Anti-depressants

Sleep and depression

Introduction to my new YouTube playlist on depression

Feel free to add any questions you have as a comment and I'll try to get around to answering as soon as I can.

Link to my Time To Change blog

I was recently accepted as a blogger for the UK's Time To Change campaign, an anti-discrimination, anti-stigma campaign for people with mental health issues.  My first blog entry was added on Monday this week and has already attracted attention on the Time To Change website and their Facebook page.  Below are links to my blog and the Time To Change Facebook page:
  
http://www.time-to-change.org.uk/blog/i-now-use-my-experiences-inform-people-damage-caused-negative-attitudes-towards-mental-health

https://www.facebook.com/timetochange

I would really appreciate it if you could share these links with others as well as the link to the main page of this blog (http://valen1971.blogspot.com).

Symptoms I have known

I think that people underestimate the range of symptoms thrown up by depressive illnesses, not just the usual diagnostic criteria but the strange symptoms and behaviours that can afflict one on the dark path.  I mention behaviours in this as, unlike some people, I actually consider some of my odd behaviours not as separate things or indications of other mental health problems but as symptoms that I would not have if not for my depressive illness.  I don’t deny that I have been recently diagnosed with a personality disorder but some of my behaviours are definitely related solely with my depression.

So, very much in the same vein as my previous article on side effects of my medications, I have decided to write about the symptoms I suffer from in the hopes that it might make someone suffering the same symptoms feel less alone in their pain.

I suppose we should start with the regular stuff first, the most common symptoms or the ones you’ll find in most books on the subject:

• Persistent low mood (for at least two weeks) plus
• At least five of the following:

1.    Poor appetite or weight loss/increased appetite or weight gain

2.    Sleep difficulty or sleeping too much

3.    Loss of energy, fatigue or tiredness

4.    Body slowed down or agitated

5.    Loss of interest or pleasure in usual activities

6.    Feelings of self-reproach, excessive or inappropriate guilt

7.    Complaints or evidence of diminished ability to think or concentrate (slowed thinking or indecisiveness)

8.    Recurrent thoughts of death or suicide or any suicidal behaviour

The above symptoms are self-explanatory and aren’t really worth discussing in too much detail, however, I do have a problem with the persistent low mood one because it could be said to be entirely subjective.  In my case, I have had persistent low mood for 35 years yet my consultant psychiatrist has been of the opinion that I don’t actually suffer with a diagnosable depression even in the presence of at least five of the other symptoms.  It’s hard enough living with depression as it is without being told that your persistent low mood isn’t technically low enough to count as depression.  But a sufferer knows how low they are feeling and how long for, by what right can a psychiatrist, who knows nothing about your usual level of happiness, dictate what is or is not low mood for an individual?  A bit of a side issue, but I think something the profession needs to think about before writing someone off as not depressed.

The trouble with this list is that some of the symptoms can be made worse by the medications you take.  Items 1, 2, 3, 5 and 7 on the list are common side effects of anti-depressants so once you’re on medication for depression, you may not know if the symptoms are genuinely hanging around or if they are, in fact, side effects of the meds.  The only real way to find out is to ‘take a holiday’ from your meds (under supervision of a mental health professional) and see what symptoms remain.

Now we need to look at the other symptoms, the weird and wonderful problems that can crop up with depressive illnesses.  To do this I will take myself as an example.

Anxiety is quite a common co-morbid problem with depressive illnesses but mine comes with sometimes quite severe feelings of paranoia, the feeling that people are looking at you in a strange accusatory way whether they know you or not.  In some ways, my paranoia can be traced to life events but there are also times when paranoia just hits with no provocation.  There are many times that I have questioned people’s motives simply because my paranoia has kicked in.

My depression has also made me quite susceptible to obsessions and compulsions.  One of my over-riding obsessions is the need to find the perfect (or nearest to perfect as possible) instance of any item I purchase.  I take a terribly long time to buy magazines because I have to make sure that there are no imperfections in or on the paper – no dog-ears on the pages, no bends on the spine, no bad printing – and it doesn’t matter how small the imperfection is because once I’ve seen it, I can’t forget it’s there.  In fact, any imperfections tend to draw my eye like a magnet.

I’m also compelled to collect things – partworks, magazines, series of books, anything collectable.  I suppose I should count myself lucky in that I limit my compulsion for collecting things to only things that actually interest me.  I don’t collect, for instance, every copy of a particular newspaper or every piece of junk mail that comes through my door but if there’s a set of books and I have the money I will attempt to buy the entire collection.  For a while, I was compelled to buy the “Very Short Introduction” series of books until I no longer had the money to buy them.  I started out by buying one that I liked the look of and suddenly my compulsion hit and I ended up buying about 55 of them.  I managed to keep myself in check by prioritising the books with subjects that really interested me but I would pick up one even if it didn’t interest me to make up the numbers because, I may be obsessive and compelled to buy the books, but I would only get them on a deal for financial reasons.  Most of the books and magazines I have collected have remained unread because, although I may be interested in the subject matter, I tend to lose interest in actually reading them when I’ve got them home.

This kind of leads me onto the other aspect of my collecting – the need to buy things to feel ‘normal’.  It’s an offshoot of the obsessions and compulsions I suffer from but also has a ‘feel’ of its own.  The more unwell I feel, the more I will seek out things to buy because for the brief time it takes to look for and purchase an item, I feel calm and just like any other person because buying stuff is a ‘normal’ thing to do and I need that normality.  Unfortunately, almost immediately after I leave the store, I am hit by a wave of self-hatred.

Due to certain events during the teacher training course I was on, I was compelled to go to the local ‘pound’ store where everything costs £1 and I would routinely go to class with a bag with five DVDs in it that I felt compelled to buy.  Thankfully, they were all films I was interested in watching but it was still a problem.  I have, however, become quite the connoisseur of the lesser known distribution companies output and there are some great foreign films amongst them, let me tell you.

The obsessive compulsion to collect things and the compulsion to buy things stem from the feelings of emptiness I feel at the very heart of my soul which in turn causes feelings of self-hatred.  Self-hatred builds with every purchase and with every new collection I start but is also added to with every insult, every bit of unwarranted criticism, every putdown that adds to my negative self image and need to punish myself for my perceived weakness.  I know in my heart that I am actually quite an emotionally strong person and possess an equally strong will but depression weakens even the strongest person as it makes you emotionally raw like having a whole in a tooth that leads straight to the nerve.  Every negative comment, every insult, every putdown is like having a toothpick rammed into the hole in your tooth and deep into the nerve.  To have endured that for almost 36 years is proof enough that having depression may be disabling but also makes you resilient...for a time, however, there will always come a time when your resilience is so low that you succumb to darker, self-destructive urges or simply breakdown.

Depression breeds a lack of motivation and a corresponding lack of interest in one’s personal safety.  Why bother doing anything if everything always seems to turn out bad?  And why bother worrying about personal safety when all you can think about is wanting your misery to end?

I don’t know about other sufferers but I have terrible mood swings.  They aren’t bad enough to warrant a diagnosis of bipolar but they can be quite severe and the duration of each swing of the emotional pendulum can vary wildly.  I have had such severe mood swings that I have gone from happy to sad to angry to back to happy in the space of less than an hour.  And mood swings, especially the emotionally violent and rapid ones can be so emotionally draining that the following depressive phase is worse than any previous phases and self-hatred and the inability to motivate yourself to do anything become almost paralysing.

I exhibit many aspects of a persecution complex which is tied not only to my paranoia but to events in my early life that left their indelible mark on my psyche.  I tend to keep stopping still when walking anywhere and turning around to make sure that no one is coming up behind me to attack me and I am almost constantly haunted by the idea that people are looking at me, talking about me, judging me.

I suffer with a very bad memory, sometimes even forgetting things that happened only minutes beforehand.  I have always put this down to my brain’s need to block out as many bad memories as possible but losing the ability to discriminate between the good and the bad memories thus deciding to repress everything to protect me.

Depression can make you feel so worthless and emotionally drained that you start to lose interest in your personal appearance even to the point that your personal hygiene becomes less of an issue for you and you end up bathing less frequently.  There have been times during my worst depressive episodes when I have gone without bathing for a week and only bathing then because my body has become too itchy to ignore.

A depressive tends to become very needy in terms of requiring almost constant external validation from those around them if only to try to counteract the almost constant droning of the voices of self-hatred running around in one’s head – not literal voices though, just the kind of thoughts you have when left with no other distractions.  It was this need for external validation that made me send in draft after draft of my various essays for the various courses I have taken to my tutors.  I knew that the work I was producing was good but my mind rejected those thoughts until I received confirmation from my tutors; even then the depression refuses to let me believe in the good things that are told to me as they conflict with my negative self-image.

It is so hard for a depressive to believe anything good about themselves because of the deep self-hatred built up over the duration of the depression and the longer the duration spent on the dark path the harder it is to ever believe anything good about oneself.  It takes ten good things to register a good thought in a depressive’s mind and only one bad thing to wipe it out so it is no wonder that depressives end up almost entirely mired in self-loathing, denying anything good within them.

With all this going on in a depressive’s mind, it is no wonder that they resort to self-harming behaviours and there are so many to choose from – cutting oneself, taking overdoses, over-eating, starving oneself, buying stuff to fill the empty void within, isolating oneself from the rest of society, binge drinking, taking illegal drugs and engaging in hazardous activities to name just a few.

I, myself, have succumbed to suicidal acts – taking overdoses and trying to hang myself – and, as I’ve mentioned before, I tend to feel compelled to purchase things to feel normal.  I tend to comfort eat and regularly isolate myself from people both in the ‘real’ world and online.  When I was younger, I over indulged with alcohol but not to the extent of binge drinking as it is currently defined; in fact, as it was at a time when I was still undiagnosed as a depressive, it could be put down as an attempt to self-medicate with alcohol to cope with my depression.

All of the symptoms and behaviours I have mentioned above I have, to one degree or another, exhibited.  Some of the behaviours, such as taking illegal drugs, have not been part of my repertoire but have been included as further examples of behaviours exhibited by people walking the dark path.

It is my hope that by being honest about the symptoms and behaviours I have suffered from myself or that have been reported by others, sufferers of depression will be able to feel less alone in their darkness, that somewhere out there someone else is going through similar experiences and having similar thoughts and in that knowledge they may find some measure of hope.

Side effects I have known

I seem to be covering a lot about different aspects of my mental health condition, what made me the way I am and such so I think it’s about time to discuss the side effects I have had with the various medications I’ve had over the years.

First off – Citalopram.  This was the first regular anti-depressant I was prescribed since leaving full-time employment although not technically the first anti-depressant I was ever prescribed as I had a two week course of on drug or other directly following my breakdown at work.

Citalopram had the unfortunate effect of almost completely sedating me into a coma by which I mean that I was sleeping for twenty hours a day when I first started taking the drug.  This side effect wore off slowly until I was down to only twelve hours sleep a day after the first couple of months but this was not the only side effect I had.  I may have been sleeping for twenty hours a day but for the four hours I was conscious I was succumbing to the increased appetite that was triggered in me.  Of course, with such long periods of inactivity I started to gain weight at a fairly rapid rate and that caused problems for my bad back.

Citalopram also triggered anxiety attacks that always struck while I was out of the flat but in enclosed public places – the smaller the enclosed space, the greater my anxiety.  That is not to say that the drug was the only cause of the anxiety and that I wasn’t already an anxious person to begin with but, before I took Citalopram, my levels of anxiety were, on the whole, manageable.

Citalopram was also responsible for some very vivid dreams, one of which became the basis for my darkest poem known only as Untitled 12.

I was on Citalopram for about six months or so but was getting no obvious benefits from the medication and all of the side effects mentioned above so my psychiatrist prescribed me Mirtazapine instead.

I had fewer side effects with Mirtazapine but the sedative effect of the drug sent me back into a long period of unconsciousness every day for the first couple of months and my appetite increased again so I was gaining weight yet again.

Again, the new medication had little or no effect on my mood but was negatively impacting on my daily life, not that the psychiatrist could ever be convinced of that fact.  I kept on telling him that the medication was making me drowsy and that I was having a lot of trouble in the mornings waking up but he never really saw the result of the side effect himself as every appointment I ever had was an afternoon one and I was well-rested and fully awake by then.  As a result, he never believed me when I complained of the sedative effect of the drug.

As the daily dosage was increased, the side effects were supposed to get less although don’t ask me how that works.  Unfortunately, the side effect never lessened enough compared with the impression the psychiatrist gave me and I was still sleeping around twelve hours a day.

When it was obvious that the drug wasn’t helping, my psychiatrist added another anti-depressant to my prescription, Fluoxetine (otherwise known as Prozac).  Sedation was the main side effect and for a short time I was sleeping long hours again but for a much shorter period.

My sleep pattern was widely erratic with all these medications and I never seemed to be able to take the medication at the right time to have a relatively ‘normal’ day/night balance.  If I took the medications in the morning I would be asleep by the evening and awake most of the night but if I took the medications just before bedtime I would end up sleeping well into the late morning.  I tried evenings, I tried mid-mornings but nothing seemed to give me the sleep pattern that would be conducive to a relatively ‘normal’ life.  I certainly couldn’t be expected to try holding down a job as I could never have been able to guarantee my time-keeping.

Again, this combination of medications was not helping me so my psychiatrist changed Fluoxetine for Venlafaxine but the change was little more than different pills, same results and same side effects.

Eventually, in December 2012, after threatening to cut off my access to services and stopping all medications, my psychiatrist suddenly changed his mind about offering me another alternative.  He was reluctant to offer me alternative medications beforehand because I had been prescribed an example of each of the different groups of anti-depressants and none of them had any positive effect on my mood.  He also suggested that I wasn’t even suffering with depression because when I saw him, and the appointments were never what you would call regular, my hygiene and appearance were alright, I displayed insight into my condition and, when asked about what was bothering me, I always tended to list the most obvious things – marital problems, no job, benefit problems, financial stresses – or as he put it, the type of stressors that would make anyone depressed.  He seemed to ignore the fact that my depression had been running for many years prior to those kinds of stressors entering my life and, as a result, he was going to cut me loose as someone the mental health service couldn’t help.

However, he had changed his mind and decided to offer me a newer drug on the market in the place of the Mirtazapine and Venlafaxine I was currently on at that point.  The new medication was Duloxetine.

Unfortunately, Duloxetine had a similar effect on me as Citalopram had, triggering heightened anxiety.  It was so bad that I almost totally withdrew from going out unless I was accompanied by my wife.  This lasted for about a month and a half and was accompanied by the almost obligatory sedative effect that turned me into a sleeping machine for that six week period.

I am still on Duloxetine and I still have sleep pattern disturbances with periods of excessive wakefulness followed by periods of ‘hibernation’.  At my last appointment, in February this year, I was prescribed an additional medication, Quetiapine, but I have not had a chance to gauge what the side effects of that drug are because, as I have needed to keep a clear head for the teacher training course I was on, I have not been taking any of my anti-depressant medication.  However, I will start to take the medications again now that I have finished the course and I will report back how they interact.  I did have the Quetiapine for a week during the mid-course break and, during that time, I did notice that my mind was rather clouded and that my body felt as though it was not my own but I suppose I have that to look forward to again now.

Depression – the heaviest burden

I think that some people really underestimate the effect depression can have on a person’s life.  This isn’t just a case of individual ignorance but of a societal taboo on the discussion of any kind of mental ill-health and the fact that the very word ‘depressed’ has lost any impact due to its over use in everyday conversation.  How many times have you woken up on a Monday morning, facing a long boring or stressful day at work, and declared that “I’m so depressed”?  I would hazard a guess that virtually every person on the planet has done so at one time or other, has assigned the word ‘depressed’ to a mere case of ‘the blues’.

True depression, on the other hand, can shatter your life and leave you unable to cope with the day-to-day rigors of life.  It saps your strength, both physical and emotional, and leaves you susceptible to every single negative comment or action of which you are the focus.  Your ability to concentrate and to make decisions starts to take a downturn to the point that everyday life becomes too hard to engage in, not that you want to engage in the social niceties because you have gained such a negative view of yourself from other people’s negative comments that you start to shun the society that has already shunned you.  You become isolated and less able to function which only makes the situation worse.

Depression makes you see bad situations in terms of catastrophes and robs you of any conception of any possible positive outcomes.  To take a personal example from my own life, I received a letter from the Department for Work and Pensions (DWP) telling me that my current Contribution-based Employment Support Allowance is due to end on 26^th March 2014 and that I may not be entitled to Income-related Employment Support Allowance (IR-ESA).  The stumbling block to me getting IR-ESA is the fact that my wife, from whom I am separated but with whom I still have to share a flat as neither of us can afford to move out, works very close to the maximum hours a partner can work before it affects the other person’s benefits.  What isn’t taken into account is that, being separated as we are, my income pays for my personal out-goings (food, drink, travel expenses, medications, etc) and without that income I won’t have the money to buy food.  In this situation, any ‘normal’ person would try to look at achieving a positive outcome from the submission of a claim for IR-ESA, not so for the person with depression.  In this case, that person is me. All I can see is my claim being turned down, having no money to buy food and drink and my slow painful starvation and death.

You’d think that that was catastrophic enough but a depressed person can always go one or two better than that.  To continue my personal example, my money also pays for health insurance for my beloved cat Merlin so, with my money stopped (as that is the only outcome I can see), I will not be able to party that expense and, although she loves him, my wife can’t afford that expense either so all I can see is that, if Merlin gets ill again, I will have to have him euthanized because I won’t be able to pay the vet fees.  I also pay the TV licence so, assuming I live that long, I may lose my cat and I won’t have the comfort of being able to watch any of the television shows I like because we won’t be able to use the television without getting a fine for watching an un-licensed television.

Still think that I can’t see a way to make things bleaker?  Wrong.  My money also covers any shortfall in my wife’s income so I pay money towards the electricity we use, groceries that we both need when my wife’s money runs out and any unforeseen expenditures that crop up.  Without my income, we may end up losing power and, as our immersion heater is electrical, that means no hot water, no  laundry, no cooking (our cooker is electric), no heat, no light and the loss of all the food that we currently have in our fridge freezer.  I could go even bleaker but I think you get the point.

Every rejection or minor slight becomes a massive thing for a depressive because depression leaves a sufferer emotionally ‘raw’.  Any negative incident or comment immediately inflicts emotional pain similar to the physical pain suffered by someone who has an exposed nerve in one of their teeth and then has a toothpick jammed into the nerve.  And it doesn’t matter how big or small the incident has to be because, as I am keen to point out, it’s not the size of the problem you face, it’s your ability to cope with it and with depression you are already at a disadvantage.

The problem with depression is that, in some cases, a person never gets the chance to recover from one problem before they are hit by another and so they never have the chance to build up their emotional resilience to a level needed to successfully protect themselves from further psychological harm.

Sufferers also have the problem that people don’t understand what depression is like because of the devaluing of the word ‘depression’.  People can see when someone has a broken limb or a physical impairment and even sensory impairments have some outward indicators such as a sensory animal companion, a hearing aid or a white stick.   It’s these outward indicators that ‘legitimises’ the condition of the sufferer in the eyes of the non-sufferer, however, there are no outward indicators of mental illness so sufferers are seen as ‘illegitimately’ ill and therefore are less inclined to be believed.

The only way to prevent this current state of affairs is for people with mental health issues to come out and tell people their story, however, talk of mental ill-health is still taboo.  It may be getting better these days but there is still a reluctance to speak out because of the inherent bigotry against the mentally unwell and the stigmatisation caused by the very association with mental ill-health.

It’s time, however, for people to see that the taboo status surrounding mental ill-health is a mistake and it’s time society learned from its mistake.  Mental ill-health is not something that is going to go away, in fact, research suggests that mental health conditions are seriously underreported and that the prevalence of mental illnesses is higher than the official figures show. 

Depression is thought to affect one in five people at some point in their lives, however, recently, the World Health Organisation (WHO) suggested that the figure should be revised to one in two people and the subject of World Mental Health Day 2012 was “Depression: A Global Crisis”.

Experts stated in PLOS Medicine, a peer-reviewed open-access journal, that depression was the second most common cause of disability worldwide after back pain and WHO launched a global mental health action plan to raise awareness of the problem among policy-makers.  (Read more at http://www.bbc.co.uk/news/health-24818048).

People need to start to see mental ill-health as what it really is – an illness, a medical condition.  Nothing will change until that basic fact is taken on board so that a dialogue can be opened up in the public arena and the taboo status of mental ill-health is forever consigned to the pages of history where it belongs.  Until that day, for those of us who suffer with it, depression will remain the heaviest burden.