Dismissed

I had another appointment with the APN on Friday. She took my blood pressure – which was a bit high, both for me and based on the health guidelines I’m aware of – and said it was “fine.”

Then she asked how I’ve been. I told her about being tired and unmotivated to do anything; sometimes I don’t even feel motivated to play Skyrim. I tried to put it in the context of everything that’s been going on: the stress of the holidays and then everything just stopping. I told her when I’m very depressed there’s less anxiety because I don’t want to do anything so there’s nothing to be anxious about, but when I’m less depressed and starting to want to do things I feel anxious about them. (To be honest I’m not sure that’s entirely true. I experience different kinds of anxiety. But I didn’t express this to her.) I also told her about the ominous voice twisting all the imagery in the guided meditation into things I found threatening. I told her I’m both excited and anxious about my classes starting next week: excited because I’ll have some structure in my life and anxious because of the responsibilities. (Not to mention my social anxiety.)

As I was talking about this stuff, she was making notes on the computer (facing away from me). Then she looked back through her notes from past appointments and the information I’d provided in the intake paperwork before our first meeting. She weighed me and told me I’m a candidate for sleep apnea. She told me to go get blood work done so she could see if there is a problem with my thyroid or something (past blood work has ruled that out, but I haven’t been able to show her the printout to prove it). She also called a sleep center for me and handed me the phone, basically forcing me to make an appointment for a sleep study.

Okay, I’ve been dragging my heels, I can kind of understand her being a bit heavy handed. But the next thing she did utterly terrified me.

She told me to stop taking the Lamictal/lamotrigine. She said I’m “sensitive” to it and it doesn’t seem to be helping. “There’s no point in taking medication just to take it.”

That’s it. No plan for slowly reducing my dose over time to minimize withdrawal symptoms. No concern over what effects suddenly stopping Lamictal might have on me. Granted, I’m only taking 75 mg, but we’ve worked our way up to that dose very slowly. If I’m “sensitive” to it, doesn’t that increase my chances of being “sensitive” to suddenly not taking it?

I honestly don’t know if it’s helping. Maybe it isn’t. Maybe it’s wreaking havoc on my central nervous system and I should stop taking it immediately. She didn’t explain why she thinks I’m sensitive to it, and gave a very simplistic explanation of why I should stop (which suggested she views me as medication-seeking). Her tone sounded dismissive to me, so I didn’t feel comfortable asking questions. I couldn’t think quickly enough to formulate them and felt like she wouldn’t listen anyway.

Maybe it is helping and my depression would be a lot worse without it. I feel like she’s not taking my life circumstances into account. I was doing great up to the wedding, then suddenly all my loved ones had gone back to their own lives, nothing meaningful had changed, and I no longer had something important to work on. I couldn’t sleep for a week or so while Mom was having work done on the roof. Then the holidays were a blur of excitement, socializing, not getting enough sleep, and thinking my godmother was going to die. Then, once more, everyone left and everything stopped – except worrying about my godmother. The floor dropped out from under me – and my pending courses for the Spring semester are looming over me.

The courses are the thing that has me the most concerned about stopping my medication. I’d like to have a bit of stability going into such a big lifestyle change; the last thing I need is unpredictable changes in my body chemistry and mood at the same time I’m going into a frightening and challenging situation. The last time I took these courses I had to drop them because they were triggering self harm and suicidal urges. I don’t feel safe trying to take them again without some kind of safety net. (I should probably talk to my instructors about this.) At least taking medication is something I’ve been able to do with some consistency; I feel like I’m doing something to help myself!

I suppose I could possibly enjoy the same effect from continuing to take my supplements (omega-3, vitamin d, and a vitamin b complex with folic acid and vitamin c), but I really don’t want to give up on the Lamictal just yet. Wakana has been urging me to take medication for so long (since before I started this blog), I hate the idea of finding that yet another one doesn’t work. I don’t want to start from scratch again…

During the meeting with the APN, my mood went from 1) low energy, depressed and a bit anxious, to 2) slightly higher energy and a bit irritable, to 3) more depressed, frustrated, and wanting to cut myself. She ended the appointment after telling me to stop taking the Lamictal; she didn’t even ask if I had any questions or concerns or anything else I wanted to talk about. I feel like she thinks I’m not really depressed or only mildly depressed and that I’m being lazy.

(Much of our conversation was her giving me advice: to make healthier food choices, move around more, make a schedule for myself, and give myself a to-do list with simple tasks that help me feel good. Some of these are lifestyle changes I want to make anyway and think would be helpful, but in general it sounds like stuff laypeople say to people with depression because they don’t understand it.)

I left and made sure I have future appointments pre-booked, but thought about not coming back. In an ideal world I would find a better psychiatrist, but with my insurance that would be a nightmare. And I’d have to start the whole medication dance all over again! When I was halfway across the parking lot I thought about going back to ask about reducing my dose slowly, but decided I wanted to consult with someone before trying to advocate for myself. I had just utterly failed at advocating for myself and was in no state to do so successfully.

I talked to someone I know who works with adult psych patients and has bipolar himself, and with his wife who has a good amount of medical knowledge – including potential effects of different drugs and what various symptoms might indicate. Together they helped me decide to continue taking my current dose of the Lamictal until I’m able to talk to the APN again. They encouraged me to talk to Wakana about it and have her talk to the APN as well. My friend with bipolar also made an important point: my insurance might not approve the sleep study right away, or in time for our next appointment, or ever. I can’t wait, untreated, while they bathe in red tape (as I have been for my tooth – brief update: I have an appointment for a periodontal consultation and another to get a root canal).

At the very least, I want a better understanding of her thought process. I want her to sit down and look me in the eye and answer my questions until I feel confident in whatever course of action she prescribes. Is that so much to ask? If I have to go off Lamictal, I feel much safer reducing my dose slowly with a plan we’ve come up with together. If possible, I intend to have Fox there with me. He’ll be there for my future scheduled appointments, at least!

a day with episodic mood disorder not otherwise specified

Today I asked my APN what her official diagnosis for me is, hoping (among other things) it might help me present myself more accurately on my blog. She confirmed that, especially based on my past response to anti-depressants, uni-polar “depression” doesn’t capture the whole picture of what’s going on. I guess she’s not sure what’s going on. To the extent that I do know, I have no idea what to call it. I was hoping she could give me an idea. But “episodic mood disorder not otherwise specified” just doesn’t have a good ring to it – even when shortened to “mood disorder NOS.” I might as well just say I have emotional issues. Well, almost. I have clinically-relevant emotional issues.

In other news, she decided to lower my Lamictal dose from 75 mg to 50 mg due to concern about possible side effects. On the one hand I’m glad she’s taking my concerns seriously and being cautious with the only brain and body I have. On the other hand, Wakana had suggested I should increase the dose – that the lower doses aren’t enough to be therapeutic – and I’d been expecting us to move in that direction. I guess there’s still the possibility of increasing the dose if that seems to be the best course of action; it’s probably better to trust the person who has the required training, certification, and experience to make decisions about this sort of thing.

But APN is talking about adding a new medication (that I’ve never taken or heard of before) to help fight the chronic lethargy I’ve been experiencing. I’m really not a fan of taking multiple medications. Even just being on one medication has me concerned about long-term effects and my ability to safely be a biological mother on my own terms someday. Let’s say I do experience side effects: how am I supposed to know which medication is causing them, or whether it’s an interaction between the two? More medications also means more risk of interaction with environmental factors, food, caffeine, and alcohol.

I may not be too thrilled with how today’s appointment went, but I still have confidence in my APN. She’s not just prescribing medications, she’s looking at the whole picture. She suggested I get blood work done so she can get a better picture of my physical health, including how it might be affected by the new medication she’s considering. She also re-encouraged me to have a sleep study done. Maybe if I do that, they’ll address the lethargy well enough that I won’t need to take a second medication! Finally, I appreciate that she asked me if I was seeing a therapist or would be interested in therapy. It shows she considers therapy to be an important part of treatment. She also encouraged me to work on setting boundaries, so I can distinguish between what I’m feeling and what others are throwing at me. That’s what most of the posts in this blog and the work I’ve been doing with Wakana are about, so I guess I’m on the right track. It’s just taking an uncomfortably long time to get where I need to be.

Good to See You… but I Wish You Weren’t Here

I just got back from my fourth visit to the APN. I told her the Lamictal seemed to be helping; I’ve been less depressed, my lows haven’t been as low, and my mood is more stable – even with the stress of adjusting to Fox’s new job and wedding planning crunch time and health issues, etc. She decided to increase my dose to 50mg daily and encouraged me to find things to do that would give my day structure and social opportunities.

Someone else was coming in for an appointment as I was making future appointments to see the APN once a month; after a short time I noticed that person was waving to me. It took a few moments for me to recognize her: a former classmate! She started asking how I was and when I was done making my appointments she came over to give me a hug. I was glad to see her but concerned: she seemed stressed and anxious and was clearly going through a rough time – otherwise why would she be at a community mental health center? I wanted to ask questions to show interest in her well-being, but I didn’t want to ask anything that might make her feel uncomfortable. And then she had to go in for her appointment.

On the one hand it was kind of encouraging to know I’m not the only one from my school / program needing to take some time for self-care. It’s kind of normalizing? And I’m glad she’s able to access at least some of the help she needs. I like my APN and I’m pretty sure that’s who she was there to see; I feel fairly confident that she’s in good hands.

On the other hand, I’m kind of shaken. I wasn’t expecting to be in a peer social situation with someone from school. We’d had some opportunities to bond as classmates but I see her more as a “friendly professional acquaintance” than a friend. I’m used to doing everything in my power to hide my mental health issues from friendly professional acquaintances; now one has seen me at a community mental health clinic! I don’t think she’d tell anyone – just like I’m disinclined to tell anyone who might know her – but it’s still awkward!

And my first response is to try and figure out what I can do to help her. What would be appropriate to say to help her feel more comfortable? How can I reach out to her to try and offer some support? I need to be careful how I proceed so I don’t risk outing her. Maybe I shouldn’t even be writing about this!

I guess it’s good that I’m so compassionate. But I need to think about how I feel and what I need. I kind of needed to be in and out of my appointment without unexpected socialization. I also need to socialize with peers other than Fox and the all-too-occasional rendezvous with other friends. I kinda want to reach out to her – “Maybe we can meet at a cafe or diner that’s convenient for both of us? Are you free during the week?” And I kinda want to hide in my shell, try to pretend this didn’t happen.

Return to Psychiatry?

I just got back from meeting with an advanced practice nurse (APN) for a psychiatric evaluation. I like her a lot: she was down to earth and personable. I felt like I could relate to her and trust her. She made a real effort to listen to me and ensure that her understanding of my history and current situation was accurate. She took the issues I’ve had with medications in the past seriously.

She screened me for bipolar and OCD, but hasn’t made an official diagnosis. First she wants to see the results of the blood work I had done when I went to see my primary care provider a few months ago. She also gave me a prescription to get a sleep study done to see if my problem might actually be sleep apnea or another sleep disorder. It could be that chronic lack of restful sleep has been keeping my brain from functioning properly and causing (or at least contributing to) my depression and anxiety symptoms.

Finally, she sent me home with a self-report measure to fill in over the 4 weeks between now and my next appointment. Every day I get to rate symptoms such as depressed mood, mood swings, irritability, food cravings, anxiety, sleep issues, difficulty doing things, and physical symptoms. There are spaces to mark day of the week and whether I have my period. As I complete it, I’ll be making a graph; it’s pretty neat.

Perhaps best of all, she agreed to talk with Wakana to coordinate my care. I guess time will tell how well they can work together to help me.

To be honest, I have mixed feelings about the situation. There’s a part of me that’s disappointed because I don’t have medication to take and either (preferably) gain relief from or complain about. It’s basically more of the status quo, at least until the data from the sleep study has been analyzed.

The rest of me likes that the APN is proceeding cautiously and trying to gather as much information as she can before prescribing drugs that may do more harm than good. She seems to be thinking about what is best for me as a whole person, not what will be the most convenient. It may take longer than I’d like before I have a treatment plan that’s truly effective, but hopefully I won’t have any more false starts and stops with medication. I may have found a keeper.