
Plus, different antidepressants affect your sex life differently. So, if it’s an issue for you, your doctor may be able to prescribe a different med or a performance-enhancing drug (the legal kind) that can be safely taken in combination with your antidepressant. If you’re in a relatively committed relationship, it might help for you and your partner to see a therapist. After all, your depression is affecting both of you and it can alleviate some stress to get your sexual concerns out on the table.
I am way oversimplifying this issue. In particular, the fact that depression can greatly exaggerate a whole lot of other issues in a relationship besides sex. Fortunately, most therapists are very aware of these dynamics, and in many cases can help.
To be crude, my advice would be, if possible, to get sane first and get laid second. And to trust that the two aren’t mutually exclusive.
Taking psychiatric medications is a commitment. Sometimes, you may have to try more than one. Sometimes, you might need some big-time psychotherapy at the same time. Sometimes, yes, you may get worse before you get a lot better. There frequently are side effects. You have to remember to take them every day and, in many cases, never stop suddenly unless so ordered.
But, if your moods have reduced you to a dysfunctional blob, remember: It’s about you, not some point on an indecipherable graph. It’s about you, not friends who think you should just think positively or should try this or that “natural” cure or do yoga or t’ai chi. It’s about you, not some drug company that says you’ll live happily ever after if you take their drug. It’s about you, not some researcher who says drug companies are getting rich by duplicitously marketing antidepressants to people who don’t need them.
It’s about you, not some guy who’s writing this book!
Talking to a doctor about antidepressants is not a sign of weakness. There’s no reason to be embarrassed. In fact, when you’re juggling your own personal blend of high anxiety and deep depression, it can take a lot of courage.
One time, at the end of a recent six-month check-up, my psychiatrist suggested that we increase my meds for the winter. I knew, intuitively, that he was right. The signs were all too present: the bottom falling out for a few hours every day or two instead of every month or two; periods of agitation that made me want to get away from everyone in sight … including myself. Few if any outer triggers for either.
“The sadness …” he asked, “on a scale of 1–10?”
I didn’t want to lie … or tell the truth. I compromised: “Uh, 7 or so.”
“And right now?” he asked.
I tried not to look down: “Uh, 6.” (He doesn’t accept 5 as an answer … he considers it a cop-out.)
He understood the question behind the question behind the statement … and he had the answer ready: it’s time to get ahead of this thing. We did. I was significantly better in three days.
Some might say: “Oh, too bad you needed to up your meds.” Whereas they would never say, “Oh, too bad, you had to up your B vitamins.”
Even though I’ve claimed that perspective is a contraindicated prejudice—particularly in my generation—I confess to sharing it. Something in me would like to find a long-lasting, more “natural” solution than having to take .03 grams of a mysterious compound called duloxetine HCl (Cymbalta).
I’m not trying to disparage anyone’s choices. I just think it’s healthy to be aware of the underlying cultural assumptions that lead some people to feel that they’ve failed when they “resort” to Western medicine; as well as the dismissiveness or even scorn other patients face when they try an “unproven” complementary treatment. I’ve learned the hard way that it’s best for me not to be swayed or limited by any philosophical ideology.
Purgatory isn’t as different from Hell as you might think. For example, in Hell, the Gluttonous lie in putrid mud. In Purgatory, they lie stretched out, face down, bound hand and foot. In Hell, the Wrathful continually tear each other limb from limb, whereas in Purgatory they have to walk through smoke darker than night. In other words, you’re damned if you do and not purged if you don’t. And both are worlds of hurt.
There are three particularly purgatorial times in a psychiatric patient’s life: (1) When you’re prescribed a med and are waiting to see if it
works, especially since you might feel worse before you feel better; (2) When (if) a medication stops working. Which can make you feel like you’ve reached the promised land only to be thrown unceremoniously back in the lion’s den; and (3) When you’re trying to find a new med that does work. Because it often takes a couple of seemingly endless weeks to wean yourself off the first drug and then another couple of endless weeks to work your way up to a therapeutic dose of the new one—which, itself, may or may not might work. (By the way: in the case of many meds, this transition can be done simultaneously.)
Recently, I emerged from a bad day or two. Maybe it was a three-week flu that kind of exhausted me. Maybe it was some stress here and there—nothing to write home about. In any event, it happened. I could tell it wasn’t that bad … that I was still several giant steps back from the edge. I managed not to panic. I didn’t push myself to write. I did do my workouts. I made sure I took some extra vitamins and a smidge more Cymbalta. By now, I have a lot of experience with these dips. For the most part, they’re just like the way most people feel when they’ve had a “bad day.” But I totally understand why patients who’ve been doing really well can get totally freaked out when this happens. You’ve survived Hell. You may still be in Purgatory, but you’re making progress and figure you’re heading in the right direction (up). The idea of going back down can be unbearable.
But what about me? What should I do? I’ve done my damnedest to explain just how hard it is to diagnose mental illness, give it a name, understand the different types of drugs available, and why they may or may not work for some of the people some of the time.
So, if you’re able to get out of that funk by working out every day, eating less sugar, taking some vitamins, getting more sunshine, and/or meeting with a therapist every week, you might consider holding off on the meds.
David's Inferno Page 11