Tag Archives: Medication

Issues Surrounding Psychiatric Medication

Yesterday, Lydia of On The Borderline wrote an interesting piece on the stigma surrounding psychiatric medications and opioids for chronic pain. Today, I am going to add my own two cents to the conversation on meds.

Like Lydia says, many people, including patients, fear that psychiatric medications will change the person taking them, turning them into a zombie. I must say there is some truth to this. However, it’s hard to tell whether the medication is at fault or it’s the person’s illness. For example, as regular readers know, I spent a long time in a psychiatric hospital, including on a long-term care unit. Most people there have severee, treatment-resistant schizophrenia spectrum disorders. Most people who fall into this category were indeed heavily sedated and could be seen as “zombies”. However, the term “zombie” is a rather derogatory term for any human being, mentally ill or not.

When I started medication in 2007, I was indeed afraid of the antipsychotic I got prescribed turning me into a “zombie”. I was on a low dose of an atypical antipsychotic (which seem less sedative than classic antipsychotics) and it didn’t sedate me that much. It did keep me somewhat calmer than I was without medication, though I still felt pretty much as miserable.

This brings me to another issue that I touched upon in my comment on Lydia’s post: medications aren’t there for behavioral management. Okay, that may not be entirely true, in that severely aggressive people may benefit from medication for behavioral management if nothing else works. However, it’s a last resort and care must be taken to assess whether the patient actually feels better or they’re just too drugged up to make their feelings known. In this sense I, being a former long-term psychiatric hospital patient given medication for behavior control, have a different perspective to Lydia. She, after all, seemed to assume in her post that it’s stigma that keeps people from taking medications that could make them feel better.

Not that this didn’t happen in my own case, but in a different respect. I was taught in my years in inpatient psychiatric treatment, that medication is pure behavior control and how I felt didn’t matter. This not only got me to take medications I feel I didn’t need, but it also kept me from getting medications I did need. This is the case with my antidepressant. I was finally diagnosed with recurrent, moderate major depression in 2017 when I sought a second opinion on my diagnosis. I’ve probably been suffering depression off and on since at least age ten, but it was masked by my challenging behavior. Because I with good reason didn’t expect anyone to care about my mood if it wans’t bothering the staff, I was never treated for depression while in the hospital. Finally, earlier this year, I got a psychiatrist’s appointment to discuss my mood and was prescribed a higher dose of my antidepressant. (I had already been put on an antidepressant several years earlier, but don’t ask me why.) It seems to be working now.

Increase in My Antidepressant Dose: Is It Working?

Tomorrow, I will see my psychiatrist for a medication review. Last month, the dose of my citalopram, an SSRI antidepressant, was increased. Do I truly feel it helps?

When I started on the higher dose of citalopram, I had no idea what to expect. I’d originally been prescribed this medication in September of 2010 and had never had its effecacy evaluated. I seem to remember I was put on citalopram after the dose of my Abilify had been increased twice in a few months’ time and I was still very irritable. Abilify is an atypical antipsychotic commonly used for irritability and emotional dysregulation of all kinds. Citalopram is primarily used for depression and anxiety, but it can also help with emotional dysregulation, or so I seem to remember my psychiatrist having said.

Even before I started on my higher dose of citalopram, my mood started to lift a little, possibly because of anticipation. Once I started on the higher dose, my mood remained relatively good for a short time. Things were looking up in the day activities department, so that also helped.

One thing I have clearly been noticing, is that I’m more active. I have less need for sleep during the day. I am also a little more motivated and inspired to get things done. Though I obviously did’t complete the #AtoZChallenge, I did write far more regularly on this blog last month than i’d done in almost two years before.

Another positive that I’ve noticed is that I am more able to keep myself from engaging in self-destructive behavior. I do still have urges, but I’m more able to reach out for help first.

Though these are all very positive changes, I must say that if I’m truly honest, my depressed mood is still the same if not worse. Same for my irritability. I still experience this feeling as though a heavy weight is on my shoulders. I still get agitated very easily. I still experience suicidal thoughts.

Then again, these are most likely more symptoms of emotional regulation issues rather than major depression. Unfortunately, there’s no medication that targets these specifically. I won’t have my first appointment with my new treatment coordinator till the 17th, and I assume we won’t be diving back into dialetical behavior therapy right then. I try to use the skills I’m learning through self-help groups and apps, but it’s all rather hard.

Changes

This week has been rather eventful and yet, nothing really did happen. A lot of changes are on the horizon for me, yet nothing has really changed yet.

First, I found out a few weeks ago that next week, my primary day activities staff will be leaving the day center. It is great for her, as she’ll embark on a new and challenging path in her career. For me though, it’s quite hard. Some of my other staff and family have been askign whether I mind at all, since I’ve been struggling at day activities and she was the one who filed the incident report that led to my day activities hours being cut. Yes, I do mind, since despite this, I like this staff a lot.

Then on Thursday, I found out that my CPN is leaving too. It’s also to embark on a new and challenging path in her career, but it’s sad nonetheless. My CPN and I have had quite a few misunderstandings over the ten months so far that we’ve worked together. However, I’ve noticed that I did make progress. It seems odd, since both my husband and my psychiatrist have been commenting on how I didn’t get far on the DBT course yet and it’s apparently my CPN’s fautl. Apparently, she should be limiting my bringing up only indirectly related topics.

I know the nurse practitioner who will be replacing her already from my intake interview last year. It is a slight disadvantage that he’s male, but other than that, I think I could get along with him just fine. However, it’s still a bit stressful that so many people are leaving at the same time. After all, my nurse will also be taken off my case. We’re not yet 100% sure who will be replacing her.

On Friday, I had a meeting with my psychiatrist. We discussed my progress on the DBT course, my medication and I mentioned I’ve been rather depressed lately. I did say it’s been going on for half a year already, so if I can hold it together for that long, it must not be that bad. She ignored this comment and proposed to increase the dose of my citalopram from 20 to 30mg. It’s a bit scary, since I’ve been on 20mg ever since 2010 with no med review whatsoever and I didn’t even know why I’d been prescribed it. IN this sense, I like it that my psychiatrist did ask to see me in a month’s time for an evaluation. I really do hope the med increase will help with mood improvement.

Considering Getting a Psychiatrist’s Appointment on My Depressed Mood

Tomorrow, I have an appointment with my community psychiatric nurse (CPN). Part of our appointment will likely be about where to go from here regarding day activities. My CPN already E-mailed me that she’d contacted the Center for Consultation and Expertise. They will hopefully take on my case and help me and my staff assess my needs. That will hopefully help us find a new place or get me the right support at my current place.

I also intend to ask her to get me an appointment with my psychiatrist. I feel too embarrassed to schedule one through the secretary. It’s been 3 1/2 months since my last appointment, so in that sense I could request one just for a catch-up. However, I want to discuss something specific with the psychiatrist and I feel incredibly ashamed of it. I’m finally coming to the conclusion that my depression symptoms are getting worse and to a point where I don’t know how to handle them anymore.

I was more or less by chance diagnosed with major depression last year. This came to light when I had my autism-related independent assessment. I had to fill out a screening tool for depression as part of the intake procedure. I scored as severe on that one. I was then evaluated further and was diagnosed with recurrent moderate depression. Because this was an independent assessment, my psychiatrist isn’t affiliated with this hospital and doesn’t need to take over the diagnosis. I don’t know whether she has.

I do take an antidepressant and have since 2010. Same medication, same dose all these years with no med review whatsoever. I don’t even know for sure why I was put on this medication, except that my Abilify (an antipsychotic) had been increased twice in a few months and I was still irritable.

This is the main reason I feel embarrassed about asking my psychiatrist to evaluate my mood. I mean, irritability bothers other people and ttat’s always been the main reason I was in care. Like, in 2007, when I was admitted to the mental hospital, it was really because of suicidal ideation but my staff always said it was because I’d been having public meltdowns.

I don’t know whether I truly believe that psychiatry’s job is to keep people, or me specifically, from being a pain in other people’s asses. I don’t think it should be. However, I’m rather afraid that my psychiatrist thinks so at least in my case. I’m not exactly sure why, as so far she’s been pretty understanding. I guess they may be left over feelings from all these years being treated like a cumbersome waste of resources.

Keep Calm and Carry On Linking Sunday

When Intense Emotions Take Over My Mind

Okay, this year’s #AtoZChallenge didn’t work out. I knew it would be tough writing about autism and related disorders when myself undergoing re-assessment for autism. It didn’t help that, from the E-mail I received on the day I posted my theme reveal, it became clear that I will not have an answer before the end of April. That wasn’t the reason I haven’t written at all since April 1 though. The real reason was my mental health.

Like I mentioned, I have been rather anxious and depressed lately. It however got extreme over the past two weeks. This likely isn’t a worsening of my depression as much as it is emotional dysregulation. That doesn’t make it less real though.

About two weeks ago, I started being more irritable and having more dark, death-related and suicidal thoughts than I had before. I had had almost-daily dark thoughts for a few months, but now they became more than daily. I also started making more concrete plans for a final step. Before then, there had been bizarre images in my head of how I’d die by crucifying myself over the staircase at home and such. These had appeared a bit laughable even to my twisted mind. Now, I started making plans and the before then bizarre-sounding thoughts didn’t seem that ridiculous anymore.

I wandered out of the house at home last week Saturday. Thankfully, my husband came back from where he’d been within aobut fifteen minutes and I was fine. Then on Sunday I had a very bad argument with my named nurse that ended in me melting down.

On Monday, I decided I’d stop taking my medication. I didn’t take my morning meds other than birth conrol and vitamin D (because I wanted to take birth control and couldn’t tell the two apart) on Tuesday. I spiraled out of control that same afternoon. This, for your information, can’t have been from withdrawal yet.

The reason I quit taking my medication was that I’d been having these dark thoughts for a while already and yet I felt I was too drugged up to express them. I don’t mean that I wanted to tell the world, like I’m doing now, but I wanted to be able to cry. And cry I did. I also felt like maybe, if I stopped taking my meds, I’d feel some kind of motivation again. I take a high dose of an antipsychotic, which admittedly the psychiatrist says can’t cause flat affect. I also take an antidepressant, but I’d forgotten why I’d been prescribed it (in 2010!) and it had never been reviewed.

Admittedly, there was also a part in me that wanted to signal to my staff that I wasn’t coping. That didn’t really work. My psychologist said that, if I wanted to be taken seriously about my mood, I needed to take my meds. Not that she’s ever taken me seriously about my mood, unless writing depression NOS into my diagnosis counts, which I don’t feel it does. She also told me that I sabotage the independent assessment if I don’t take my meds. I don’t like to admit it but that was one reason I started taking them again on Saturday. I hate to admit I give in to authoritarian manipulation, but I do.

on Wednesday, I started experiencing what I believe are brain zaps – a kind of weird dizzy spell caused by antidepressant withdrawal. I at first thought they were a side effect of a failed attempt at an overdose. They weren’t. By Friday, they occurred about every minute. I was then ready to start my antidepressant again, but wasn’t sure I could safely go back on it after five days. The nurses had to ask the on-duty doctor or some kind of head nurse or whoever and I didn’t get an answer till Saturday afternoon. Now I feel so stupid for havng bothered the nurses with this question on a week-end. I am glad for no more brain zaps though. I did also start back on the anitpsychotic. Not because I want to be on it, but because it seems I need to.

Since late Thursday evening, I’ve felt relatively well. I still experience anxiety and depression, but my emotions aren’t as out-of-control as they were before. Some things that helped were one nurse taking me on walks and allowing me to use her boxing equipment to blow off some steam. It sucks that I can’t do this at home.

#Depression: What It Feels Like to Me

I have had experience with low moods since I was a child. Nonetheless, until a few months ago, I was never diagnosed with depression. During the last round of diagnostic revisions, my psychologst decided to diagnose me with depressive disorder NOS along with dependent personality disorder and borderline personality disorder traits. I am not sure I agree and my psychologist admitted at first that it was more her needing to give me a diagnosis on axis I to warrant me staying in the institution than my actually needing treatment for this.

Today, Aspiecat described what depression is like for her. I could relate to some of these experiences, but nto others. I am going to describe what it’s like to be depressed for me.

Let me first say that low moods are my default. I am pretty sure that dysthymia, ie. chronic but mild depression, is a more useful diagnosis for me than depressive disorder NOS. Apparently though my psychologist doesn’t feel I meet the criteria for that. Really not remembering a prolonged time when I did not feel low makes me wonder whether I’m truly depressed or just pessimistic. I know that depression and optimism do not mutually exclude one another, but I tend to gravitate more towards the negative than the positive.

Then there is the state, as opposed to the trait, of being depressed. Like Aspiecat, I experience two forms of depression: the first in which I feel numb and inert and the second in which I mostly feel despair, sadness and often anger. The former tends to last longer and be harder to overcome. During this state, I sleep more than usual, eat irregularly but usually more than normal, am slower than usual and generally unmotivated. I don’t usually experience the extremest of dark thoughts in this state. Rather, I worry and feel a bit anxious. I may experience suicidal ideation during this state, though it’s rarer than when I’m in my state of despair. I am also less likely to act destructively, unless you count binge eating. When I do experience suicidal ideation in this state, it’s more of a logical, thought-based kind focused on self-hate rather than an active wish to die. I just can’t be arsed to care about life.

In the state of what Aspiecat refers to as meltdown, I, like her, experience all kinds of negative emotions. I think I may be somewhat alexithymic (unable to read my own emotions) too. I often express my emotions as anger when I’m in this state anyway, even though I think I experience many other emotions. I am more likely to experience suicidal thoughts and to engage in destructive behaviors in this state. I am usually agitated rather than slow.

Unlike Aspiecat, I prefer the state of despair to the state of numbness and inertia. There are several reasons for this, one of which may just be the fact that I’m currently numb and not liking it. Any emotion seems better than this state of inertia now. I however also feel that my despair is more actionable, because it tends to be more situational.

Other people also tend to understand my state of meltdown more than my state of inertia. They see me lying in bed all day as a choice, whereas when I’m in meltdown, they see my despair. They may not accept my agitation in this state, but at least they notice that I’m not doing well. My medication also tends to help with this state more than with numbness. I do take an antidepressant in addition to an antipsychotic, but I’m not so sure it helps with my low moods. The antipsychotic and maybe the antidepressant too do take the edge off of my agitation.

Unfortunately though, people see my state of despair as more needing treatment than my state of numbness. This may be because I don’t tend to respond well to psychotherapy and medication-wise, there is simply more to be done against agitation. I take a high dose of an antipsychotic on a daily basis. I also have a low-potency neuroleptic, an anti-anxiety benzodiazepine and a sleeping pill (also a benzo) as PRN medications. All of these can be seen as depressants. Like I said, I do take an antidepressant too, though in a low dose. I am not so sure it works, but then again it isn’t a great medication for the kind of atypical depression I experience. By this I mean that it isn’t shown to be too effective with depression that is characterized by inertia, eating and sleeping too much and general anhedonia (numbness). This kind of depression is particularly hard to treat.

Because other people are more bothered by my meltdowns than by my state of anhedonia, I also feel they tend to want me to be numb rather than agitated. I mean, of course they don’t actively want me to be numb, but they see it as less of a problem, because it causes little disruption to others. I go along with this and have never asked for more help, medication-wise or otherwise, with my inertia-based depression. I am not so sure that I should.

X – #AtoZChallenge on Mental Health

Welcome to the letter X post in the #AtoZChallenge on mental health. I have two words for you today, so this is a short post. Here goes.

(E)X-Patient

I have said this when discussing “survivor” in my letter S post, but many patients have endured traumatic experiences while in psychiatric care. As such, many are happy to be freed from psychiatry. There is a movement called the C/S/X movement. The C stands for “consumer”, ie. those still in psychiatric care. The S stands for “survivor”. Once consumers/survivors have completely freed themselves from psychiatry, many feel comfortable only with the label “ex-patient”, which signifies they are no longer involved with psychiatric care.

Xanax

Xanax, the brand name for alprazolam, is one of the strongest benzodiazepine tranquilizers. Xanax is commonly used to treat anxiety or panic. Other benzodiazepines are also used as sleeping pills, but I’ve never heard Xanax being used for this purpose.

Benzodiazepines are highly controversial drugs because they are often overused and they can become addictive. In the Netherlands, for this reason, people can only get benzodiazepines covered by insurance if they have epilepsy, an anxiety disorder for which they’ve tried at least two antidepressants, or if they have severe mental illness requiring high doses of benzodiazepines (for chemical restraint). On this last ground, many severely mentally ill people take benzos on a daily basis. Worse yet, people without mental illness can get only one prescription for ten sleeping pills, to be used over the course of ten weeks, and even then they have to pay for them out of pocket. People in the psychiatric hospital almost always take sleeping pills much more frequently and many take them everyday. When patients are in the psychiatric hospital, benzos are paid for by insurance. I wonder whether I’ll get my benzodiazepines covered once I leave the institution. Depends on whether my condition is seen as a severe mental illness requiring high doses of benzodiazepines.

M – #AtoZChallenge on Mental Health

Welcome to the letter M post in my #AtoZChallenge on mental health. We’re finally halfway through the challenge. It’s proving pretty hard for me. Particularly, I’m finding it hard to comment on others’ posts regulalry. Sorry about that. This letter was an easy one.

Medication

Medications are usually believed to be an essential part of treatment for severely mentally ill people. The most common psychiatric medications used are antipsychotics, antidepressants, mood stabilizers and benzodiazepines. I will discuss benzodiazepines separately.

Practically everyone on a long-term inpatient unit takes an antipsychotic. It seems every psychiatrist has their favorite medication of first chooice, though a large number of patients take clozapine. This is not the antipsychotic of first choice, since it can cause potentially fatal side effects, but many people on long-term units are treatment-resistant. Other well-known antipsychotics are aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa) and quetiapine (Seroquel).

Commonly-used antidepressants include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). These belong to the newer class of antidepressants, called SSRIs. Venlafaxine (Efexor) is an example of an even newer class, called SNRIs. It isn’t as commonly used though. (Efexor in partiuclar was heavily promoted by big pharma in like 2008 but it seems it’s not the wonder drug originally thought.) When people have treatment-resistant depression, they may get older antidepressants (tricyclics of MAOIs) or an antipsychotic (particularly Abilify) may be added. Mood stabilizers are primarily for people with bipolar disorder. Lithium is th most well-knwon mood stabilizer, but anticonvulsants (originally intended for people with epilepsy) are becoming more and more commonly used.

Mindfulness

Mindfulness is one of the recently hyped-up treatments for mental health problems. There are mindfulness workbooks for everything from depression to bulimia to obsessive-compulsive disorder. Mindfulness can be a great part of psychotherapy, but of course it isn’t for everyone.

Movement Therapy

Movement therapy utilizes exercise, yoga or other movement-based techniques in the treatment of mental illness. Exercise can alleviate depression and anxiety. Relaxation techniques are also used in movement therapy. Often, a movement therapy session consists of first doing an exercise and then talking it through with the therapist. Movement therapy can be done both in group and individual settings. I have experience with both and it’s been a help in channeling my irritability..

Music Therapy

Like movement therapy, music therapy is a form of non-verbal therapy for mental illness. I have never had music therapy, because it wasn’t offered at my old institution, and I get the impression that most people here use it to learn to play an instrument. For some though, merely listening to music can be healing and may be part of music therapy.

I – #AtoZChallenge on Mental Health

Welcome to the letter I post of my #AtoZChallenge on mental health. This was a hard letter again, but I stil have a few words for you. Here goes.

Intramuscular Injections

Antipsychotics can be taken by mouth, but many can also be injected in a patient’s muscle. That way, they need to be administered only once every week or two rather than taken daily, because in a muscle, they’re absorbed slowly and steadily. Intramuscular injections, also caled “depot medication”, are often used on patients who refuse oral medication.

Involuntary commitment

Like I said in my letter D post when discussing danger, patients who are a danger to themselves or others can be committed to a psychiatric hopsital involuntarily. In the Netherlands, there are several ways a patient can be committed involuntarily. In acute situations when a patient is a grave danger to themselves or others, they can be taken into care with the mayor’s approva. Usually, this takes the form of a simple phone call by a psychiatrist to the mayor (or their substitute), who will almost automatically give the go-ahead. A judge will see the patient committed this way within a few days and approve or deny the involuntary commitment. An acute section lasts three weeks and can be prolonged with another three weeks once.

If a situation is less of an acute problem or after at most six weeks on an acute section, a patient can be brought to a judge for a longer section. A patient does not need to be an immediate and grave danger to themselves or others; merely being a danger suffices.

There are two newer forms of commitment too. First, there’s the observation section, which lasts three weeks and is meant for people who haven’t yet been diagnosed with a mental illness and aren’t a grave, acute danger either. A patient on an observation section can’t be subjected to force. A patient who realizes they might become a danger at some point, can file for self-commitment, indicating they will be admitted to a hospital and treated if certain criteria have been met, whether they want to at this time or not.

A patient can’t at this point be forced into outpatient treatment unless through a provesional section, threatening involuntary inpatient treatment if they don’t comply with their treatment plan while in the community. The government is trying to change the law so that patients can in fact be forced into any form of mental health treatment.

Milestones in My Mental Health Recovery

This week #theprompt celebrates its 100th edition. I was guessing at the prompt for this week, as I often do, and this time, I was right: milestone. There are many milestones in one’s life. Birthdays, particularly important ones like eighteen or thirty. Graduations, be it from preschool, high school or college. Getting married, the birth of a child or grandchild, and the list goes on. When I thought of the word “milestone”, however, I thought of the milestones in my recovery from mental health problems. I am going to share them here. I include steps I’ve taken in my journey with autism here too.

1. Realizing I have a problem. In a way, I was always aware of my being different, but I didn’t realize there might be somethng really, clinically “wrong” with me till I was fifteen. Then I realized I may be autstic. Or something else. I quickly developed quite the obession with about half of the DSM-IV. Then, when I was seventeen, my parents talked me out of thinking I was autistic or otherwise anything other than blind and extremely intelligent and oh maybe a hypochondraic. Never mind that hypochondriasis is a real mental illness.

2. Admitting I need help. I first admitted this the day after I decided I might be autistic, so when I was still fifteen. Then again, I was too shy to tell my parents or my teacher or basically anyone that I really needed more than a teacher with a social skills checklist telling me all that I was lacking in terms of social skills. I remained too shy to directly ask for help for years. They were other people asking for help for me. First, it was the teachr with the social skills checklist calling the blindness rehabilitation center for me. Then it was my staff at independence training calling mental health services. Then it was the police calling the crisis service after I’d made a suicidal threat in public. I still have a problem asking for help directly.

3. Starting counseling. My first experience with counseling was at the blindness rehabilitation center I went to after high school. That wasn’t all that successful. Then, at the mental health agency where I was diagnosed with autism in 2007, I started sessions with a community psychiatric nurse. This was quite helpful. It was probably my most successful counseling experience so far.

4. Starting medication. I first started medication in the summer of 2007. That wasn’t a success. I hadn’t expected the psychiatrist I saw to suggest I go on an antipsychotic, because the nurse I mentioned above was suggesting a benzodiazepine on an as-needed basis. I did end up taking said antipsychotic, but stopped taking it again several months later. The second time I went on medication, another antipsychotic this time, I was extensively educated and got plenty of time to think it through and make a decision. I consciously decided I wanted this medication and it’s been a great help (with an antidepressant and several PRN meds added later on).

5. Checking myself into a mental hospital. Of course, it wasn’t literally that I checked myself in. I didn’t take the initiative to call the crisis service or my treatment provider, which I didn’t even have at the time. After all, I’d moved a few months prior and the new mental health agency was doing the diagnostic testing all over again. Nonetheless, I consider it a major milestone that I agreed to be admitted into the psychiatric hospital.

6. Moving to a resocialization unit. I spent sixteen months on a locked unit, largely because my meltdowns and emotional outbursts were too severe for any less restrictive unit to want me. Finally, however, the resocialization unit did want me after I half lied myself into being accepted. I think this was a major step, as I got much better care on the resocalization unit than on the locked unit. After spending over four years there, I moved to my current unit, which is also rehabilitaiton-oriented but doesn’t have as strict guidelines on how long you can be here. Not that they were followed by the other unit either. I really went here to be closer to my husband, whicch I currently am not anymore since the move, but oh well.

7. Discharge. This milestone is to come this summer. I’m going to move out of the psychiatric instituttion and live with my husband. I’ll continue to get some form of psychiatric treatment, but of course this is a step towards recovery of a “normal” life.

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