Into the system…

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8mg…

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I saw Dr M this morning. I’d not seen her for ages. It was back in July, just before I went to Europe (I haven’t written about my trip, but anyone following my twitter feed will know that I spent 2 and a half weeks InterRailing during July/August), so a lot has happened since then. She suggested that it was a good sign I hadn’t needed to see her sooner, but I indicated that it wasn’t especially. It probably would have been if I hadn’t have wanted to see her about a month ago. I couldn’t get an appointment then. This was the first Monday we could both do.

She asked about my trip. She was impressed and relieved that I managed on my own whilst I was away. It feels so long ago now, I didn’t really know what to say, other than that I coped, enjoyed most of it, but found it really exhausting.  I could have told her more, but didn’t see the point. There was limited time and plenty of other things to cover.

We talked about things with the bloke. Before I went away, things between us had been somewhat up in the air. When I last saw Dr M, there was a very real chance that we would split up. I haven’t written about this here before now, because I don’t think the bloke would be overly comfortable about me sharing this with the world.

The whole idea of the trip to Europe, was to give us some time apart to reassess things. I was going to just take a “boring” holiday somewhere, but options are limited for solo travellers and I’d always wanted to go InterRailing, so I decided to give it a go. It also seemed like a great chance to test myself to see if I could be more independent and to cope on my own.

I’d talked about all of this at my last appointment and Dr M was keen to know what has happened since then. Things between us have settled down and pretty much gone back to how they were before things became difficult. It’s almost as if nothing had happened. Neither me, nor Dr M could decide if this was a good thing or not. On the whole, it is probably good. Things were not good at all when I left and it is nice to know that he missed me a lot, but it has also been a little disappointing. When I got back, we talked a bit about what had happened and how we should try to improve things and appreciate each other more. Unfortunately, it doesn’t feel like anything has changed or improved.

We talked about my trip to Occy Health. I explained what he said about not starting a proper scheduled return yet, but how we tried to think about the ways we can solve some of the problems that are stopping me from getting back to work. I told her that he’d said I could try to visit the office and that I managed to go to a meeting last week for a couple of hours, which she was impressed by. It was a really big step, so that’s good. However, she seemed disappointed that there was nothing further planned yet. I suggested that I will probably try to go in again in the next week or so, but I hadn’t decided when yet. She wanted me to try to commit to a time and hoped that I could start to go in on a more regular basis, even if it is only once a week for a few weeks. She thinks that a routine and commitment to going to work on a specific day, would help me prepare for it better. I said that is actually what I’d hoped for, but that Dr Occy Health wasn’t sure and she seemed to accept this, but she thought it would probably be okay if I chose to do it, rather than having my work-place imposing it on me. She may be right and I was considering this myself. I will try and decide when would be best.

We did talk about my mood and how it has recently dropped quite a bit. I don’t think she was too concerned or especially surprised, although she was possibly a little disappointed. She asked about the usual stuff . Sleep, suicide, anxiety… She was not surprised to hear of my nightmares or generally rubbish sleep (occasionally too much or usually too little and never feeling rested). I had to admit that suicidal thoughts had returned, although they were a lot less frequent and different to how they were a year ago. She hadn’t actually realised that the thoughts had pretty much gone away over the summer, which was a surprise. I’m sure I’d told her last time that I wasn’t really suicidal any more and that I no longer felt that life was completely hopeless. Although I can feel pretty awful at the moment, I have got my hope back that I can be well again. A year ago, I could never imagine a life without feeling horrifically depressed, so it was no wonder I could see no future and wanted to end it. I do get frustrated at the fact that I have got worse again. I wonder if I will always be waiting for the next relapse and if so, is it worth it? I am able to cope with these thoughts at the moment, as I still have some hope of a recovery.

We talked about the risk that I may do something impulsive if I have a particularly bad day. I told her there was no immediate risk of me killing myself and that I have no intention to make any detailed long-term suicide plans like I have in the past, but that I couldn’t guarantee that I wouldn’t just do something on impulse. I don’t tend to be impulsive and have never made the decision that way in the past, but if an opportunity presented itself, there are times when I can be very tempted to take it. She recognised this and I guess she knows that there is always a greater risk of completed suicide when people are either recovering or deteriorating. When you are really, seriously depressed, it is far too much effort to kill yourself, but when you’re having a bad day after a series of not-so-bad days it can seem a lot worse and you are also more likely to have the energy and drive to do something about it.

I mentioned that I felt that the arrival of autumn did not seem to be helping and she agreed that there was probably a seasonal element. She had noticed back in the spring that things seemed to improve a lot faster for me when the weather picked up in April, so it is natural, I guess, that things would get worse again when the summer ended.

We talked about my medication and she agreed that it probably needs a tweak, if only to help me get through winter. Her first instinct was to add Quetiapine. Apparently, it was licensed the other day in the EU as an augmentation treatment for Major Depressive Disorder, although she admitted that most psychiatrists had been using that way for a while anyway. She asked if I’d been on it before and I confirmed that I had. I was taking it along with Venlafaxine, back in February 2009 when I overdosed on it. She asked what doses I’d been on and I said I couldn’t remember but I did get right up to 550mg. She said that for MDD they use a max dose of 300mg, but I had been on that sort of a dose for a while too, so I’m not sure it would help. I also mentioned that it never seemed to help with insomnia and that I had put on weight last time. She said she didn’t expect it to help the insomnia and she seemed genuinely surprised about the weight. Although it didn’t help me with insomnia, I know plenty of people who find it knocks them out, so that seems a little strange. There are also plenty of people that have found it made them put on weight too, so I am not alone. Both drowsiness and weight gain are listed in the common side effects, so you would have thought she was aware of that. Anyway, I said no to Quetiapine.

The other options were to do nothing, increase the Reboxetine, swap the Reboxetine or try to add something else. I wasn’t sure doing nothing was a good idea and we both agreed that stopping the Reboxetine was a really stupid idea, as it is the first AD that has ever helped me. Reboxetine has shown that Noradrenaline is probably the key to my wonky brain chemicals and there aren’t many others that help on that front, so we’re not sure what else to do. She didn’t have any bright ideas of anything else to try really. If not quetiapine, then she said we’d probably be looking at augmenting with Lithium or another anti-depressant, but she wasn’t sure what would be best. She said she would have a look for some ideas though before I next see her and she was welcome to any suggestions I may have – so if anyone has any ideas, let me know. I’ve been on most of the common combinations already and my only real thought is perhaps bupropion, but it’s not licensed as an AD here (although it is used an awful lot in the US), so I don’t know if she’d give it a go. I know a couple of people who have found it helpful though, so it may be worth a try.

In the end, we decided that increasing the Reboxetine was probably the best option for now, although I am worried about how I will be with the side-effects. It is worth a go though and if it is too much then we will have to try something else. I hope it helps, without making me feel too awful. She said she’d get a letter sent to Dr N. I have plenty left at the moment anyway, so will just increase the dose myself for now. It only comes in 4mg tablets anyway, so it makes little difference. So yes. I am now going to be taking 8mg of Reboxetine. I didn’t actually tell her that I’ve occasionally taken 8mg anyway, when I’ve not been able to cut one of the tablets in half to make the 6mg. One day doesn’t make much difference though, but 8mg over a week probably will. We will see anyway.

After that, I remembered that I had also been for the therapy assessment. I told her what had happened and that I will probably be waiting for someone to come back from maternity leave. She named the person she thought it would be. We shall see what happens anyway. She isn’t impressed that I’ve been waiting over a year and was shaking her head saying “it’s probably only going to get worse, only going to get worse…” as she looked at her diary to book our next appointment. It really isn’t good.

Anyway, time was up then and I had to go. I see her again in 6 weeks, so we shall see how we go with the Reboxetine.

Written by intothesystem

Monday, 11th October 2010 at 2:08 pm

8 Responses

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  1. Hope the increase in the AD lifts your mood.

    Take care,
    Differently

    differentlysane

    Tuesday, 12th October 2010 at 10:11 pm

    • Thanks diff.

      So far it has just reminded me how bad the sleeplessness was when the dose was increased last time! I can’t fall asleep until the stuff is pretty much out of my system – e.g. about 7am! Such a looong night, lying next to the bloke snoring (he has man flu too so is loud). I need to get up and do stuff tonight I think!

      intothesystem

      Wednesday, 13th October 2010 at 9:25 am

  2. I’ve been reading your blog for a while but this is my first comment, so nice to “meet” you! :)

    I hope the increase helps and that the side effects aren’t too intolerable. FWIW, I did meet someone once in the UK who was taking buproprion for bipolar depression – she’d initially been prescribed a short course for smoking cessation (which is what it’s licensed for here) but it helped her mood so much that her psychiatrist decided to keep her on it. I don’t know whether this is common practice or if he was just unorthodox, but thought you might be interested.

    Hope you feel a bit better soon,

    RC

    residualcraziness

    Wednesday, 13th October 2010 at 9:37 am

    • Hi there. Good to meet you too. I’ve just been having a nosy at your blog.

      I know someone that takes buproprion for bipolar depression too, which is why I’m aware of it. She swears by the stuff. When I met her (in hospital), she was very, very ill and seemed like one of those patients you never expected to recover. After trying so many combinations of drugs, her private psych at the time asked her what she’d like to try. After researching meds, she tried the buproprion and with a mood stabiliser (can’t remember which) she is now pretty stable. It may just be one case, but it worked for her and she seemed to err on the side of agitated depression like I have done.

      Generally though I think private psychs are a lot more willing to prescribe off-label. I tried a few different things off-label (although usually licensed in the US) when I was with The Priory.

      I think of Buproprion though, because like Reboxetine, it is another atypical AD and it also works on norepinephrine. Noradrenaline seems to have been the key with Reboxetine, so perhaps a further boost of it would help.

      Only concern is anxiety can be a side effect, as can be further tummy troubles and insomnia – all the things I seem to be having problems with due to the Reboxetine.

      Dr M did mention she’d been using Quetiapine semi-off-label anyhow, but I somehow think she’d be more reluctant with this. I don’t understand why it isn’t licensed though when it is apparently the 4th most prescribed AD in the US.

      intothesystem

      Wednesday, 13th October 2010 at 4:45 pm

      • I’ve a feeling it’s something to do with an increased risk of seizures, although I can’t remember where I read that – it was years ago. I assume you’ve tried all the usual culprits that act on both noradrenaline and serotonin?

        I guess private psychs are free to just use their clinical judgement, whereas NHS ones probably have some manager breathing down their necks. ;)

        residualcraziness

        Thursday, 14th October 2010 at 8:11 am

        • Aye sounds about right.

          I wonder if the fact I would be taking Lamotrigine with it (anticonvulsant) would help on that front anyway. I did see a risk of seizures with discontinuation, but there are plenty of meds with that risk anyway and if you can have it for another purpose it always seems a bit strange.

          I’ve been on two SNRIs (Venlafaxine and Duloxetine) and neither really helped and both made me feel awful and agitated.

          SSRIs send me loopy, so I’m guessing more serotonin is not helpful for me!

          I’ve not been on Mirtazapine, which has been suggested in the past, but I am overweight and don’t need anything that is going to be likely to make me gain. I do wonder if it might help on the sleep front though, yet I don’t want to be in a drugged haze either.

          I’ve tried a stupid number of different ADs though and Reboxetine has been the only one to do anything particularly positive.

          intothesystem

          Thursday, 14th October 2010 at 12:55 pm

          • Interesting that you mentioned mirtazapine – that’s what I take, and has been the only thing to really work for me – SSRIs and SNRIs both send me loopy(er). Mirtazapine’s lifted me out of severe depression to a place where I can function pretty well most of the time, although I still have “issues”. It does help me sleep and sometimes it’s difficult to wake up in the mornings, but I don’t feel sedated during the day – I am calmer, though. Difficult to comment on weight gain as I have eating issues anyway but I would say it’s increased my appetite.

            Anyway, this might all be academic if the increased reboxetine does the trick – I’ll cross my fingers for you!

            RC

            residualcraziness

            Thursday, 14th October 2010 at 5:57 pm

  3. Hope the added increase works for you ITS. x

    Ms Leftie

    Wednesday, 13th October 2010 at 9:22 pm


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