Mental Health Post #17: Medications

Ah, medications for mental illness.  I thought there was nothing more controversial to talk about in health care until Covid came to town.  ;) Now we get to fight about masks, vaxxing and people spit-talking at us.  But this post isn't about Covid.  Today I want to talk about my (limited) experience with antidepressants and what kinds I've taken and what I know about them.  Which isn't a lot, but that's okay--we have Google and all sorts of reputable websites (see my previous posts about good medical websites) for the in-depth stuff.

The first time I wandered in to the arena of antidepressants was after I bore my first child and had severe PPD (post-partum depression).  I was prescribed the generic of Prozac (fluoxetine) which I took for about 8-10 months if memory serves me correctly.  I took a medium dose during that time and then eventually weaned off of it.  I don't actually remember how that wean went, but that tells me it probably wasn't a huge deal and I didn't have severe side effects from going off of it.

The second time I started antidepressants was when I had PPD after the birth of my second child, AND realized that I had never felt truly good since I had weaned off the Prozac a couple years before.  This time, I was committed to stay on the anti-depressant until I was sure that I could function well without it.  (Joke's on me since that will be my death probably!  ;)  I tested out the generic for Zoloft (sertraline), which was newish at the time.  I started on a medium dose, but after months of consultation with my amazing psychiatrist (Sheila Marcus at UofMich, she's famous!), I moved to the highest dosage.  At this dosage, I found my anxiety was better managed than at the lower doses.  The depression was kept at bay by all but the very lowest starting doses, but anxiety is a little trickier beast.  

I took the Zoloft for about 2 years before I "pooped out" of it (this, I kid you not, is a technical term!).  See I kept getting pregnant and when you are pregnant, your blood volume increases drastically, and you need higher and higher doses to maintain healthy mood.  During this time I found that some drugs did absolutely nothing for me (looking at you Celexa (citalopram) & Nexapro (escitalopram)), and I ended up back on Prozac when all was said and done.  Unfortunately, I pooped out out of Prozac (as well just pooped a lot in general) during my last pregnancy.  I went back to Zoloft which was fine for a few years before it began to lose it's efficacy.  Not because I was pregnant anymore but because after a period of time, the body seems to habituate to the drug and they no longer do as good of a job at keeping those neurotransmitters hanging out.  This is absolutely not the same thing as becoming dependent on a drug (like an addiction)--the mechanics are totally different.  You can Google it if you want the complete run down since I don't want to go too in-depth here.

Eventually, I started taking a new class of antidepressants, called SNRIs (serotonin and norephinephrine uptake inhibitor).  All of the previous anti-depressants I mentioned are in the SSRI drug class (selective serotonin reuptake inhibitors).  These newer type of antidepressants affect more than one neurotransmitter and seemed to be more effective in general.  I started with a drug called Cymbalta (duloxetine) which worked well for about a year before it seemed to abruptly stop working at all.  Though pharmacogenetic testing (tests that see what drugs you don't respond to because of your genetics), I found out that I was an ultra-rapid metabolizer of Cymbalta.  Bummer, that.  I moved to a newer drug called Pristiq (desvenlafaxine) and I loved it.  Unfortunately, I started getting baboon syndrome a couple years later (go look that one up, it's a real party) and as part of my efforts to see what was causing it over a period of a year, I moved off of Pristiq and back onto good old Prozac.  (It probably wasn't caused by the Pristiq, since it seems to be nickel and formaldehyde among other things that are my primary allergenic issues.  But some drugs can contain more of both of these trace allergens, so it's hard to know.)

Here's the thing about antidepressants.  Individuals have totally different responses to medications.  There may be observed averages in populations on many things like side-effects, half-life of drugs, etc, but people all have slightly different chemistries that means everyone can have slightly different affects to any medication.  You noticed that I said Celexa & Lexapro did absolutely nothing for me at all.  But I knew others who LOVED those drugs and found them super helpful.  A related note is that honestly we are still learning a lot about these medications.  When I first took Prozac, the pharmacists told me to take it at night because it would make me tired.  That was never the case for me.  It woke me up and I routinely took it in the morning.  (They also told me that I needed to talk to my doctor about taking it during pregnancy and that I was harming my baby when I was literally being prescribed to by one of the foremost depression-in-women experts in the world.  Note to everyone: gather lots of facts and remember that information that comes from someone in another industry may or may not be accurate.)  Now that I am taking it again, my current psychiatrist tells me all the time that Prozac is "activating".  I can back that up personally.  ;)  

Another medication that I have taken for probably over 20 years is called Buspar (busperone).  Buspar is an interesting drug, the only one in it's class.  It is specifically a serotonin agonist meaning it increases serotonin activity in the brain, but it also seems to have a mild impact on dopamine as well.  It's especially helpful for anxiety, and works well in conjunction with other antidepressants like the SSRIs and the SNRIs.  I also came off of this drug about a year ago in the search for what I was allergic to and found that while it REALLY SUCKED to wean off of it entirely, it also didn't improve my dermatitis.  So I'm happily back on it for life if I have any say about it.  

Here's a fun one I took: amitryptaline.  Before I knew I had POTS (a cardiac syndrome that can cause fainting, vertigo, etc), I was diagnosed with an inner ear disorder and was given amitryptaline to see if it helped.  It did nothing for the "inner ear disorder" but man did I sleep soooooo good every night.  Amitryptaline is part of a kind of older antidepressants called tricyclics.  They increase serotonin and seem to block some pain signals in nerves.  Some people take them for neuropathies and other nerve problems with varying degrees of success.  A big problem with the tricyclics is they are fatigue-inducing. So while I didn't keep taking amitryptaline, it did help me to find that moving to the SNRIs would be a good thing for me.  (I believe they have related affects on anxiety.)

Last, but certainly not least, I have taken a benzodiazepene for about 12 years, first only a couple times a year, and now still not daily, but more often than before.  I initially took Ativan or Xanax (depended on my prescribing doctor and since we moved a few times, they sometimes changed my medication).  They both worked fine, but later I discovered that Klonopin has a longer half-life and moved to it and found it to be highly effective for controlling the anxiety (which is much hard for me to control than the depression).  I've also had to use Valium for a couple of medical procedures, but baby, that stuff is strong and I hope I never have to take it again.  You feel "comfortably numb" to quote Pink Floyd, but not in a good way.  Here's the thing about benzos: they ARE addictive, deeply so.  I don't recommend them for just everyone because you need to know how addictive they are and use extreme caution so as not to fall into drug abuse.  I personally feel like I have the potential to have an addictive personality and exert extreme caution with how I use them.  But even more scary to me is the thought of not having that lifeline when things spiral out of control.  I don't know if anything is quite as motivating as the thought of losing a helpful tool in your mental health kit.  So I have certain nights of the week that I take it before bed to assure that I get a good night's sleep that night (yes I totally need to do a post just about sleep because people SLEEP IS EVERYTHING!!).  For all of these reasons, I think these are a drug class that are perhaps not always suitable for teens and young adults and anyone else that thinks they may struggle with abusing the prescription, much in the same way that opioids can be abused.

A note about the half-life of a drug: you know how you learned about Carbon-14 dating in school?  How the radioactive isotopes decay and when they are halfway decayed, that is their half-life?  The concept is similar with the drug's half-life.  The half-life of fluoxetine (Prozac) is 4-6 days.  That means around day 4-6, you have half the amount of the drug circulating in your body.  (BTW 4-6 days in a very long time for an antidepressants.  Part of the reason I do love Prozac.)  However, if you are an ultra-rapid metabolizer, as I am with Cymbalta, which already has a very short half-life, you may literally be experiencing withdrawal every day because your body is breaking the drug down and excreting it the way the Kardashians spend money.  I am also an ultra-rapid metabolizer of ibuprofen which means it basically doesn't work for me.  Knowing this stuff can be so helpful, and if you have the funds and the opportunity, I highly recommend getting the pharmacogenetic testing done for yourself and loved ones.

I would be remiss if I didn't also briefly talk about withdrawal feels like.  A couple of Christmas's ago, I ran out of my antidepressant and forgot to order more.  So when I took my pills out of my pill packs, I wasn't taking the Pristiq.  I got super sick, like I had the flu.  I literally thought I was going to die by day 5.  Thankfully, I realized what was going on by day 6, but it really showed me the value of putting reminders in my calendar so that hopefully NEVER happens again.  When I had to go cold-turkey off of Buspar, I had similar symptoms of nausea, dizziness, extreme fatigue and moodiness, but not at quite the same severity.  Going cold turkey off of Cymbalta was actually not super difficult since, as I mentioned, since I was basically withdrawing every single day as my body speed-walked the Cymbalta to the exit.  <<insert eyeroll at my body having to be a special snowflake in this way>>

A couple important things I've learned over the past two decades: one I already mentioned, that everyone can have small or big differences in effect of the same drug because everyone has different chemistries in their bodies.  Two, that sometimes a medication may not work, and that it takes time to move from one drug to another (when you taper off of one antidepressant and taper on to another one at the same time, it is called cross-tapering).  It can be a difficult time for anyone experiencing it, but I know it helped me so much to know that the next few weeks or months would be difficult and adjust my expectations.  A couple of times I have been asked by my doctor or have had to go cold turkey off of an antidepressant and I highly do not recommend it.  One of those was Buspar, and at the time, I was desperate to figure out why I was having extreme eczema in my basement.  If I have to change drugs, I try to do it when the day is lengthening (late winter, spring/summer) and never in the autumn.  But I had no choice with the Buspar and that fall was a difficult one for months even once I had completed my taper off.  

One final observation: the medications I have mentioned are the tip of the iceberg.  There are other classes of medications and even therapies that do not involve a pill, like ECT (electroconvulsive therapy), or TMS (transmagnetic stimulation) or VNS (vagus nerve stimulation).  I feel like the world is truly starting to blossom with better knowledge about the multitude of causes of poor mental health, and treatments are slowly catching up with that knowledge.  I truly pray that my children and grandchildren will find it so much easier and cheaper to get the relief they may need, especially as we see the world erupting into vast numbers of mental health crises over the past few years (particularly since the pandemic began).

Photo note: I found my first silver leg hair.  I had no idea that all of your body hair eventually turns silver until a few years ago.  And when I say all, I mean everything, including the stuff in the basement.  You can thank me later for this educational moment...  (And just in case someone is really freaking out about why I don't shave, there is nickel and/or lubricating strips on all the razers in the whole world.  I'm very happy to have hairy legs year round, honestly.  Have you ever felt your leg hair flutter in a breeze?  Or sway around in the water?  I'm telling you, ladies, you are missing out on some cool sensory experiences.)