I had been intended to post something rather earlier, especially in the buildup to my MRI scan, however I got sidelined by something a tad unexpected.
As you may have gathered from my previous posts, I’ve been taking a rather large dose of Venlafaxine (in excess of 400mg a day) for quite a while now; suddenly however the expected rise in blood pressure became a real point of concern. When my consultant looked at my GP’s notes and found that I had recorded a BP of 180/131 he advised me to withdraw from Venlafaxine “As rapidly as possible”. This has been a fair ask.
When I gave up smoking (after around ninety tries in my life), I had rather hoped that that was the most miserable I would feel in regard to withdrawing from any compound – to my considerable disappointment I found coming off Venlafaxine to be much, much worse. If asked to compare the symptoms of nicotine and SRNI withdrawal I would say the latter is about six times worse.
Unlike smoking, where you get the rapid re-stabilisation of your mood/physiology when your spine cracks and you have a craft cigarette, there’s no immediate reward with taking another dose of Venlafaxine – instead there’s a very gradual rise back to normality over the course of several hours – and of course it’s just prolonging the overall withdrawal.
Within hours of missing my first dose, I got my usual punishment for not boosting my brain with something that it had become actually dependent upon. Numb lips, twitches, headache – all recognisable and taken in stride. The second day however was not so much fun.
The “electric shocks” that some people refer to were an ever-present horror – sometimes with major muscle-group twitches and pain. My concious brain slipped away, leaving that “I’m ill” type persona who just wants to lie down and wait for the universe to stop being quite so mean. My speech slurred and stuttered, nasty things happened to my digestion; all underpinned by the kind of headache that makes you want to smash things. Skin sensitivity shot up, even the gentlest of touches set off bruising feelings and left tingling aftershocks.
The only thing that brought even a small amount of comfort was eating, and for some reason I developed a short-term craving for scrambled eggs. While my brain insisted that I was hugely hungry, I would tend to feel sick after two or three mouthfuls of anything.
In all, I’ve not been in a state conducive to much abstract thought (or indeed much thought at all). After just over a week, things are starting to subside and I’m probably back up to about 80% functional. All this in mind, I’m a little confused as to how it can be that only 5-10% of people will have a cessation reaction to SRNI withdrawal – I think that this may well be a case of the reporting gap; I think that most people would experience some range of these symptoms, but just never mention it to anybody. Certainly I’ll be filling in a yellow form (a drug feedback form available in the UK for notifying of drug side-effects or cessation symptoms).
If you are going to be stopping Venlafaxine (or any other SRNI), I would recommend the following:
Take a week off work if you can.
Get lots of comfort food ready – preferably in small portions and as ready to eat as you can make it.
Tell all your friends and family to ignore any febrile ramblings that you come out with.
Hide anything breakable.
Lock your house and do not leave.
In short, the “sickboy” method of giving up Heroin from Trainspotting.
Normal service should be resumed soon (I have had my MRI, but haven’t been in a state to write anything coherent about it). In the meantime, if you are considering taking an SRNI I would still recommend it if your doctor or consultant is keen – just be aware that coming back off them is not always pleasant.
I’ve been giving a fair amount of thought recently to the different ways that people think. I don’t pretend to any great philosophical leaning, but I thought it could be helpful at least to discuss some of the problems I have had in considering modes of thought – especially with mindful thought being one of the most evidence-based approaches to depression. First, a rattlestop tour of the growth of self.
One of the egocentric ideas that most people retire quite early on in life is the notion that everybody thinks the way that you do. Given that this usually occurs to you when you’re about four, the result is the reality-shaking realisation that not everybody cares about your favourite cartoon in the same way you do. Even finding out that one of your friends doesn’t quite hold it in the same regard as you is something of a revelation.
It’s here that psychologists pick out the burgeoning growth of conciousness and sense of self – the point at which the mind realises that there are things that only it knows; this is when children begin construction of the wonders that are conscious lies, when duplicity and ego-protection begin.
As you grow older though, it’s sometimes difficult to remember that not only do some people not hold the same values as you, but that they may be in a completely different mode of thought. As an example, I was recently talking to someone about the mechanics of mindfulness – when I suddenly realised that they didn’t share the same context as me, and mindfulness as a whole didn’t make sense to them on a visceral level. I found myself running back over some key discussions I’d had in my twenties which had started me developing my sense of self further.
Let’s have a look at the history of my consciousness – or at least that part since my head injury. I did fight with depression quite a bit back then, as detailed in earlier posts, but things like CBT didn’t really gel with me; partly because some of the things seemed a bit obvious, and partly because I lacked the internal tooling and representation of my mind that would make the techniques useful.
Through many discussions with a couple of my friends, we first decried the failure of the Greek philosophers to provide us with a decent set of language tools to describe the mind (their perfect philosophical language), and then my friends rather gamely attempted to get me to join them in investigating the process of thought. I suspect that I may have disappointed them – at least initially.
I had a certain bull-headed arrogance that comes from a broad education and being “smart”; how could there be anything about my own process of mind that I didn’t already know? In this, I was falling straight into the common fallacy; and looking back it must have been the worst possible outcome for my companions – watching me bog down in the trap of self-satisfaction with my own intelligence.
Gradually, however I began to realise the truth of what they were driving at, and in doing so presented them with the fact that analysis of the mind is a complex meta-task; that the whole process is analogous to opening a box with the crowbar that’s inside. We realised then that nobody can be presented with a “golden road” to mindfulness or understanding their own mechanism of mind – there’s that massive gap between receiving something second hand and actually feeling the thought unfold in your own mind. Each person has to find a way to make it relevant to them.
The first and most powerful thing I learned was that I was not the product of my thoughts. Manly P Hall put it thus:
“…most persons are convinced that the thinker in themselves, is themselves. This identification of the being with it’s own mental processes has disturbed philosophy for a very long time…”
This realisation was hard fought for me, and yet looking back it’s so simple and obvious – I can quite understand why my buddies got so angst-ridden trying to get me past my arrogance.
I started to develop some tools to help me think further about my process of thought, and I gave some thoughts or modes of thought a level. Looking then at types of thought, I started to categorise them like this:
A thought that arises “of itself” – the flow of these is what some people consider to be their conscious mind.
Simply that – an emotion, possibly tagged onto a spontaneous thought
A thought brought into existence by willed action; such as “I will not steal that ice-cream”
A catchall for thoughts from the hindbrain; the half-formed, barely verbal demands to eat, sleep etc.
Defines the problem solving thought-process – although this is a gross simplification!
The next step was working out the flow of thoughts through my mind – I stopped and worked out what my mind was doing for most of the day and what modes of thought it spent most of it’s time in. The first mode of thought is essentially reactive:
Spontaneous thoughts are the normal-ish boxes, lizard brain thoughts are the filled in, fuzzier items, and emotions are the big red splatter things. As you can see, as time bumbles along there are thoughts that pop in and out; the uncontrolled stream that is baseline consciousness, with emotions that tumble along underneath, colouring all the thoughts above.
The next mode of thought is almost exactly the same, only this time we add willed and concentrated thoughts into the mix:
Almost exactly the same – except there’s a new thought, to stop myself eating the biscuit, which is an application of will. In my twenties, I probably spent as much as 95% of my time in this mode of thought – and like most people thinking that this actually was me. What my friends were really trying to get me to however was here:
Now we have another source of thought added; that of the mindful self, sitting above the black separating line. Here you can see this mode of thought taking place as more of a conversation with self; with thoughts being examined and categorised. This part, which does the examination, which observes the different aspects of your own thoughts is what I currently believe is the source of ‘self’.
This is the part that some people dismiss as part of “navel-gazing” culture, but is in fact that part which allows us to examine ourselves against what we want to be and make effective changes to our patterns of thinking and our response to emotional thoughts. This pattern of thinking is where we should spend our time, if for no other reason than it allows us to inspect the chaos thrown up by the spontaneous, lizard and emotional areas of the brain and decide what we want to do with them. As much as I try, I only currently manage to spend about a third of my waking life in this pattern of thought, and that’s a real effort of will. This is the state that you are looking for when asked to concentrate on living in the moment; to be mindful.
I have difficulties staying in this state for a couple of reasons – firstly, it does require an effort of will; it’s not a default state, otherwise we’d all do it all the time. Secondly, I have a problem with how this mode deals with emotions. Despite my slightly gung-ho and callous exterior, I’m an emotional person; thinking in this mindful way allows an overview of emotion that feels rather more detached, and I felt it as a bit “cold”. It literally felt like some of my connection to the emotional cause of the situation dropped away, and I could make rational choices.
Because of that, I came to view it negatively rather than positively – instead of seeing the benefit in being able to respond to things the best possible way, I clung to my emotions; thinking that they should define me. I think that my confusion after my head injury didn’t help, as I came to view the emotional self and thought patterns as a source of truth. In fact, I was doing everyone a disservice by not bringing these things into check. Unbridled emotions are for love and genuinely dangerous situations, not for business decisions.
When thinking mindfully, I can help my friends through emotional crises more effectively; I can prevent myself from become upset at their pain and still act with integrity.
I have absolutely no doubt there are modes of thought above the three I have described; the one me and my friends started to explore was the mode that examined the mindful self – to start to find what were essential details of our characters, and what were things we’d picked up to defend ourselves with, flaws we could work on, and what genuine good came straight from our un-willed consciousness.
If nothing else, I’d like to hope that this has helped anyone struggling with mindfulness by giving a slightly different way of thinking about it. Any thoughts, pop them in the comments.
It’s been a little while since I’ve talked about depression, so let’s get back into that.
I do still find it quite difficult to write about while I’m in “the thick of it”, but I’ve had some more discussions with people with access to therapies and I’d also like to follow up on my promise to talk about the effects and various oddities of the current medications I have taken over the years.
Starting with recent events, I have now been referred by my GP to a psychiatrist. This gentleman took the single most complete history of my mental health that I have ever been asked for, and as a result we’ve got two elements that we’re going to follow up on. First, I am to be scheduled for an MRI of my brain – because it’s most likely my depressive episodes where triggered by my head injury they would like to see if there’s any visible structural damage to my grey matter. This is both wonderful and slightly scary, the idea that the source of my “self” could be physically scarred is a harsh reminder of the dependency principle, that you can be “turned off” with nothing more than a sharp blow to the head.
Secondly, I’m going to be taking rather more of my current medication, and I was ‘threatened’ with Lithium. This takes us rather neatly onto the drugs bit I’ve been promising for so long.
Lithium has been described to me before as the “Gold Standard” of mood stabilising drugs, and it’s was the first success story of the drug based treatment of psychological problems. Before the clinical use of lithium there was really no pharmacological approach, and it acted as a gateway to the development of modern psycho-actives. That’s not to say that it doesn’t have some issues, because it does. The effective dose is uncomfortably close to the “drop down dead” dose, and because lithium can take the place of other ions in the body a sub-lethal dose can become quickly lethal if you – for instance – become dehydrated. This is a bit of a disadvantage in terms of therapeutic usage.
Wind forward a few years and we go through the development of the tricyclics, the SSRIs and the SRNIs. These too, have side effects.
All drugs have side effects. It’s a comforting mental image to think of a drug as a perfectly shaped key that fits into a lock somewhere on the door that is a cell – this is after all what they teach us at school, more or less. This model is correct however only if you fill the door with locks, and each key can fit in multiple locks. And the door is made of jelly and can retreat from the key. And the locks change shape when the key is inserted. And there are different kinds of door, where the lock makes the door open differently. It’s really not a good metaphor – for more insight I’d suggest reading “In The Pipeline”, where Derek Lowe (an active drug discovery chemist) gives great insight into how drugs actually work. He seems to be moving blogs at the moment, but you can find his archive here.
The fact that each drug fits multiple “locks” and multiple different kinds of cell is what causes many of the side-effects. Each drug will not only hit it’s more or less understood target, but also several others (the purpose of which may not be quite so well understood). Also, differences between the exact state and setup of your body chemistry can mediate how many side effects you get; sometimes a drug will be well accepted, other times something you’ve taken for years can suddenly turn round on you and bite you. Now, I’ve taken a fair few of the anti-depressant drugs over the years, so here’s my who’s who of the pharmacopoeia – and an idea of what to expect if you’re talking about possible drug treatments with your GP or other brain-care specialist.
This is probably the oldest drug that I was ever rotated through; it belongs to a class of medications called the “tricyclic” group – named for the shape of the molecule. Lofepramine was fairly rarely prescribed in the UK when I first start taking it, and it’s been largely replaced by SSRI’s as a first line treatment.
Compared to some of the other medications I have taken, the adaptation period was relatively mild and the side-effect profile relatively good. I did have a little dizziness and confusion for the first couple of days, but after that it was back to business as usual. At the time I was underweight (hitting less than 7.5 stone at one point), and I was really hoping that one of the advertised potential side effects of weight gain would pop up – no such luck.
I took Lofepramine as a first fix treatment, and I was moved off it when my mood failed to respond. After some consultation I was switched to Cipramil.
There’s a big warning in most of the leaflets I’ve read that says that SSRI’s like Cipramil should not be taken after tricyclics like Lofepramine without a “washing out” period after your last dose. That in fact didn’t happen when I switched, and because of that my first two days on this medication were not typical. I have a memory of cold sweats and Lucosade (if you’re not from the UK you may not have quite the same “I feel ill, I shall drink Lucosade” thing that we do over here). I also remember reading what was in hindsight a fairly pedestrian book and feeling like it was in the literary equivalent of immersive 3D with surround sound and a hidden bass-bin. As I say, not typical.
This was my first SSRI, and SSRI’s are the source of some controversy (of the type “do they even remotely work”, which isn’t good for a drug class). There’s some evidence that they are more effective in steep chronic depressions, as the placebo effect pretty much gets flattened by one of those, but there’s still some argument as to whether they are very helpful, or just slightly helpful.
In my first few depressions I tolerated Cipramil pretty well – not so in my most recent episode; that instead felt pretty much like having ants under my skin. There’s an effect that people who spend much time with SSRI’s talk about quite a lot, which is the feeling that you’re being electrically shocked every few moments. While it’s generally felt during discontinuation, I’ve found that it can creep up any time; this however was grim torture – almost constant “zapping” and shudders, badly disturbed sleep and mood problems. After only a fortnight I switched away to Duloexetine.
Now, because of my previous positive experiences with Cipramil, and despite my recent experience I certainly would consider using it again; and this is the thing with psycho-actives – you never really know how well tolerated or effective any of these medications are going to be until you try them. Despite how well tolerated Cipramil had been in the past, that was never any guarantee it’d be dealt with so well in the future. As a result, most treatment for depression tends to wander through the available compounds until something that is both effective and relatively gentle.
My wife has slightly bad memories of Duloexetine, as after the initial adaptation period we found this one of the most heavily sedating drugs; to the point where I could occasionally fall asleep mid-sentence. This kept me off the motorbike for a fair time for obvious reasons; narcolepsy and rapid modes of transport are not good bedfellows.
Duloexetine is an SNRI, but not one you’ll have heard of if you’re Stateside – the FDA never approved it as an antidepressant over there over suicide and toxicity concerns. We gung-ho Brits stuck it through though, and it’s become a flagship for the SRNI gang over here. Rather than just raising the level of seratonin in your synapses, these drugs also prevent the re-uptake of norepinephrine – another important factor in mood regulation.
I stayed with this one for a good few months, but after a brief lift in mood it felt like things were slipping backward. This also was the worst anti-depressant to miss a dose of – the withdrawal effects of Duloexetine were fast, unpleasant and dependable. After my fifth wasted morning caused by missing my first dose of the day, one of my friends got me a key-fob pill box, and I’d seriously suggest investing in one if you’re considering an SRNI.
Venlafaxine and Mirtzipine
Having had no great luck with Duloexetine, and getting a little fed up of falling asleep so much, it was decided that it was time to switch to another SNRI. Known as Effexor in the States, this is often given in combination with Mirtazipine in a combination known as the “California Rocket Fuel”. Taken individually these drugs are good for mid-level depression, taken together they are considered an excellent hammer for smacking even the hardiest depression into submission.
Of all of the medications I have been rotated through, this combination has so far been both the gentlest in terms of side effect profile and adaptation period; I started feeling ‘normal’ within a couple of days – although the first dose of Mirtazipine will likely knock you flat next morning. It’s a moderately good sedative, and I did get a sleepy hangover the next morning, but there’s an effect called paradoxical sedation where the higher the dose you take, the less sedating the drug is. One thing to note is that Mirtazipine will almost certainly make you put on weight – I’m up a stone, and my cravings for sugar are almost unstoppable!
Unfortunately my current depression has been fairly resistant even to this potent combination. I did have two minor lifts in mood during the dose staging, but these faded after a week; hence my referral to the psychiatrist and the increased interest in the physical structure of my skull’s contents.
I hope that’s given you at least some idea of what you could face if you’re considering adding medication to your treatment plan for depression; if you’d like me to drill into any of those medications specifically then just pop a message in the comments and I’ll queue it up for a future post.
Code, and things