Bipolar 2 From Inside and Out

Posts tagged ‘depression’

Functioning While Bipolar

Bipolar disorder is a funny thing. Mine leaves me alone part of the time. Until it doesn’t.

I have had full-blown depressive episodes, with the sobbing and the immobility and the wretchedness and everything else associated with it. I have had one major episode that lasted for three years straight, plus everything else from minor breakdowns to that vague, lingering miasma that comes when you’re untreated and you don’t know that what is really happening to you is clinical depression.

I have also had full-blown anxiety attacks, the sort that leave you twitching all over, feeling like you’re about to jump out of your skin, gasping for breath, and imagining that every driver on the road is swerving into your lane. I’ve twitched and shaken and stammered. I’ve scratched myself. I’ve hidden under the covers until I can’t breathe. I’ve taken anti-anxiety meds that did nothing at all.

Right now I am sufficiently medicated and have been relatively stable long enough that I think what I have is functional depression or maybe high-functioning depression, or whatever you want to call it. I have enough wherewithal to work part-time from home, do other writing-related projects (like this blog and my other one), and do assorted tasks like paying bills and making business-related phone calls. (Occasionally, if the phone tree is lengthy enough and the person on the other end is uncooperative enough, I have a small-scale meltdown. My voice goes up in pitch and tears start rolling down my face. My husband takes over the transaction when he notices that.)

But secretly, I know depression is lurking and can rear its ugly head again with little or no provocation – a trigger or nothing at all. So can anxiety, which is how my brain usually responds to hypomania. It’s a little like those commercials for psychotropic meds you see on TV, where the person has a little sign with a smiley face and hides behind it. Except that’s not quite accurate.

I understand that high-functioning depression is also called “smiling depression.” That’s not my experience of it. I’ve almost never been able to “fake it till I make it,” slapping on a happy expression when inside I’m dying. Besides, it doesn’t work, as far as I can tell. The depression or the sorrow always leaks out around the eyes. I’ve seen this in myself and in other people.

Before I was treated, I used to have what you’d call “resting sad face.” Once a boss of mine encouraged me to smile more (and is there anything more annoying?). I didn’t feel particularly sad at that moment, though I’m sure that I had at least a low-grade depression, like a low-grade fever. But I was at my job, and functioning even then, if not very well or cheerfully.

The phrase “high-functioning” gets used a lot to describe certain varieties of autism. I don’t have autism and I’m not an expert on it, but my suspicion is that high-functioning depression is similar in some ways. I don’t always react the way other people expect me to. I feel out of my depth a lot, especially in environments with lots of people or lots of noise. But that doesn’t stop me – or lots of other people – from carrying on with what I need to do to be a functioning member of the populace.

But back to bipolar disorder. Even if someone seems to be “high-functioning” doesn’t mean he won’t have a meltdown sooner or later. Even someone who “slaps on a smile” may let it drop once she is alone. Even someone who is “coping well” may not be coping at all tomorrow or next week or next year. Sometimes you can’t tell on the surface what someone is going through inside. Like I said, bipolar disorder is a funny thing.

Bipolar Disorder Has Turned Me Into a Pouty Child

I am blessed with many friends, online and off, who are as dear to me as anyone can be. We have laughed together, cried together, eaten together, danced together, sung together, joked together, mourned together, and loved together.

Now that I’m back in my cycles of depression and hypomania, hurtling around like a marble in a shoebox, I haven’t heard from any of them.

A lot of the contact I have with friends is on Facebook, and I have almost entirely stopped posting or replying, or otherwise interacting there. No one seems to have noticed. At least no one has called or IMed to check on me.

Am I ghosting them? No, because I don’t want the relationships to end. In fact I very much want them to continue. My scattered moods, primarily depression, have sapped my ability to reach out. It may be that they assume since I post my blogs every Sunday, I am all right.

I desperately want someone to reach out to me. This is selfish and childish and unworthy. If I want human contact, I should be able to reach out and initiate it myself. But I haven’t been able to. Between the exhaustion of depression and the exhaustion of hypomania, it’s difficult to make any kind of effort.

The memes say that if you have a depressed friend, reach out to them, even when they can’t reach back. And there have been times when my excellent friends did that, back when I had been in the Pit of Despair. And they kept reaching, even when I didn’t respond.

I guess I miss those days – not the Pit of Despair – but the little parachutes of care that rained down and demanded nothing. The phone calls “just to check in” or to distract, the invitations that I was never going to be able to make myself go to or reciprocate, the awful jokes that I might not even be able to laugh at.

I understand that everyone is fighting their own battles these days, with isolation, anxiety, panic, and other reactions to the pandemic, the lockdowns, the vaccines, the separated families. Mental health struggles, especially including depression and anxiety, are spreading to people who have never experienced them before. A lot of people are suffering, and a lot of people don’t know what, if anything, they can do about it. People have had to resort to Zoom weddings and funerals and outside-the-window visits to relatives in nursing homes.

Part of the problem, I suspect, is that I have been so relatively stable and functional for so long now. I made it through a tornado and a year of home dislocation and all the associated disruptions and bureaucracy without having one of my famous meltdowns. So, now, when even I have not been expecting or experiencing any psychological trauma to speak of, it’s easy to understand that no one else has seen it or noticed.

Then there’s my husband. He is my rock, my caregiver, my “emotional support animal.” Ordinarily, he takes up most of the slack in making me feel seen and heard and cared for. But unfortunately, he is having depression and anxiety of his own right now. He has recently had health problems, has changed jobs, and has physically strenuous activities he must complete, within a deadline. Of course, he is reacting with depression and anxiety of his own. And when both of us are depressed and anxious at the same time, it’s not pretty. We don’t have enough psychic stamina to help ourselves, much less each other.

So, I understand why it isn’t happening. But I miss the check-ins I’m not getting. The calls that don’t come. The personal long-distance reach-in. The wave from outside the window.

I’m not quite to the point of, “Nobody likes me. Everybody hates me. I guess I’ll go eat some worms.” But close.

Hypomania and Exhaustion

I’ve done so much. I should feel exhausted. I do feel exhausted. Why do I keep doing so much?

The answer, of course is hypomania, or maybe a mixed state.

I had been thoroughly depressed over my writing, as I sent out query after query to agents, and getting back rejections or the horrifying limbo of “no response means no.” I kept doing this for nearly four months, until I had apparently run out of agents to query. (I know that can’t be literally true. There are thousands of agents in New York alone, but I had been through all the usual lists and gone pretty far down the Google pages.) Yet I trudged along, depressed but pushing myself. Get the queries done. Get my work done. Get these blogs done. Go to bed. The same the next day. Call it functioning depression. I was still in motion, doing what I told myself had to be done, but enjoying none of it (or anything else).

Then I got an invitation to try out for some work-for-hire (which is sort of like ghostwriting, only different). Instantly, preparing submissions (three of them!) for this gig consumed me. And I kept on with the queries, the work, and the blogs. But I was tipping over into hypomania.

I wrote the submissions insanely quickly, when I knew I should have taken the time to analyze them, polish them, try a couple of different drafts. But no. I found myself pushed to get them done and get them out there. Or rather, I pushed myself to do it.

My submissions were rejected, but this time instead of slipping back into a funk of depression, I wrote a nice note saying that if another opportunity like this came up to please consider letting me apply again. They responded to the note, seeming astonished that I had sent it, and complimenting me on my attitude. Nothing like a pat on the head to keep the juices flowing.

It was at about that point that hypomania truly hit. I focused everything on my writing. I reworked the first three chapters that I had been submitting to agents and submitted them to still more. I started taking on extra work assignments. I took only brief breaks to eat a bowl of soup, then plunged back into it again. I had trouble getting to sleep and trouble sleeping, even though I was so exhausted that I turned in early each night. And I woke early, ready to keep on keeping on.

Then the miracle happened. I got a positive response from an agent. They wanted to see more of my work. I tweaked the newly revised first three chapters and sent them in. Now I’m waiting, nearly bouncing out of my chair, for them to respond. I just know that they will want to see the whole novel and become my agents. I do know that the deal is a long way away from being sealed, but hope after so long of slogging through my depression, hypomania has taken control.

I am (sort of) still contemplating my WIP (work in progress, a sequel to the novel that might now become real), thinking I need to rethink it entirely or try a different plot altogether. I am still taking on extra work, though it exhausts me. During my brief breaks from work, I scour the internet for presents for my husband’s birthday, and spend more than I had intended for more presents than I had planned.

And I am writing this blog post the day before I need to post it, rather than the three to four days I usually allow myself to write it. And I still need to polish the post for my other blog. And pay bills. And find a place for us to get a health check that’s required by my husband’s employer. (I have already set up appointments for our vaccine shots.)

I think it is most likely that if the agent rejects my work after all this, I will once again sink into depression – the I’m not worthy anything, I’m a fool to have put this much energy into it, I should just give up kind. Cutting back my activity to the bare minimum – work and blogs. Sleeping more, enjoying it less. Enjoying everything less. My old familiar functioning depression that is only possible because of the meds I take that don’t allow me to swing too far down.

I know people who, when you try to tell them about hypomania, tell you to enjoy it while you have it. They don’t know how wrong they are.

Laughing Out Loud

There’s nothing funny about bipolar disorder. In fact, one of the ways that I know I’m having a spell of bipolar depression is that my sense of humor flies out the window. Nothing brings a smile or a laugh – not my husband’s awful jokes. Not my friend Tom’s silly songs. Not a funny movie like Arsenic and Old Lace.

I have been in a spell of depression for a little while now. As I mentioned last week, part of it may be reactive depression. But here’s the thing. Reactive depression feels the same as bipolar depression. You have the same sense of misery, loneliness, helplessness, hopelessness, anomie. But you know what caused it and that it will end pretty soon, relatively, unless you tip over into a true depressive episode, which can last a lot longer than that.

But yesterday I laughed. And that was a good thing. It didn’t pull me completely out of my depression, but it let me know that escape was possible, and maybe even starting.

It happened like this:

My husband and I were sitting on the couch, watching TV. I was not enjoying it. Then a commercial came on about “man-boosting” pills that increase testosterone. It promised everything: strength, leanness, stamina, and outstanding performance in the bedroom.

Dan turned to me and said, “Hey, honey. Maybe I should try some of that. Improve my performance in bed-woo-woo-woo!

I turned and looked him straight in the eyes. I said, in a solemn, deadpan voice, without a trace of a snicker: Woo. Woo. I never got to the third Woo because we both dissolved in giggles. And it felt good – not only that I could laugh, but that I could make him laugh. Just thinking about it made us laugh all over again.

Today I am back to feeling overwhelmed, if a little less miserable, but still functioning on some kind of level. I don’t think my depression is over with. But for just a moment, I saw a ray of hope. Yes, it was over something stupid. Yes, I delivered the line with a flat affect. No, I didn’t know it was going to be that funny. I even thought Dan might be offended that I was making fun of him. But the important thing is that we both laughed. 

What I’m saying is that laughter, by itself, is not a cure for depression, however much the memes and the positive thinkers tell you that it is. But if laughter happens to you, it at least reminds you that the depression will end sometime – maybe quicker than you think. The giggles are building blocks that will help you climb up out of your hole, or at least see that there is a way out.

That’s a lot of philosophizing about two words (or syllables, really), and I’m not sure the magic would happen again if either one of us said Woo. But I am taking the memory of that moment with me, for whatever strength it can give me and whatever amusement will stay with me when this depression ends.

How Depression Sneaks Up

I had a blog post all written and ready to go. It was about my fluctuating moods and my writing, and how they affected each other. Some of what I wrote is still true. The depression I suffered during my early years and the exceedingly depressive poetry I wrote during that time allowed me to learn something about how poetry works and something more about how depression works.

I wrote about how hypomania affects my writing, and that is still true. Hypomania pushes me to do my writing, even when I don’t feel like it. In fact, at times it pushes me into doing more writing than I can probably handle. Case in point: This week I wrote three samples for a work-for-hire outfit when I should have been writing or at least outlining my WIP (Work In Progress), a sequel to the mystery I have already written and have been sending around to agents.

And last night, that’s where I hit the wall. I figured out that I have sent out about 180 or so query letters and gotten only the most minimal results – rejections that said I had an interesting premise that was not right for them. Most, though, have received plain rejections or the dreaded “no response means no.” I am now second-guessing myself and everything about the manuscript.

Last night, the depression caved in on me. I spent the night in bed, not sleeping except for nightmares, and not wanting to get up in the morning.

Because my identity is invested in being a writer, though, I did get up (late), sent a few more queries, and got to work on rewriting my blog posts, which I had determined were wretched. In the blog post that I abandoned, I had pontificated about how keeping a schedule kept me going with all the writing projects and various other work I do. 

I had also crowed about my relative stability and how that was helping me keep that schedule, which was supposed to be keeping depression at bay. I found out that I lied. The fact that I have maintained functionality for some time did absolutely nothing to prevent the depression that hit me.

Admittedly, this is probably a reactive depression, with my lack of success being the trigger. The thing is, it’s awfully difficult to tell apart from endogenous depression. In fact, I have known the first to melt into the second. At first you have a clear cause that would depress anyone, then you find it clinging to you long after what would seem to be reasonable. (This is subjective, of course. What is the “right” length of time to be depressed over 180 rejections?)

What’s left? Self-care, of course. Trying to sleep if I can, and squeezing in a nap if possible. Eat something, even if it’s only some guacamole and chips or a bowl of soup. Take my meds religiously. Try to cling to that schedule even when I don’t want to.

But the truth is, I’m running out of agents to submit to. I’m running out of energy to try. And I’m running out of the frame of mind to keep me functional. I’ll be okay, I know, but it may be a long, hard climb. 

My Triggers

By shane / adobe stock.com

Bipolar disorder is a funny thing. It can come on with no warning. One moment you’re fine, and the next you’re in the infinite doldrums or jagging on a spike of enthusiasm. Most of the time, it’s like that. The moods come on unexpectedly and stay as long as they want.

Sometimes, however, there are things in your life that seem to trigger a bout of depression or mania.  This isn’t quite the same as what’s commonly called a trigger. In the usual sense, a trigger is something in your past, like a traumatic memory, that comes bursting through when you read, see, or otherwise encounter a reminder of that memory. Suddenly, you are thrown back into the situation that triggered you, reliving the trauma, feeling as if you were still there, re-experiencing it. Triggers are most commonly associated with PTSD (or Post Traumatic Stress Disorder). Many people associate PTSD and its flashbacks with veterans and war, but other traumas, such as rape, assault, and natural disasters can also cause PTSD.

Trigger warnings are controversial. Some people need a warning that the content – especially books, blog posts, or films – may trigger a suppressed or otherwise traumatic memory and leave the person caught up in the sensations during a public moment, such as in a classroom. Obviously, people with traumatic memories would prefer to avoid this, so a trigger warning is placed at the beginning of a story, novel, or even a song that deals with rape, domestic abuse, or other traumas, especially ones depicted in a particularly graphic manner.

To other people, reacting to a trigger is an admission of fragility, at best, or at worst, an excuse for avoiding content that most people can easily handle. This is part of the mindset that leads to calling the severely traumatized “snowflakes” for their perceived inability to deal with stimuli that “normal” people take for granted. They do not understand the power of traumatic memories or the power they have over people who have been through trauma. They consider such people weak. They consider themselves strong, even if – or especially if – they have been through traumas themselves.

In general, my life has been less traumatic than some, more traumatic than others. There are memories that invade my dreams, situations that cause me panic, and stimuli that rev me up. I am not in control of these stimuli, or what they do to me.

Most of the stimuli trigger depression in me, as my bipolar disorder is heavily weighted towards depression. (In fact, I was diagnosed with unipolar depression before a psychiatrist finally recognized my condition as bipolar 2 with anxiety.) When I encounter one of these “personal” triggers, I am panicked, unable to communicate, and immobilized, or nearly so, and must rely on the help of others, especially my husband, to get me through. There’s no telling how long that depression will last.

Primary among my triggers is what I call “the rotten ex-boyfriend who almost ruined my life.” It was a toxic, gaslighting relationship that left my soul sucked dry and my emotions shattered. Fortunately, I do not often encounter anything that reminds me of those days. A friend I met during that time, in fact, has helped me heal both then and for many years thereafter.

Still, I have dreams – ones where I am traveling to the man’s house, ones where I am in the house but he is not present, and ones in which he is. I wake feeling vaguely seasick and nervous. The feeling persists like a hangover through most of the next day. It interferes with my ability to do work and to interact with people. My reactions used to be much worse, with specific words even able to throw me into panic and depression.

Another thing that triggers me is disastrous financial matters, or at least ones that I perceive that way. IRS dealings are by far the worst. A letter with that return address throws me into a panic. Once I even collapsed on the street after an IRS engagement and was unable to get up without assistance. Overdue bills and dealing with personal finances are triggers, exacerbated by the fact that I pay most of the bills, despite the fact that I make less than half the money. This is one of my contributions to the household since there are many things I am unable to do. Such situations leave me with my head in my hands, shaking and catastrophizing, unable to do what must be done until I calm down. (My husband is by now adept at helping me do this.)

And I have one of the more “traditional” trauma triggers – a natural disaster. A year and a half ago, our house was destroyed by a tornado. At the time it hit, I was upstairs in the bedroom. I remember the roof coming off. I remember putting a pillow over my head and hoping for the best. For many months I suppressed the trauma. But now it has come out. When the wind blows very hard or the rain blows sideways, I panic. Despite the fact that upstairs is the very place I shouldn’t go, that’s where I end up – in bed with a pillow over my head. (I also avoid movies like Twister. I’m not even sure I should try The Wizard of Oz.)

As for hypomanic triggers, I have few. Most of my hypomanic flights are unexpected, lifting me up with no warning. Although they can be exhilarating, they are also dangerous. One of the hazards is unwise spending, which of course can lead to the aforementioned financial depression triggers.

One trigger that takes me as near as I ever get to hypomanic sexuality, though, is a sensory, rather than a situational, trigger. For some reason, the smell of Irish Spring soap brings up the heat in me. I distinctly remember the first occasion on which I noticed this. A coworker walked past me and I smelled the distinctive scent. It started my juices flowing. Later, we became lovers. My reaction to Irish Spring is less extreme these days, but it still triggers a memory of the feeling. I seldom encounter the scent anymore, as my husband prefers Zest.

At any rate, it is my experience that triggers can arise from sensory memories, from dreams, from upsetting situations. I have few triggers related to textual representations, though I am not immune to those in films (I left the movie “What Dreams May Come” before it was over and waited in the lobby until it was over).

What I can say is that people’s triggers do not make them “snowflakes.” Triggers elicit visceral reactions that are no less real for not being visible to outsiders. While I don’t advise purging any possible triggering material from, say, academic curricula, I do think a trigger warning on syllabi or blog posts is only polite, and possibly psychologically necessary.

 

All Mixed Up

Leigh-Prather/Adobestock.com

As I mentioned a few posts ago, my psychiatrist and I are working on a medication change that will, I hope, pull me out of bipolar depression. The medication that we changed was a mood-leveler, which sounds like a productive way to start.

We’re increasing the dose, which means it shouldn’t take the time it would for the old drug to “wash out” of my bloodstream (and/or brain) while we’re waiting for the new one to kick in. I’ve been that route before, and it’s miserable.

While I haven’t noticed my moods becoming exactly stable since the change, I have noticed certain effects. I am able to get through the minimum of what I need to do each day, though nothing more. And I have noticed that I am getting irritable. This does not happen so much when I’m depressed. When I’m depressed, I don’t care enough about anything to be irritable.

In fact, irritability is one of the ways that hypomania manifests for me, before I get to the euphoria/super-productive/reckless spending stage. I get snappy with my husband about all his annoying habits, like never giving me a straight answer to a simple question. (What are you watching? A movie. What did you get at the store? Food.) I think he thinks he’s being funny, but I find it frustrating. Not that I don’t have annoying habits too, especially when I’ve either depressed or irritable.

So, I guess in one way, the irritability is a good sign. It doesn’t mean I have level moods yet, but it seems to mean that I’m not totally stuck in the depression. (I explained to my husband what was happening with me, and he seems to understand more. Though it remains to be seen if he’ll answer simple questions informatively.)

I think what I’m experiencing is a phenomenon know as mixed states. If to be depressed is to care about nothing and mania is to care about everything, a mixed state is some hellish combination of the two. Imagine being immobilized and jumpy all at the same time. That’s what it’s like, paradox that it is.

I haven’t had mixed states too often in my life, though I have had emotions that swerve drastically from happy to depressed in an instant (which is an extreme version, I think, of what’s known as ultra-rapid cycling). This is something different, though.

Now, I use up all my spoons early in the day and nap, or I stay up but go to bed at around 8:00. Ordinarily, if I went to bed that early, I’d read for a couple of hours, but these days half an hour or 45 minutes is it, tops.

Still, I think (or hope) that this mixed state of affairs is a step along the way to level moods that are higher than the numbness and not-caring of depression. It’s not comfortable to go through, but then neither is depression or mania, even hypomania.

It’s been about six weeks since the change in my medication. Within another four to six weeks, it will likely become apparent whether the change, once set in motion, will have an outcome I can live with. Until then, I need to spend my spoons as wisely as I can and try to remember not to snap at my husband, even when he’s being annoying.

Distance Psychotherapy: Is It for You?

By Alice / adobestock.com

I will make a confession: I have never used distance therapy, except for when I couldn’t drive to my therapist’s office, my husband wasn’t available to drive me there, or when I had the last-minute I-just-can’t-go-today feelings or I’m having-a-crisis feelings. This was in the days before teleconferencing, texting, and other long-distance forms of therapy, so occasionally my therapist would agree to do a telephone session, which I appreciated greatly. In general, they didn’t last as long as the standard psychotherapy 50-minute hour, but at times they were lifesavers.

Now, when everything seems to be online, and especially during pandemic lockdown, quarantine, or simply fears of going outside, tele-psychotherapy seems to be becoming a thing. Many services are now available via the internet, smartphones, and whatever way you pursue your online life.

I’ve been looking at these services, not because I need one now, but because I want to know what’s available in case I ever should. The APA (American Psychological Association) provides a lot of helpful information on the subject. Their site has provided a list of pluses and minuses regarding telehealth for psychology. They note: “With the current research and with the current technology, mobile apps and text messaging are best used as complementary to in-person psychotherapy…Research does show that some technological tools can help when used in conjunction with in-office therapy,” though “There are cases in which Web-conferencing or therapy via telephone does seem to be a viable option on its own for some people.”

Inc.com provides a helpful list of the pros and cons of online therapy. Some positive aspects are that:

  • People in rural areas or those with transportation difficulties may have easier access.
  • Most online therapy services cost less than face-to-face treatment.
  • Scheduling is more convenient for many people.
  • Individuals with anxiety, especially social anxiety, are more likely to reach out to an online therapist.

among the negatives are:

  • Without being able to interact face-to-face, therapists miss out on body language and other cues that can help them arrive at an appropriate diagnosis.
  • Technological issues can become a barrier. Dropped calls, frozen videos, and trouble accessing chats aren’t conducive to treatment.
  • Some people who advertise themselves as online therapists might not be licensed mental health treatment providers.

Despite the concerns, research consistently shows that online treatment can be very effective for many mental health issues. Here are the results of a few studies:

  • 2014 study published in the Journal of Affective Disorders found that online treatment was just as effective as face-to-face treatment for depression.
  • 2018 study published in the Journal of Psychological Disorders found that online cognitive behavioral therapy is, “effective, acceptable and practical health care.” The study found the online cognitive behavioral therapy was equally as effective as face-to-face treatment for major depression, panic disorder, social anxiety disorder, and generalized anxiety disorder.
  • 2014 study published in Behaviour Research and Therapy found that online cognitive behavioral therapy was effective in treating anxiety disorders. Treatment was cost-effective and the positive improvements were sustained at the one-year follow-up.
  • A recent review of studies published in the journal World Psychiatry compared people who received CBT treatment online with those who received it in person.  The two settings were shown to be equally effective.

One possible pitfall, warns APA, is that “online therapy or web therapy services are often not covered or reimbursable by most insurance providers. If you plan to be reimbursed, check with your insurance company first. Otherwise, prepare to pay for the full cost yourself.” The services I explored charge about $35 to $80 per week for unlimited messaging and one live session per week. MDLive provides a psychiatrist at $284 for the first visit and $108 afterward. (They have lower rates for seeing a therapist rather than a psychiatrist, and do accept insurance.)

Business Insider, in its article on the subject, dealt specifically with a service infelicitously known as Woebot. Unlike the other services, Woebot is a “chatbot” that substitutes artificial intelligence and natural language processing for a real, live therapist. It uses cognitive behavioral therapy. Their website claims that Woebot “is the delivery mechanism for a suite of clinically-validated therapy programs that address many of today’s mental health challenges, from generalized anxiety and depression to specific conditions like postpartum depression, adult and adolescent depression, and substance abuse.” Like a non-directive therapist, it asks probing questions and responds to questions and answers from the user. For now, it is free to users, though they seem to be exploring a paying model.

Other telehealth counseling services include:

Amwell

Betterhelp

Brightside (depression and anxiety, not bipolar or mania)

Online-Therapy.com

ReGain (couples therapy)

Talkspace

teencounseling (will consult with parents)

If you decide to try online therapy, it’s best to compare services and determine what services they offer, at what price, and what the credentials of their therapists are. If you have already tried it, I would be glad to know the results. Feel free to comment.

 

 

The Journey to Proper Meds

By areeya_ann / adobestock.com

This week when I went to my four-times-a-year med check, I told my psychiatrist that I thought I needed a change in medication. The previous time I saw him I had expressed concerns over assorted Life Stuff that was making me extremely anxious. Given what was going on in my life at the time, the anxiety was understandable.

Since then my anxiety has lessened somewhat, now coming out mostly as irritability and difficulty sleeping. And my depression now makes me feel like I have a low-grade fever – logy, listless, exhausted (which is not helped by the sleep problems) – plus the usual depressive numbness, lack of holiday cheer, and all the rest.

My psychiatrist listened to my symptoms, then discussed my meds with me. There were only two, both mood levelers, that he would recommend increasing. I chose the one that had had the most dramatic effect on me when I started taking it. So he increased the dosage from 200 mg. to 300 mg. We’ll see how that works out. I’m to call him before my next med check if I need to.

I’m used to changes in medications. It took a long, trying – even painful – time for my previous psychiatrist and me to work out the cocktail of drugs that would alleviate my seemingly treatment-resistant bipolar disorder. We tried various antidepressants, anti-anxiety agents, anti-seizure meds, antipsychotics, mood levelers, and I-don’t-remember-what-else. At last, when we were about to give up and try ECT, one of the drugs worked. It took some more tinkering before we got the dosages right, but for years now, I’ve been on basically the same “cocktail” of drugs.

Psychiatric Times, in an article on switching antidepressant medications (most of the literature seems to focus on antidepressants), reports that approximately half of all patients fail to achieve an adequate response from their first antidepressant medication trial. High treatment failure rates make it critical for prescribers to know how to safely and effectively switch antidepressants to ensure patient-treatment targets are met.” Other publications put the figure at nine percent, one-third or two-thirds. Whichever is correct, it’s a substantial number.

One method of switching medication is simply called “the switch.” The patient goes off one drug and onto the other. But there are problems with that, including drug interactions between the old medication and the new one.

The technique most recommended is the one that my previous psychiatrist used with me, which is known as “cross-tapering” – tapering down on the first drug and then ramping up on the second. A “wash-out period” when no drug is given allows time for the first med to clear the body before the second is given. This is promoted as the safest method.

I can testify that it is also the slowest and most miserable. Going off one drug, being basically unmedicated while you wait for the second drug to ramp up, and then possibly going through the whole process again when the second drug doesn’t work either (or has side effects you can’t tolerate) is brutal. I went through the process more than once, and it was hell. Basically, it took me back to full-strength depression during the wash-out period and minimal to no effect as the new drug being tried ramped up.

However, eventually, we found a drug that made a huge difference and that, in conjunction with my other medications, allowed me to function almost normally. Close enough for jazz, as they say. The recent adjustment in dosage does not appear to be having much of an effect yet, but I didn’t expect it to. Pretty soon, relatively, I’ll know. And if it doesn’t help – or if it induces side effects – I still have my psychiatrist’s phone number.

References

https://www.psychiatrictimes.com/view/strategies-and-solutions-switching-antidepressant-medications 

https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

https://www.healthline.com/health/mdd/switching-antidepressants

Take a Hike: Nature and Mental Health

photo from the author’s collection

 As a child and as a teenager, I was a Girl Scout. We hiked. We camped. We did all sorts of nature-related crafts. We ate wild plants. Well into my 20s, I was an outdoorsy-type person, hiking on the Appalachian Trail, walking to all my classes through the leafy green environs of my college campus, even trudging contentedly through the copious snowfall. One year I lived in a log cabin on a hilltop so far from civilization that you had to go to town to pick up your mail.

All the while, I had bipolar disorder, and it was relentless, I experienced the inevitable mood swings, the crashing lows, the tempestuous highs, the confusing mixed states. 

Now, everywhere you turn, there are articles and memes touting how time spent in nature is good for various psychiatric conditions. When you look more closely, though, the studies often refer to simply alleviating bad moods or improving cardiovascular health. Very few of them seem to apply to actual mental illnesses. Perhaps this is to be expected, since improvements in emotions or mental health are largely self-reported or tracked by means of a survey. It’s hard to quantify mental health. But let’s take a look at some of the studies anyway.

Harvard Men’s Health Watch published an article called “Sour Mood Getting You Down? Get Back to Nature.” The subtitle on the piece read, “Research suggests that mood disorders can be lifted by spending more time outdoors.” Then the article went on to suggest that “ecotherapy” shows “a strong connection between time spent in nature and reduced stress, anxiety, and depression.” 

The subtitle suggests that the outdoors has an effect on alleviating mood disorders. The body of the article, though, stresses alleviating unpleasant moods in general, not primarily what psychiatrists would class as mood disorders. The article cited a 2014 study saying that “people who had recently experienced stressful life events like a serious illness, death of a loved one, or unemployment had the greatest mental boost from a group nature outing.” Stressful and sad events, certainly, but not mood disorders such as PTSD, clinical depression, or bipolar disorder.

The article also cites a report published online March 27, 2017, by Scientific Reports, which suggests that “listening to natural sounds caused the listeners’ brain connectivity to reflect an outward-directed focus of attention, a process that occurs during wakeful rest periods like daydreaming. Listening to artificial sounds created an inward-directed focus, which occurs during states of anxiety, post-traumatic stress disorder, and depression.” It does mention psychiatric disorders, but it says only that inward-directed focus occurs during these states, not that inward-directed focus causes them.

Greater Good published an article that claims, among other things, that “scientists are beginning to find evidence that being in nature has a profound impact on our brains and our behavior, helping us to reduce anxiety, brooding, and stress, and increase our attention capacity, creativity, and our ability to connect with other people.” Again, this says nothing about actual psychiatric disorders.

The article also cited a Japanese study: “Results showed that those who walked in forests had significantly lower heart rates and higher heart rate variability (indicating more relaxation and less stress), and reported better moods and less anxiety, than those who walked in urban settings.” The researchers concluded that there’s something about being in nature that had a beneficial effect on stress reduction, above and beyond what exercise alone might have produced.

This, of course, does not apply to those in urban settings who do not have much access to forests or sometimes even parks. And the abstract of the Japanese study says, “Despite increasing attention toward forest therapy as an alternative medicine, very little evidence continues to be available on its therapeutic effects. Therefore, this study was focused on elucidating the health benefits of forest walking on cardiovascular reactivity.” It doesn’t really deliver what the headline offers: “How nature makes you kinder, happier, more creative.” Good heart health is, of course, a good thing, but to extrapolate that to mental health benefits is quite a stretch.

The UK’s Mind.org does offer a link between ecotherapy and mental health in one instance, at least: “Being outside in natural light can … be helpful if you experience seasonal affective disorder (SAD), a type of depression that affects people during particular seasons or times of year.” This article also acknowledges that there are “other options for treatment and support – different things work for different people….You might do an ecotherapy programme on its own, or alongside other treatments such as talking therapies, arts and creative therapies and/or medication. Some ecotherapy sessions follow a set structure, and incorporate types of talking therapy, such as cognitive behavioural therapy (CBT). People in the group may or may not have experience of mental health problems, but the main focus is usually working together on the shared activity.” This at least sounds both more scientific and more likely to produce results.

If a walk in a natural setting does you good and alleviates your symptoms of mental illness, then by all means, make it part of your routine (or do it as often as you can manage). My bipolar depressions, however, are so debilitating that I am unable to plan, much less embark on, a walk in nature, even as far as the mailbox. Bringing nature indoors is, of course, an alternative. But the little plant pictured here, which needs two ounces of water once a month, is all I can really handle.

Resources

https://www.health.harvard.edu/mind-and-mood/sour-mood-getting-you-down-get-back-to-nature

https://greatergood.berkeley.edu/article/item/how_nature_makes_you_kinder_happier_more_creative

https://www.hindawi.com/journals/ecam/2014/834360/

https://www.mind.org.uk/information-support/tips-for-everyday-living/nature-and-mental-health/how-nature-benefits-mental-health/

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