Monday, September 26, 2011

My Depression Story (Updated)

There's been a request at a discussion blog I frequent to learn more about my story, surrounding my depression and suicide attempts. This is a sensitive topic and so be aware that this may not be appropriate for younger audiences. I'm opening up here to the public, which I've not done before, to educate, bring awareness, and fight stigma/shame, and so I only ask for a listening ear and for you to withhold judgment.

Millions of Americans, including an estimated one in five families are affected by mental illness: major depression (beyond "the blues"), schizophrenia, bipolar disorder, panic and anxiety disorders and other disorders, which disrupts a person’s thinking, feeling, mood, ability to relate to others, and daily functioning. Mental illness is a biologically based brain disease believed to be caused by an imbalance in neurotransmitters, the naturally occurring chemicals in our brains which effect our moods, thoughts/behaviors, & movements. (A PET scan, measuring the  neurotransmitters in the brain, which show a brain with decreased activity due to depression can be seen alongside a PET scan of a normal brain here.) Just as diabetes or heart disease, mental illness is a medical condition, which can result in serious life-disrupting symptoms and as a result, a diminished capacity for coping with the ordinary demands of life, without treatment. I am one individual with a mental illness. I have major depressive disorder. This is my story.

In the fall of 2002, I began college for the first time. I had a great social life there, but was struggling with academics. I struggled & fell behind in classes, but plodded through. I had struggled with Attention Deficit Disorder since childhood & decided try to my ADD medicine, a low dose of the anti-depressant Wellbutrin, again for a month in hopes it would help my academic performance, but it didn't seem to help, so I gave up on it & stopped taking it by September. What I didn't realize was that medicine was the only thing keeping me from falling over the brink from blues to full blown depression. I went home for midterm break in October, and felt even more sad, and very argumentative/irritable, but still thinking it was just the blues, didn't reach out to family. The night I arrived back from midterm break, I was sitting in the dorm lounge & suicidal ideation/thoughts of cutting entered my head, but I pushed them away, dismissing the idea as ridiculous. As the night went on, the suicidal thoughts became more intense, and I became frightened and sought help from my resident advisor in the middle of the night. The following morning, I was escorted by my resident advisor & resident hall director to the student counseling center, where I started seeing a counselor. I was diagnosed by the counselor as having a major depressive episode. I agreed with my counselor's suggestion that leaving school would be in my best interest, and moved back home with my parents, but I saw it as a personal failure.

In the spring, I landed a job in fast food, working full time and my depression didn't return. By the fall of 2003, I was ready to try college again, this time at a small community college away from home, where I got help with both life skills and my learning disability. I did better in my academics and had normal ups and downs with depression, but more good days than bad. My second year I decided to take on an active role in the campus ministry. Looking back, it was a mistake, on top of the demands of school, the commitments of the campus ministry over-taxed me, took a toll my academics, and my depression became worse. I immediately made an appointment to start seeing a counselor, but didn't improve during the time I was seeing her. Once again, I made the decision to drop out of school in January of 2005, but this time with plans to finish my degree at a later time.

After returning home to live with my parents, I lost my health insurance coverage because I was no longer a college student and private insurance was difficult and expensive to obtain because the depressive condition was preexisting. Anti-depressant therapy costs upward of $60-200 (at the original time of this writing), depending on the medications and therapy can cost upwards of $90-150 a session. I gritted my teeth and continued to pay for my medication out of my own pocket, however therapy was out of reach.

In June 2005, I landed my dream job at a library, only to loose it in September and with the realization that it was a hostile work environment and I wasn't suited for the job. Loosing my job on top of my other shortcomings and personal struggles was a big blow to my self esteem and self-confidence and so I sought out a counselor at the local community mental health clinic.

Clinics such as these are a vital part of our community, offering much needed mental health services. Most people with serious mental illness need medication to help control symptoms, but also rely on supportive counseling, self-help groups, assistance with housing, vocational rehabilitation, and other community services in order to achieve their highest level of recovery. At the clinic, I was able to see a therapist in addition to a nurse practitioner for medication and my medication was affordable. However, like many community mental health clinics, they are under-staffed and poorly funded, which can result in poor quality of care. In addition, persons with a mental illness are often faced with additional challenges in the workplace, in the home, and in the community due to barriers to obtaining treatment and the stigmas surrounding mental illness.

In November, I landed a new job at a small community library with the help of a family friend. I haven't told many people, but around this time, there was an incident in which I was severely bullied online, which negatively impacted my self-esteem. In December, my counselor suggested maybe I would also benefit from medicine to help my depression and I started also seeing a nurse practitioner who prescribed a selective serotonin re-uptake inhibitor or SSRI. (Did you know, there are 40 different types of anti-depressants, every person's brain chemistry is slightly different and individuals respond differently to each medication. Usually the most effective treatment for depression is a combination of medication and therapy.) On the first night of the medication, I went ice skating with the family and felt great, energetic and even "normal" again. I started the new job at the library in January, but even with the job going well, I still struggled with self-doubts. After a few weeks, I stopped taking the medicine, thinking I no longer needed it. Eventually my self doubts began to play like a tape in my head over and over enough to where I started believing myself to be a failure, ans coupled with the shadow of depression , I began a downward spiral. (I can honestly say that during this time, I didn't understand my illness very well and the importance of staying on my medication).

On January 23rd, 2006 I made my first suicide attempt, while my parents were out of town. My then-boyfriend (husband) sensed something was wrong over the phone and came over. He called his parents, who also came over and took me to the hospital. At the ER registration desk I told them in a soft voice I had taken too much medicine & my boyfriend's mom clarified I had overdosed. Seeing I was pretty unsteady on my feet, they got a wheelchair, & took me straight back. As I was wheeled through the ER to a room, I remember feeling ashamed, I wanted to hide under the hood of my sweatshirt, but didn't have the strength to lift my arms, which felt like they were encased in lead. A lot happened quickly. I was hooked up to monitors and they took my vital signs.  When it came time for the nurse to put in an IV, I struggled due to my innate fear of needles from a difficult blood draw when I was a child (later that week, I was grateful to be able to hide the bruising on my arm under the sleeves of a sweater). Staff returned in protective masks & gowns & I knew what was coming next. I became scared & asked my boyfriend's mom to stay & hold my hand, but alas, they asked her to step out of the room. I'll never forget the name of the kit I saw on the bedside table: Tum-E-Vac. They pumped my stomach and gave me activated charcoal through a wide tube inserted through my mouth down into my stomach. The experience was traumatic, both physically and mentally. A family friend arrived & in kindness offered reassurance as she wiped my face with a cool cloth, which helped with the nausea. I was assisted to a shower & by the time I returned to my room, my parents had arrived. It was getting late into the evening, & so the family friend & my boyfriend's parents said their goodbyes & went home for the night. As I was transferred up to the intensive care unit for observation, I can just remember thinking how surreal it all was. The next morning, the intensive care physician shared that he had battled & overcome depression, giving my parents hope. I also saw a kind psychologist from the hospital, who evaluated me. Because the stomach pumping procedure had shocked me out of suicidal thoughts, following an evaluation, the psychologist said it was ok to send me home, with a safety plan and follow-up care in place. I was discharged  that same day and one of the fortunate ones to be able to walk out of the intensive care on my own two feet.

After that experience, my parents took precautions such as checking with me every day for the first couple of weeks and ensuring my safety. As I felt better, I felt grateful for the help and support I received from my boyfriend's parents & the kind family friend who visited & got them flowers as a token of gratitude.

I was still able to continue to work afterwords and my supervisor has been wonderfully understanding that I was in the hospital and even allowed me to even make up the hours. In February, my nurse practitioner emphasized the need for me to continue therapy. Following my suicide attempt, I felt things weren't working out with the counselor I was seeing, so I found a new counselor at a student practicum clinic, through the local teaching college. Also, I wanted to try a natural approach instead of medicine and with my nurse practitioner's acceptance, tried St. John's Wort, an herbal supplement used for treating mild to moderate depression, as well as more frequently exercise and light therapy. I didn't take the St. John's Wort consistently enough & alternative medicine alone wasn't enough for the severity of depression I was experiencing, which resulted in my depression worsening, & another trip to the ER when I started having suicidal thoughts & didn't feel safe (I was evaluated & released under my parents care) at the beginning of April. During the follow up visit, the nurse practitioner and I decided to try prescription anti-depressants again, this time another SSRI. I was still having major depressive episodes and more frequently, now at least once a month.

My new therapist did some diagnostic testing and I was diagnosed as having major depression. This was a huge relief for me, because now I had an official name to what I was experiencing and it was more concrete to me. I started out on the lowest dose possible of the new SSRI, but it wasn't reliving any of the symptoms and at the therapeutic level, made me feel heavily sedated. I became physically and mentally exhausted from constantly battling depression, frustrated and discouraged. In hopelessness and despair, I made my second suicide attempt in May 2006, just over two months after the first one.

Early Wednesday afternoon (May 10th), I attempted to reach my nurse practitioner to schedule an appointment to discuss increasing the dose of my med because I wasn't seeing any changes and I was concerned about how bad I was feeling. Instead I was given to her medical assistant and told her that I was feeling suicidal, but they weren't able to get me in sooner (because she only had short-notice availability during my work hours and I felt I shouldn't take any more time off work), so she I asked that I go in during walk-in hours, which was 2 days away. Well, in retrospective, I don't think the medical assistant understood the severity of the situation (nor maybe did I) and because I was having suicidal thoughts, I should of called their hotline & talked to one of their crisis counselors instead. I got worse over the next 24 hours. I left work early that afternoon, telling a co-worker I was feeling ill. I went to my boyfriend's apartment, knowing that he was out of town, and in desperation and hopelessness, overdosed again. I then laid down on the couch and while waiting for the end, asked God for forgiveness (I think divine intervention is what kept me alive). I drifted in and out of consciousness and my mom called my cell phone around 4 hours later, worried that I hadn't returned home. After talking to me on the phone, she could tell something was wrong and immediately came over. Seeing the condition I was in, she took me to the hospital & my dad met us there. This time at the ER, we had  to wait for what seemed like a long time (but probably was 45 min) for a room. Once I was taken back, like the previous time, they hooked me up to monitors, got my vital signs, & inserted an IV (only I didn't struggle this time). It was too late to pump my stomach so the nurses gave me two bottles of activated charcoal with a straw and an order to drink it (or they would give it to me by stomach tube). Once again, I was held overnight in the ICU at the hospital for observation and my boyfriend stayed with me this time. The next day, I was medically cleared to be released home. A hospital psychologist came in to speak with me and I was glad to see it was the kind psychologist who'd seen me before. Following the evaluation, when it came to time for him to ask me what I wanted to do, I admitted I was still feeling like hurting myself and was willing to be admitted to the psychiatric medical center in the same hospital, which was operated by the community mental health clinic. It was at first a scary thought for me, not knowing what it's be like, and understandably upsetting for my mom. My admission was voluntary and would last 72 hrs, then we'd decide where to go from there. It was a very safe and non-threatening environment. I was on an adult acute treatment unit, where the majority of the patients had mood disorders. Also, it was nothing like what is portrayed in the movie "One Flew Over The Cuckoo's Nest," but rather it looked like a floor of a college dormitory, only with a nurse's station. I felt bad though, that my Mom had to come visit me in the psych unit of the hospital on Mother's Day instead of me making her breakfast in bed or taking her out flower shopping. Still, going to the psychiatric medical center helped, it was a chance to get my medication dosage adjusted while I was in a safe environment. I had an awesome psychiatrist there who used analogies and spoke at our level. Also I saw a clinical social worker (therapist/case manager), who was my karate class instructor, and while it was a bit humbling, I didn't feel judged, she's kind and got me taken care of.

Initially after I got out of the hospital, I struggled with depressive symptoms. I did attend the follow up appointments scheduled for me in the hospital as well as went to an appointment with my counselor at the University. During that time, I made some breakthroughs in a couple of issues in therapy & I'm glad the therapist didn't give up on me & supported me through it. Also, 3 weeks later I had another appointment with my nurse practitioner and we made some adjustments and tried different medication combinations over the next couple of months. My boyfriend and a couple of close friends who know had been really supportive and encouraging. As for my parents, well they were supportive, but were having a hard time trusting that I was safe at home alone, understandably.

I had been on an SSRI for about 5 weeks consistently, but didn't see any improvements and at my last couple of appointments with my nurse practitioner, my depressive symptoms were markedly worse. In addition to depressive symptoms, I was having difficulty with Attention Deficit Disorder as well and my work performance was suffering. I was experiencing what I can only describe was rapid cycling with depression and anxiety up to a couple of times a day.

I reached a point where I felt like the nurse practitioner was no longer able to help me, as we were out of treatment options and she was ready to put me on lithium, which can harm the liver & has a lot of side effects. My primary care doctor, who had taken the time to come to see me that last time I was in the hospital, seemed to have both compassion and a knowledge of Eastern and Western medicine, so I went to see this doctor for a second opinion on the best medication for me and diagnosis. After the initial consultation and reviewing the notes from the psychiatrist at the hospital, he gave me a diagnosis of major depression with a possible genetic disposition. Based on my past history with medications interactions and depression/ADD, he recommended a new atypical anti-depressant which was supposed to work on a few different neurotransmitters (the chemicals in our brain which regulate our mood, appetite, behavior, etc) called Effexor. After the medication change, my moods were a lot more stable and I hadn't had any pronounced side effects, that is until I had, looking back I'm pretty sure was, a hypomanic episode in July. I was afraid it was bipolar disorder, but the weird thing is that while there's a history of major depression in my family, bipolar depression is not. But for the mean time, my doctor put my on a mood stabilizer, "Lamictal" which helped, but made me feel sedated and my mind foggy.

Now into August, after the previously mentioned hypomanic episode I had or whatever it was, I continued to feel worse and I talked to my counselor about my how I've been doing depression wise and we looked over my mood chart. Also, he asked questions and used reflective listening to help us understand what I was feeling. I wasn't feeling suicidal at the time, but did let him know about recent depressive/hypomanic episodes I've had. He seemed almost skeptical that I was having hypomanic episodes, I don't quite fit all the criteria for bipolar. He advised that I review my medication with my doctor, we needed to make sure this is the right medication for me and I'm on the right dose. Later that week, I went into work as normal, but continued to feel more and depressed and by mid afternoon, I just felt like I couldn't go on and planned on committing suicide after I got off work. But at the same time, there were times were I was better, so part of me knew I still had hope, so I went back to the break room to call my counselor. The counseling clinic was already closed for the day so I called the community mental health clinic hotline and talked to a counselor. After talking to the counselor, I called my best friend, who's been my rock and support through my depression, and asked her to come pick me up from work. My friend drove me to the hospital and stayed with me until a little while after my mom got there. My mom reassured me that I was doing the right thing. Basically, in my ER room, they took my vitals and I talked to a doctor. I was mentally out of it, groggy and slightly confused. I slept until the actual evaluation itself, which was done by a social worker from the community mental health clinic. After talking to my mom & I, she decided that I didn't need to be held overnight and we created a plan for safety, which included involving my mom more involved in my mental health care. Also she gave me their after-hours emergency hotline (which I of course already have) and the nurse said to come back in if anything changed or things became worse. The next day, I still felt depressed, but was defiantly more clear minded and more functional. I'm glad I called the hotline and went to the hospital.

Fast forward several months to April 2007. Once I got past the initial months of first being on the atypical anti-depressant, the hypomanic episodes decreased and eventually ceased and I eventually was taken off the mood stabilizer since I no longer needed it and the side effects outweighed the benefits. Also, I hadn't had a major depressive episode in a few months (and virtually no hypomania in around 10 months) and with my doctor's ok, I was off all meds, although continuing therapy. I was stable for the first time in over a year, I was engaged to be married, and had received a job promotion at the library. Life was good.

Unfortunately earlier in the year my paternal grandmother had been diagnosed with a cancerous brain tumor and in May, she lost her battle and I began to grieve. Also, the stress of planning my wedding caught up with me. At that time, I was diagnosed with treatment resistant depression and my doctor and I decided for me to go back on the Effexor as well as another atypical anti-depressant called "Wellbutrin," but I've got to admit that I wasn't exactly compliant either due to side effects. I got fed up with the constant hunger and weight gain I had experienced while on Effexor. I had expressed concerns about this with my general practitioner at a three month check-up and pretty much felt like my concerns about weight gain weren't taken seriously. I finally reached a point where I was fed up and frustrated and dropped the medication completely against medical advice, while still continuing the other anti-depressant in my regimen (Wellbutrin).

Then in about mid July, my mood took a downward turn very quickly and I didn't see it coming. On the day for my regular counseling appointment, I felt down and really didn't want to go, but knew I needed to because I wasn't feeling well. My counselor immediately sensed something was off. When I told my counselor what was going on, he became concerned and asked me to sign a no-self harm contract (which has been effective in the past). When I wouldn't, he told me he was concerned about my safety and wouldn't let me leave until he felt I was safe. He asked if I wanted to go to the hospital and I flatly told him, "Do what ever you feel you need to do." He thought about it for a few minutes and then asked if he could discuss my case with his supervisor and I nodded my head yes. After 15 minutes, which felt like a life time, he returned and told me that they would like to send me to the hospital for an evaluation. At the hospital, I was put into the same examining room I was in for my first suicide attempt, which brought back bad memories. The attending physician decided it would be best if I was hospitalized for 72 hrs observation. While I was in the hospital, I started feeling better & got go outside to the court yard for fresh air and activity. I also had a different psychiatrist, they changed me to Cymbalta, instead of Effexor, in addition to the Wellbutrin which has worked better and I've been on this combination of anti-depressants for the last few years.

Today, I look back at how far I've come: I've learned and improved in my coping skills, learned to be aware of how I'm feeling, learned the warning signs of when my depression is worsening, reached out for support and found some great resources as well as strength in my friends and family which I didn't know I had. Sure, setbacks are bound to happen, but I can honestly say I'm in a better place than I was 5 years ago. The outlook for individuals with depression, who seek treatment is hopeful. By working with a qualified and experienced mental health care professional, you can regain hope, as I have.

Updates:
September 2013
Since I've last wrote, my marriage broke down & I divorced in 2012 (another story for another time). Earlier this year I moved back to my hometown to be closer to family. While I was married, I was living in another city and the medical practice where my primary care physician and physician assistant had diagnosed and treated my depression closed in 2011, at the time of original writing. While I was married, I didn't have a primary care doctor, I just used the local healthcare system urgent care center on the rare occasion I got sick and found a great psychiatrist, who took the time to listen.
Also, speaking of, psychiatrists, I just got out after another stay in the inpatient psychiatric center. Leading up to this, I had gone to my regular pharmacy to get my Wellbutrin refilled, but they pharmacy technician told me they didn't have it in stock but would be getting a delivery anytime. While waiting, the inevitable happened, I ran out of Wellbutrin and  manage my depressive symptoms, I spiraled downward. Feeling worse, I didn't feel up to making an hour and a half drive to my psychiatrist but didn't want to burden my parents by asking them to drive. Knowing in my gut that I needed to see my counselor, I kept my counseling appointment at the local university practicum counseling clinic that day. After speaking with my counselor for a few minutes & telling her how I was feeling & probably noticing my disheveled appearance, she consulted with her supervisor, whom once again referred me to the hospital. I was given the option to drive myself voluntarily or to be taken by University police, so I opted for the former. Once I was given a room, I was one of probably a dozen people waiting for psych evals in the ER, so I ended up bedding in the ER overnight and didn't end up seeing a social worker from the community mental health clinic until the next morning. This time, including the weekend, I stayed a total of 5 days. This time was different, it was rougher. I felt pretty anxious the entire time, and spent the evening in the ER pacing and my first day on the psych unit pacing the hall. This time I chose not to reach out to anyone, leaving me without much of a support system. My roommate was challenging, to say the least and I didn't get along with one of the older nurses. Also, despite letting the psychiatrist know I have treatment resistant depression and SSRIs haven't worked in the past, he insisted on trying another SSRI w/ the Wellbutrin. Not sure this SSRI is going to work, but I'll give it a month or two to see. Unfortunately, at the time of the follow up appointment at the practicum counseling clinic, my counselor expressed that due to the severity of my case, the clinic didn't feel they could meet my needs & I would be better served by the community mental health clinic. In other words, I'm too much of a liability. This left me without a counselor when I needed one the most, as I was still struggling w/ moderately severe symptoms after I was released. Based on my prior counseling experience with the community mental health clinic, I wasn't too keen on seeking counseling through them either. Fortunately I was able to find an affordable private practice physiologist near my home a short time later. Also, I've made the difficult decision to no longer see my psychiatrist, as his office is too far away & to seek care closer to home. I found a new, kind primary care physician through our local hospital health system & he is prescribing & managing my medications for now.

At the time I went into the hospital, I was working in home health, with inconsistent hours, and inadequate insurance. I knew going into the hospital I wasn't sure how I was going to afford it, I but knew I needed to take care of my mental health first, and I'd figure out how to pay later. I had a high deductible, short term health insurance policy but unfortunately it had expired two weeks prior, resulting in my being responsible to pay for the full amount of the hospital bill. Although I'm considered low-income, I don't qualify for traditional Medicaid because I'm not disabled and don't have any children (my state only covers family planning for single women) and the Affordable Care Act health care exchange plans don't begin until this coming January 1st. I've applied for patient assistance and with careful budgeting, am making monthly payments until the balance is paid off.

May 2014
Despite being compliant and consistently taking my meds, I've remained in a low mood and barely functioning & it's began to affect my work. Also, the primary care physician I had been seeing through our hospital health care system had moved away, with the practice failing to notify me, leaving me without a physician. At my mom's insisting, I went and saw the physician's assistant (from the primary care medical practice which closed), who's now working at a local urgent care clinic. He's always seemed to know what he's doing, he re-prescribed Cymbalta and upped my Wellbutrin dose. Unfortunately, I couldn't continue to see him at urgent care for ongoing medication management because it's outside of their scope of practice. In the mean time, I will need to find a new primary care physician. Fortunately, through the Federal Healthcare Exchange, with income-based tax credits I now have affordable full-coverage health insurance, even if it is an HMO :P

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