Wednesday, October 18, 2006

Are You On Drugs or Something?

In response to my prior post, some people have requested specifics about the medications.

My first was sertraline (Z*l*ft), an SSRI. Started at 25mg daily, then 50, and eventually 100. Worked great. Felt like myself again, except that I didn’t get depressed and I was no longer afraid of spiders. (I still had some trouble talking on the phone—another phobia of mine—but it was a lot better.) Side effects were entirely manageable, not unlike having had an extra cup of coffee … with the exception of that one pesky thing. Libido wasn’t so much the issue. I could open negotiations, I just had a hard time sealing the deal. I enjoyed casting, but I didn’t reel one in very often. I could crank the starter, but the engine didn’t always turn over. The water got hot, but the pot wouldn’t boil. I could paddle the surfboard, but it was hard to catch a wave. I had a nice time mountain climbing, but had to turn back before the summit. If I were Cracklin’ Rosie, even Neil Diamond might have run out of time.

What’s that? Get to the point? I couldn’t, that’s the point.

It didn’t matter too much at first, because I was busy and single. But then I met my future husband, and I began to long for what I was missing. I’d never been a zero-to-60 in four seconds kind of girl to begin with, and we didn’t have that much free time. So, as I described previously, I stopped. But being happy in the sack doesn’t make up for being clinically depressed, as it turns out.

The next medication I went on was buproprion (W*llb*trin), 150mg twice a day. It’s in a completely different class than sertraline. Worked great for the depression, and practically no side effects. Its one drawback is that it doesn’t have any effect on anxiety; SSRIs are really the only ones available that work for that. So spiders started to freak me out again, and it got harder to start conversations with people I didn’t know. But overall a good choice.

Enter infertility treatment. Much stress, much anxiety, not much sleep. Then a new job on top of that. I started to feel as if I was overloading the buproprion. I got a new psychiatrist finally (I had been seeing my PCP, who was great, but not, obviously, a specialist in tweaking these meds). And he said, you know, the sexual side effects of SSRIs are dose-related, and you were taking a relatively high dose. How about we leave you on the buproprion, but add a whiff of sertraline back?

Simple but brilliant. I added 25mg of sertraline, with no appreciable effect on my sex life but a definite dampening of the anxiety.

I was, naturally, worried about what to do if I ever did manage to get pregnant. When I broached the subject with my husband, I was relieved to find he had a strong opinion that it was much riskier to go off meds during such a stressful time than to expose a baby to medication that has not been shown to do any real harm. We decided that since the real issue was depression, once/if I actually got pregnant, I’d taper off the sertraline, just to decrease any possible risk. In fact, I upped the sertraline to 50mg during the worst of the IVF treatment and left it there until we’d seen a heartbeat, then tapered off. I continued buproprion during pregnancy and restarted 25mg of sertraline once the baby was born. (Buproprion does get into breastmilk, but again we decided that the benefits clearly outweighed the risks.)

I find it interesting that a lot of people are afraid to try antidepressants, not because they might not work, but because they might. If you start and find out that you feel like a completely different person, what then? Are you stuck forever? It’s hard to explain why this doesn’t really make sense, because you won’t truly understand unless you try it. What I tell my patients is that if the antidepressants work, you will feel—normal. Not a different person, just yourself, the person that you can remember being, though perhaps long ago. As testament to this, most people who are on antidepressants for a long time eventually get to a point where they feel like the meds aren’t working, because they feel utterly normal. And a lot of people can eventually go off while continuing to hold on to their normal self. The reason I can’t is that it is very likely that if I were not to continue antidepressants for the rest of my life, I could expect the episodes of depression to come more frequently and become more intense. Some people have episodes every once in a blue moon and can use antidepressants as needed, but my last depression came with so little warning and so little provocation that I don’t want to risk it.

And as long as I can make the sale, catch some fish, start the car, boil some water, catch a wave, and get to the top of the mountain, I’m good.

38 comments:

Menita said...

I'm beginning to suspect that I shouldn't EVER be allowed to go without anti-depressants. The difference now that I am on P*zac is just so enormous, in a very positive way, and for exactly the reasons you describe. It seems such a struggle to hold on to my "normal self" when I am not taking them. So it is possible to be on them for years at a time, uninterrupted? I was always given the impression by doctors that this was temporary, a case of a few months or so, so I go off them after a few months before the next awful crisis.
I have major phone phobia too, but not, I know, related to depression but to past baggage...

Leggy said...

Phobia of the phone? And Menita has it too? Never heard that one. I love to gab for hours, but can't find anyone else that has the time except occassionally old high school friends after they put the kids to bed.

I totally agree on the A/D's. If I hadn't had such a spectularly bad episode with Proz@c in college, I'd have used them much sooner in the IF process. But to go through all this stress, without help- ugh, that's just almost asking for trouble.

bihari said...

bi

bihari said...

Hmmm. How did that happen? I was going to write a little encomium on your ability with metaphor, but instead...."bi."

Mignon said...

bihari, given your praise of docmama, could it be your sexuality crying out for recognition...?

Doc, how about a medication for someone who's never been able to seal the deal, get to the point, start the car, etc.? When I read that you felt well and normal except for the car-starting thing I was all, "Meh, whatever." But then I realized it probably is a big deal. Just for everyone else...

Finding My New Normal said...

I was on Celexa (40mg once a day) for years and then this summer I hit the lowest low depression I've had for a long time. The doctor tapered me off the Celexa and had me add in Zoloft. I am feeling much better. Still not much zing in the zinger, but I feel so much better.

Kim said...

I loved Z - self-diagnosed and got my ob/gyn to prescribe it. Got a real hang-up about needing to deal with the real me and went off it. On and off again for a couple years, then tried W to help with quitting smoking and loved that. Went off it with the last pregnancy, as if that did any good, m/carry at 8 weeks. Haven't gone back on either, and hubby has recently mentioned perhaps it is time. Funny how I can feel such a self-imposed stigma. Like I should be able to cure my brain chemistry solo. Hmmm.
Love your blog!

Anonymous said...

Would one of these help postpartum anxiety? I'm anxious about things like my baby falling out of a window and other crazy things. But I can usually control it. I keep hoping it's hormonal and it'll work it's way out, the baby is 10 weeks old.

Menita said...

To Leggy: Yes, total phone phobia. Which just goes to show you how much I lurv you. But yes, hate it, hate it, hate it. Email was the best thing that ever happened to me, and in-person meetings are da bomb. But the phone? Urck.

DoctorMama said...

Menita—the PHONE!!! I clearly inherited my phone phobia from my mother. We have to force ourselves to call each other, even though we get along great—how sad is that? Caller ID has helped a lot, as has having to be on call, since habituation is a good treatment, but it’s still a tough one. Having to talk to someone blind, I’m just terrified that I won’t be able to figure out what they really mean. Plus my attention wanders, and then I really don’t know what they mean. For me, the worst is having to talk to someone with limited English skills. No lie, before I met my husband, I never even ONCE ordered takeout by phone. I’d rather starve.

And sure, you can be on this stuff forever, or so it appears. Now that there are some generic choices available, it’s getting a lot more affordable, too.

Leggy—a 45 minute conversation is outrageously long for me, and reserved only for my oldest best friend who lives in another state, and even then only once every few months.

bihari—bi will if you will.

Mignon—you mean, ever? Never ever? Never ever ever?

Finding My New Normal—it still means something even if it ain’t got that zing, right?

Kim—I wish I could be more open about my AD use. My close friends and family know, but not my colleagues or students or patients, and sometimes I think it would be helpful for them to know. But that stigma, yeah.

Anonymous—hormones can do crazy things. But meds can help.

Anonymous said...

You know, I'm going to print this off and show it to the psychologist who's treating me for emetophobia. Thank you for being so open. Still though, like you, I've never divulged any SSRI use to my colleagues. The psychiatrist wanted me to put an article in the local paper and be a cover girl for the mental health movement...but...no way. Hmm, lots to think about.

Fiona

Ariella said...

Sometimes I feel like the only person in the world who's not on any kind of treatment for depression. Yes, I get depressed -- very depressed, in fact -- but I am extraordinarily uncomfortable with the thought of medicating myself.

And, if I'm going to be completely honest, I would rather be depressed and thin than I would be happy and skinny. The weight gain side effect is basically a deal breaker for me, as is the possibility that I would not be able to "seal the deal" with my husband.

I know you're probably thinking that maybe I'm not "that" depressed, but I've been offered ADs by various psychologists throughout the years and always turned them down. The only things that have EVER worked on my depression are: exercise, healthy eating (especially cutting out wheat and sugar for the most part), and positive thinking (as in, when I think to myself, "You are a disgusting, lazy cow and are totally worthless," I have to force myself to say "No, you are very well educated, well liked and personable" or whatever).

I'm NOT saying, by the way, that this would help everyone. I'm just telling you my personal reasons for not going on ADs. I'm not afraid I'll be a different person; I just don't think that the side effects are worth it. I have heard, anecdotally, that wellbutrin increases the libido AND works as a weight loss aid, which, hell -- sign me up for that!

Mignon said...

Once. 12 years, 6 months and 12 days ago (checked my journal). And as much as we've tried to recreate the scene, no luck. Apparently this is hard for you to imagine?

leslie said...

I had the same set of side effects as our hostess with Z & W - and W did indeed both hasten my ability to boil some water and reduced my appetite - a good thing since my most recent round of depression was kicked off by a long recovery from a broken ankle so lots of sitting around time. I also had trouble with insomnia from W though and that's a common side effect. One has to manage the range of effects from all of these drugs clearly.

Anonymous said...

Grr...stupid Blogger isn't letting me post my comment!G
DM, you're so awesome!! Thanks to your blog I know I'm OK. You are obviously educated, brilliant, funny as hell, and you have phone phobia, too!
My phobia has more to do with talking to people I don't know. I guess I'm afraid of not knowing what to say; the lack of predictability makes me sooo anxious. So, I'm OK with (old) friends and family... It's only been recently that I've been able to call/answer when Boyfriend calls. The problem is that we broke up almost 1.5 years ago. Heh.
I live by caller ID. If your number shows up as private, there's no way I'm going to answer!
I didn't realize until now, but my phone phobia has gotten better since I've been downing my cocktail of choice (effxr/wbtrin)each morning. Now, I at least return the calls of clients I know.
-ReturnOfSaturn

Val said...

Many thanks, Dr M!
& Ariella, you sound like me; I can't really explain my deep visceral aversion to taking AD's... After all, I'm not able to overcome my dependence on SYNTHROID by an effort of will am I???
& my libido, alas she seems to be long gone, so no big loss there!

artemisia said...

I had to delurk to say EEK, ME TOO! on the phone-phobia. Messages on my answering machine freak me out as well. I make myself check them once a week after two glasses of wine.

I'm very open about my A/Ds with friends in the same boat. But I don't tell anyone else. Even my husband isn't really clear on what I'm taking or if I'm taking anything at all. And yet it's a lifelong thing, as far as I can see.

Wonderful reading, Doctor!

DoctorMama said...

Fiona—I could imagine having emetophobia, and I’m glad I don’t.

Ariella—I think you meant to say “I would rather be depressed and thin than happy and fat”? Which, wow. When I’ve been at my most depressed, I think I would have been willing to give up a limb to get out of it.

Of course no one should go on antidepressants if they don’t want to, and if other things work, terrific.

I do want to point out that with the exception of paroxetine, weight gain is not a very common side effect of SSRIs—some people even lose weight on them. People just tend to gain weight over time, antidepressants or no. And none of the side effects are permanent.

Mignon—Not too hard to imagine—and I know that something like 10% of women don’t, but I guess I assumed that was women who were either repressed or suppressed—you know, not allowed to touch themselves. Not liberated, sassy, bold women such as yourself. I did have a friend who thought she couldn’t, so we went to an adult store (no internet then) and got her a toy. She disappeared for about three days and then finally reemerged to say “So, I was wrong!” But it must be something like infertility—everyone saying “you just have to relax!” or “try acupuncture!”

leslie—yeah, I do get some insomnia too.

ReturnOfSaturn—you can post as “other” and then fill in your name … We should start a Phone Phobia support group, eh? All arrangements for meetings done by email, of course.

Val—maybe if there were a TSH for mood, it’d be simpler.

artemisia—Yes, the messages too! I HATE hitting that button. I’m just sure it’s going to be something awful. (I have a similar thing about opening unfamiliar mail, come to think of it. But I’m more afraid of missing something important than opening it.)

B.E.C.K. said...

On AD stigma -- My doctor told me he'd been on Lexapro for years, and I really appreciated his openness about it. Maybe it would be beneficial to your patients to know about your AD usage sometimes...?

luolin said...

Chris Clarke had a hilarious post about the will-I-be-myself question and W*llb*utrin.
http://faultline.org/index.php/site/comments/day_two/

(Probably not as funny if you don't know how he usually writes, though).

Menita-that's interesting, because when I started taking ADs, I was told it would probably be forever, especially when I ended up hospitalized for the depression. I heard the analogy to diabetics and insulin a lot. I went off after 10 years, and hope I will be smart enough to get back on fast if necessary and not let the stigma slow me down like it did before.

Ariella said...

DoctorMama -- yes, that is what I meant to say. I know we all have different body "issues," and the way I was brought up, it was better to be sick than fat, or even depressed than fat. In fact, I can't think of a thing that was worse in the eyes of my mother, grandmother or other female relatives than being fat.

So, I guess if you take my statementin that context, you'll have some idea of what I mean when I say that. As far as the weight gain side effect, you are the doctor, but almost every AD I've ever researched, with the exception of Wellbutrin, lists weight gain as a side effect. This includes prozac, xanax, effexor, paxil, etc.

And, I know this is anecdotal, but all but ONE of my friends on ADs has gained a significant (defined as more than 20lbs) amount of weight after starting them.

Sandra said...

My partner of 5 years started taking citalopram (C*l*xa in teh states) and few months ago and the result was more amazing than I had imagined. He started really slow on 10mg a day and then they upped to 20mg which he's currently on. His anxiety and depression are almost a thing of the past. He does occasionally still get freaked out by the crowds at the train station on the way home and takes some time out to relax until the rush subsides. We've talked about the fact that he could increase his dose further if need be as he's still on a relatively low dose.
The effect on him has been profound. He is more social with people too. (We did wonder at one point if he was autistic because his social awkwardness was so strong.) He now says he doesn't know why he didn't do this years ago.
His libido has improved as it was a once a month if I was lucky before the meds. Not good for planning a baby!

Moxie said...

I knew nursing had affected my hormones to put my depression into remission because I felt normal. Or, as I described it, "like normal people must feel all the time."

Yeah.

Anonymous said...

I actually found the TCAs best - the SSRIs killed sex, and also made me feel like a totally different person - way more outgoing and numb. Sort of spacy, and it made it hard for me to think quickly and sharply like I needed to in medical school. I did gain about 15 pounds with nortriptyline, but I SOOOOOOOO don't care - that's so minimal compared to the suffering. And I exercise hard now, which I never did before, so it's gotta even out cardiovascularly somewhere.

I'm glad you wrote about staying on during pregnancy. I felt the same way, but then felt evil - though all the indications are that it would be horrible to stop (I have been very hormone-sensitive always, never could use ocp, etc). I basically came to the conclusion that I'll stay on...but feel bad about it - even though there isn't really a shown risk...

Glad you posted this...and the Fat Doctor too...for me as a woman in medicine, it's been my deep dark secret forever - I just sooooo don't want anyone to ever find out. And then sometimes, I wish my friends among my colleagues would, so I'd know they wouldn't hold it against me...accept me as I am...and know that it's not something that just happens to weak people.

So I guess I'm staying anonymous for this post - even online, I feel the stigma...but thank you, DoctorMama...

E. said...

DoctorMama, you are a true educator.

Mignon, I'm constantly sealing the deal and starting the car all by myself, not to mention with a friend, so maybe I'm not one to give advice. But from what I understand (and a la DocMama's friend), if you can get there on your own it makes it easier with your partner. Toys are nice but my advice is: old fashioned hand-to-clitoris stimulation, lube (even if you're alone, it can help get things going in the right direction), and lots of creative fantasizing.

Maybe you've already tried all of the above together. Good luck.

Anonymous said...

DoctorMama,

I have been told one reason for not going off AD's, that I haven't seen mentioned here is sometimes the AD's are less effective when stopped, then restarted at a later time. I don't know whether this applies only when someone goes off AD's AMA (while still depressed), or whether this may apply to anyone who stops and restarts AD's.

Would be interesting to hear your opinion on the matter.

I have been on AD's for six uninterupted years now, and feel fine, but don't intend to stop taking them. Started and stopped a few times, over several years, before I decided it was best to just keep them.

Have thought about changing from Vitamin P(roz) to Vitamin W(ell...) I suspect it's a better med for, considering I am also AD/HD, but I am reluctant to change meds when it's working resonably well.

C. said...

My mom is one of those people that puts a huge emphasis on weight and size. Each of the three children in my family (including myself and all girls) have had an eating disorder. My younger sister and I had anorxia and my older sister, bulimia. She had me and my younger sister on diets at the age of 8 and told us we would get fat like our aunt.

Clearly mom has issues. No matter the point in life or achievements, her focus on how much we weigh.

I started taking AD during a horrible breakup four years ago and gained 50 lbs over 2 years. I probably was too thin for my height at the time, but the weight gain has been very hard. I have lost 25 of it, but the rest just hangs on despite a good, balanced diet and regular exercise. It is my body now and I must deal with it.

My point, however long winded is thin and depressed is hard for me to understand. I was there once and like DM, I would have given a limb to pull out of the depression. When over stressed, I still fall into the hole, however now I can get myself out. I would rather be average and happy and I have never been average at anything. Happy is better than almost anything, in fact everything is better when one is happy.

C.

cluelesscarolinagirl said...

One of Madeleine's friends at school, okay, her mom called us the other day to "touch base". Left a message. I immediately jumped to the conclusion that she had 1. found my blog 2. noticed that I swear a lot 3. Madeleine had let it slip about the orgies we have after she goes to "sleep" (ok, j/k there) 4. that she had noticed I've Flickr'd some pictures with her kid in them or 5. that something else Very Very Bad was going on, no details. I still haven't worked up the nerve to return her call, although I just figured out that she probably wanted to arrange a play date for yesterday when the kids were out of school.

Yep, major, MAJOR phone phobia here.

Sugar Pixie said...

Is there a name for that syndrome in which patients take their meds until they feel "normal" and then decide that since they feel normal they obviously don't need to be medicated, and then quit taking their meds and go off the deep end?

Remind me never to do that. Just started switching from Z-loft to WellB so my PC can boot up, so to speak.

ozma said...

It's interesting you could take medication when pregnant. Maybe it is something about being a doctor. I simply could not do that. Not in the moral-judgment sense but in the way too scared to take the chance sense.

I had some major problems when pregnant. I had full blown prenatal depression I assume because I could barely function and I was sure that there was really no point to human existence. In some ways it was kind of funny because I was so negative and depressed and my thoughts were so catastrophic that I almost laugh looking back on it now (almost!). My thinking was also significantly distorted. But being pregnant prevented me from the worst side effect of such crazines--which would be suicide. Instead, I was just hoping to die in childbirth. Heh. OK, I'm strange but it sort of seems a little bit funny to me now. Some of the dark things I used to say still crack me and my husband up.


Looking back it is clear that I am so crazily hormone sensitive that I have a medical condition when pregnant that might warrant medical treatment. Considering I have a child who will be very affected by seeing mommy cry all day, every day, there are some good reasons to take medication if I have the same problem and do manage to get pregnant in my ancient state. But unfortunately when I get those hormones in my bloodstream I am 99% sure I will then refuse to consider any treatment.

I hate to talk on the phone (as does my mother and sisters), spiders are my main phobia and I have problems in social situations. But then I've got a lot of issues so maybe overlap with other people happens a whole lot if you are me.

Anonymous said...

Absolutely LOVE the descriptions of no sex-drive. I thought it was pretty much a "given" that taking anti-depressants would kill the sex drive of someone. Isn't that so?

RPG said...

I think that the inability to "reel it in " may be unique to women. My husband has been on Z*l*ft for over a year for anxiety and he has had no problems "getting there" (kinda wish he would every once in a while when he leaves me hanging, so to speak) and is in fact much more interested in sex because he's not afraid of having panic attacks anymore. My doctor put me on Wellbies (150 XL) when I was pregnant with my second child and I have stayed on it but I don't feel like it does me a lot of good. I manage not to strangle my children or scream and run away but I still want to. Could another medication make me feel a little less desperate and helpless?

Old MD Girl said...

In the past, I've been afraid to try antidepressants because of the stigma they carry. I don't want to be running for office someday and have my opponent say, "She's unstable! Look at my proof, she took antidepressants!"

Plus, I was never sure I needed them since when I removed myself from the shitty situation I was in, my depression resolved itself. Though sometimes you just can't remove yourself. Then, I still don't know if I'd try them.

Liza said...

I clicked over from Little Bit Pregnant, and I love your blog.

Much like Julie, your "maggots" posts have me actually considering running, as opposed to my usual LALALALALALALALA-I-CAN'T-HEAR-YOU reaction when people talk about exercise, especially running.

Heather said...

Very informative read. I'm sending a link here to a friend with depression issues during pregnancy who wants to breastfeed.

Thanks a big ol' bunch.

susan said...

i took lovely, sweet Lexapro that made me like a cat in heat. and i caught the first wave everytime. hell, i caught the first ripple. but then came along infertility and the RE would not treat me if I was on Lexapro. i'm no doc but even I knew that was shit, ass-covering nonsense. but i did as i was told. iui #1 didn't work. and IVF #1 didn't work. don't think i'll be doing anymore treatments. mostly because my puppy pooped herself at 3am and i realized that i am not cut from the right cloth for mothering an infant.

i loved lexapro. it was a monumental relief to find my old self. i regret having spent so many years, stifled by fear and depression when i could have been taking it and feeling good.

yeah, i'll probably go back on it one day soon.

Kris said...

Some people are afraid to go on antidepressants because then they might be labelled as "depressed" which in turn if you apply for new life insurance and have to disclose that you will be refused. Just another point of view.

K.

baggage said...

Thank you for this post. I needed to read it today.

I also have a phone phobia, by the way.