Tag Archives for antidepressants

Life after mirtazapine – and moving on

I will do the important part first so that nobody misses it. I have a new blog! It can be found here: Songs & Sonnets.

I’m not planning to post on Seeking Myself for much longer (although I will keep the site open), so please take a moment to update your bookmarks / RSS readers / WordPress follower or whatever you use to keep track of new content. I will continue to discuss mental health on the new blog, but it will also include my poems and more posts about Christianity, politics and other issues.

I’ve now been completely off all meds for just over a month, and am starting fertility treatment. :) And my mental health is at least as good as it was before I began to reduce the mirtazapine. I’ve had some issues with anxiety and insomnia, but I’ve been able to manage these myself. It’s been quite a revelation, to be honest. I think my GP is still half expecting me to relapse, but it’s become clear to me that although I desperately needed the drugs when I was first prescribed them, at some point they had stopped keeping me well, and the side effects (sedation and increased appetite > weight gain > body image issues) were outweighing any benefits. I’m not in therapy either, and although I have seen a couple of awesome counsellors who really helped, I’ve also been treated by some complete duds and I think now it’s time to find my own path through my residual craziness.

The result of all this is that my view of my mental health difficulties has changed. I see them less as a medical illness requiring treatment (whether that be meds or psychotherapy), although it’s hard to put into words what I do see them as. I don’t think I could have recovered without medication when I was severely depressed, and the better therapy I’ve had has definitely changed my life. I also think it can be very useful to view depression as a medical condition in terms of understanding how disabling it can be and how, well, ill it can make people. I suppose I feel, though, that the medical model is too rigid and doesn’t take into account all the complex factors influencing my mental health.

The issues I’m working on now have to do with both the after-effects of childhood trauma and what I think is my inherent makeup, but while they might make me more prone to depression, none could be diagnosed as mental illnesses or treated with medication. And while you might think therapy is more appropriate for these kinds of issues, my experience has been that most of my therapists adhered to overly restrictive models too. It seems to be so rare to find someone who is actually willing to truly listen and help me find my own way forwards, rather than trying to squeeze me into a theory that doesn’t quite fit. I still haven’t ruled out the possibility of further therapy, but right now my faith and church community are doing at least a good a job as any counsellor I’ve seen.

Hence the new blog – somewhere I can take a more holistic view of mental health and write about the many other facets of my life. I hope you’ll follow me there.

Reducing the mirtazapine

It’s going well!

In March, I dropped from 60 to 45 mg with no ill effects whatsoever. In April, I went down to 30 mg, and that’s where things got a little hairy. First I had withdrawal symptoms, and stepping up to 37.5 mg temporarily made no difference, but just dragged out the whole process. Then I began to notice that my mood felt ‘wobblier’. I was getting upset more easily and having more intrusive thoughts, or perhaps it was just that the intrusive thoughts were ‘louder’ and harder to brush off. So it was with some trepidation (but my GP’s support) that I reduced the dose again to 15 mg last week.

The effect has been immediate. Despite some withdrawal symptoms in the first couple of days, from the start I’ve had more energy and drive. The concept of working full time and doing a little housework in the evening is no longer alien to me! It’s much easier to wake up in the mornings and I no longer need to mainline tea. Of course it makes sense that this has happened, as mirtazapine is a very sedating antidepressant, but this has been the first dose reduction where I’ve noticed a change in side effects, and these are adverse effects I’ve been living with for years. The last time I was on 15 mg was in 2006.

Even more excitingly, my mood has stabilised and the intrusive thoughts have stopped bothering me. This is harder to explain, as when I started taking mirtazapine, stabilising my mood and quietening down the ‘noise’ in my head were two of the ways in which it really helped. However, I think I’m more vulnerable to these symptoms when I’m tired, so it kind of makes sense that being on a less sedating dose has made a difference. 30 mg felt like an unpleasant no man’s land where the drug had stopped doing much for my mental health, but I was still getting all the side effects.

Of course, it remains to be seen what will happen when I come off mirtazapine altogether, currently scheduled for some time in June. Watch this space!

Alternatives to medication

I have been taking antidepressants more or less continuously for the past decade. During that period, I’ve had five episodes of moderate to severe depression, ranging from two months to three years in duration. But now I’m coming off medication completely in order to start fertility treatment. It’s a daunting prospect, and with my mood becoming a little more labile, my GP has suggested I think about non-medication strategies I can use to keep myself well and manage any mental health symptoms that occur.

What follows is a list of pretty much everything other than medication that has helped me in the past and that I think could be useful now. I haven’t limited myself to depression, firstly because mirtazapine has done more than just lift my mood (it’s also reduced my anxiety and helped me sleep), and secondly because I think everything has a knock-on effect when it comes to my mental health. It’s not unusual for prolonged stress and high anxiety levels to trigger an episode of depression, for example.

I hope this post will be useful to others who, for whatever reason, need or want to manage similar mental health problems without meds. It comes with some caveats, though: 1) What works for me may not work for you. 2) Always seek appropriate medical advice. And feel free to make suggestions or share what’s helped you in the comments. :)

Spa items on a straw fabric: candles, natural soap, fizzy bath bombs, straw and flower

Baths: A hot bath (preferably with Lush products) is great for calming me down and reducing the generalised aches I sometimes get when depressed or fatigued.

Books: This could be a whole post in its own right! My favourite fiction and cartoon books are real comfort reads when I’m feeling a bit rubbish, but some mental-health-related ones I think will be especially useful are ADD-Friendly Ways to Organize Your Life (concentration), When Things Fall Apart (mindfulness), Radical Acceptance (ditto) and the psalms in the Bible.

Blogging: When there are too many distressing thoughts swirling around in my head, blogging or journalling gets them out onto the screen and helps me make sense of them so I can figure out a way forwards.

Breaks: It’s important to take regular breaks when I’m working, especially if I’m finding it hard to focus.

Choral music: Listening to choral music is one of the best and fastest ways to calm me down. Singing is also very cathartic and making it to choir rehearsals is usually one of my top priorities!

Church: Going to church regularly helps me feel closer to God and makes it easier to separate what’s really important in life from what’s not. I need to make more of an effort to get to church on weeks when I’m not required to sing. Attending a different church from usual can also be helpful (great to get a different perspective on things).

Compassion: Beating myself up for not being perfect and pushing myself too hard are surefire routes to stress and depression. Being compassionate doesn’t mean that I can’t acknowledge when I’ve genuinely done something wrong and make amends.

Counselling / psychotherapy: In the near future I’ll be able to afford to see someone privately. I think this would be a good idea, though I don’t want to get into anything too deep and heavy while I’m adjusting to life without meds. Someone who could help me with more practical coping strategies and provide ongoing support would be good.

Fun relaxation: Activities that are both restful and enjoyable (like reading Harry Potter) seem to be much better for my energy levels than doing something fun and energetic followed by a boring rest.

Humour: My sense of humour has been my lifeline at times, and laughter helps whether I’m depressed or just struggling a little. This can include funny books and cartoons, comedy programmes, being silly with my partner and of course The Real Energizer Bunny.

Mindfulness: I try to practise mindfulness by regularly taking a moment to connect with what I’m really feeling and what my needs are in this moment. Mindfulness helps ground me – counterintuitively, really focusing on how anxious I feel actually makes me feel less anxious! It also has an important role to play in preventing depression. I have a tendency to stick rigidly to goals, rules and plans that made perfect sense when I created them, but might no longer be the best way forwards, and I think this is often a key factor in relapses of depression.

Never put things off: Nothing drains me more than putting off doing something that’s very important but scary or challenging. I need to get these things out of the way if I want to maintain good mental health.

Reaching out: Letting other people know what I’m feeling and how they can help me is something I really struggle with. This ties into my longer-term work on learning to trust people more – which I still plan to write about in depth, but which has somewhat taken a back seat as I figure out how to cope without meds. It’s something I will keep chipping away at, though, because having good support really does help.

Reducing responsibilities: When I’m depressed or really struggling with my mental health, I try to reduce my responsibilities to a level that feels manageable.

Relaxation CDs: I particularly like Experience Yoga Nidra.

Rest: It’s important that I get enough of this.

Pacing: When I’m depressed or fatigued, I try to start with a level of activity that feels comfortable to me (which often means doing very little!) Then I gradually start to stretch myself by adding activities, but always remaining mindful to how that makes me feel.

Prayer: For me this ties in closely with mindfulness. Asking God to calm my mind and help me focus on what’s important really helps.

Prioritising: I resisted this for years. I’ve finally come to accept it’s essential for avoiding stress, exhaustion and overwhelmed-ness! For work stuff, I use the ABCDE method.

Professional help: Although I’ve been asked to try coping without mirtazapine, it’s important that I stay in touch with my healthcare professionals and let them know how I’m doing. Medication in pregnancy is always a balancing act between the risks to the mother and baby from the drugs, and the risks from the mental health problems themselves. If I become too depressed, my GP or psychiatrist might recommend I start taking antidepressants again, or they might be able to offer other treatment. I’ve also bookmarked some local charities on Delicious.

RET for freak-outs: I find this exercise helpful when something has happened that’s really triggered me. It’s supposed to be for anger, but I find it helpful for any intense, overwhelming negative emotion. That said, sometimes when I’m very upset I don’t want to do anything constructive about it, because it feels somehow invalidating. The best thing to do when I feel like this is just get into bed and let myself grieve – I might be grieving something “trivial” but allowing myself to feel whatever I feel is important.

Step away from the smartphone: The second most draining thing I know, after putting off important tasks, is circling around Twitter, Facebook and my RSS reader mindlessly checking for updates. Of course, these two things often go hand in hand. ;)

Showers: I find taking a shower calms me down, helps me think more clearly and can “reset” me.

Small goals: When I’m depressed or otherwise struggling, I find it helpful to set a few small and achievable goals, breaking larger tasks into lots of baby steps. This helps give me a sense of achievement and by combining it with prioritising, I can stop an episode from derailing my life completely.

Small treats: Likewise, when I’m depressed lots of small treats are better than one big treat – because there’s less pressure and disappointment if I can’t enjoy something. I try to focus on what I really feel like doing in the moment, as long as it’s not totally self-destructive. Even if I’m not capable of enjoying anything, there are usually things I can draw some comfort or relief from.

Staying hydrated: This doesn’t apply to full-blown depression, but it’s amazing how often problems concentrating or focusing go away when I have a drink of water.

Sunshine (or light therapy): Getting out in the sunshine helps lift my mood whether I’m depressed or not. Unfortunately, it’s been pissing it down solidly for about a month, so I might have to reclaim my lightbox from the friend I lent it to and see whether that helps.

Supplements: I’m currently taking evening primrose oil (which stops me from aching) and omega-3 fatty acids (which are supposed to help with mood and concentration). I need to double-check whether these are safe in pregnancy. Update: I’ve just been advised that EPO is best avoided in pregnancy as it hasn’t been proven to be safe. However, most omega 3 supplements are fine (not cod liver oil; check with a pharmacist, or get one that’s specifically formulated for pregnancy).

Thought records: Irrational thoughts aren’t as big a feature of my depression as they used to be, and I’ve become a little wary of (NHS style) CBT-based self-help, because I got sick of being given a sticking plaster and told it would cure me. Nonetheless, when I am being tortured by thoughts I suspect aren’t accurate, listing the evidence for and against them does help me cope in the moment.

Walking: Walking helps ground me. It’s been part of my daily routine since January and I intend to keep it that way. (I’ve never found exercise effective as a treatment for depression, however.)

More will probably be added as I think of them…

Edited to add: Compassion (11/05/12).

Where I’m at

Things feel a little scary at the moment. I’m coming off my mirtazapine in preparation for getting pregnant, and I’ve left my therapy group. Intellectually I have no qualms about these decisions – after all, I can always go back on ‘safer’ antidepressants or find alternative therapy if I need to – and emotionally it feels good to be saying, “I am normal enough. I am well enough. I have my issues, but I have the strength to deal with them within me.” But emotionally there’s also the fear that comes with any venture into the unknown.

Meds-wise, things are easy enough to explain. My GP has agreed it would be better to start reducing the dose sooner and take longer coming off the drugs, than do it all in a month as my psychiatrist had suggested. So I’ve spent three weeks at 45 mg with no ill effects on my mental health, and I’m now enjoying some lovely withdrawal symptoms, having dropped to 30 mg two days ago. Dr Right has also emphasised that no one will expect me to go without antidepressants if it turns out I need them, but it would probably be a different drug. Unfortunately, the main ones used in pregnancy – sertraline and Prozac – are SSRIs, but we’ll cross that bridge if and when we come to it. She thinks SSRIs are more likely to work for me than they did ten years ago, because I’m in such a different place now, and I think that at least if they do Bad Things to my brain I will recognise the early warning signs and know what to do about it.

Therapy-wise… I’ve previously written a lot about what I learned from therapy, and why I don’t think Group Therapist’s approach was right for me, even if I haven’t been able to sum it all up neatly. I am very grateful for the things GT taught me. I definitely don’t agree with all his opinions and beliefs about my issues and about mental health in general, but even where he ‘got it wrong’, it’s been helpful to bump up against a different perspective and that’s been a chance for me to clarify and reconsider what I do believe.

At the same time I’m 100% certain that walking away was the right thing to do. It’s funny, but I don’t think the ‘official’ reason I gave for leaving the group – that therapy in a group setting didn’t work for me – had much to do with it in the end. Once I’d committed to my decision, a lot of that fear seemed to melt away and I was able to participate fully and connect with people in my last few weeks. I left with the sense that actually, this was a group of people with whom I could have worked on learning to trust – but that my problem was with Group Therapist and perhaps psychoanalysis in general. It’s a shame I didn’t feel able to articulate this in the group to him, but I need an approach where practical stuff can be incorporated and where the good as well as the bad in me is understood as important.

I’ve spent most of the past decade struggling to get mental health professionals to take me seriously, and having to fight to get any help. GT was the total opposite, which lured me in at first. But having someone ignore your achievements, dismiss the things that have helped you, and assume you must be feeling really depressed and worthless when actually you’re fine – my issues are cyclical – is no better. And that last sentence sounds very critical, but in fact one of the best things GT did for me was get me to recognise that and push me to a place where it’s no longer about communicating how much I’ve suffered, but refocusing on what I need to do to continue my recovery. I think I’ve finally come to terms with how badly the NHS let me down in the past and I feel ready to move on from this. Was that GT’s intention? If so, he played his cards very close to his chest.

What am I focusing on now? Two main things, really – one is depression relapse prevention, which ties in a lot of threads from other issues I’ve been writing about (perfectionism, mindfulness), and the other is learning to trust people and reach out to them more. I will write more about both of these things at a later date.

Of psychiatrists and therapists

I saw my psychiatrist last week, and she’s discharged me back to my GP. I’m reasonably happy about this. With my mood and energy levels stable, it doesn’t seem like the best use of my time or NHS resources to have me trekking out to the hospital every couple of months. In an ideal world, I’d like to remain on her books without regular visits to see her, and to be able to phone for an appointment when and if I experience any mental health issues, but the NHS just doesn’t work that way.

I did ask whether my recent episode had changed her opinion about me taking antidepressants in the first trimester of pregnancy. It hasn’t, although she now wants me to be referred back to her as soon as I become pregnant, even if my mental health is good. She seemed to be saying that I could wait until I’m actually pregnant to come off the meds, but I’m a bit confused about that because she also said I should reduce the dose gradually over a month to avoid withdrawal symptoms. Surely that would defeat the object of not having mirtazapine in my system during the crucial first month when the embryo is developing and the risk of miscarriage high? The thing is, my main concern isn’t getting through three months of pregnancy without medication – that’s a relatively short period, and I know some women find the hormones actually help their mood – but coping without meds for potentially months and months of failed fertility treatment. Anyway, I’ll see what she’s written in the letter to my GP and what my GP and the fertility clinic advise.

That’s the easiest part of this post out of the way. It’s going to be much harder to write about group therapy, because I’m still struggling to make sense of how I feel about it and what I want.

For some time now – maybe since about November? – I’ve been questioning whether the therapy group is right for me. The first reason is that I just don’t feel I’m getting much out of it. That might be an odd thing to say when my mental health has improved so dramatically, but I honestly don’t feel the group has had much to do with it. In the past, when therapy has helped, it’s been obvious to me how and why it’s helping. Talking about the bullying, and coming to a new understanding of what happened to me as a child that doesn’t place the blame on me, cured me of social anxiety disorder and there’s no doubt in my mind that that’s why I no longer have difficulties socialising and making friends. On a less radical scale, learning some CBT techniques for coping with depression has made depression easier to cope with (duh) so that it no longer has such a devastating impact on my life. With the therapy group, everything’s more tenuous. I have developed some new insights which may well have helped me to change but the link is far less obvious. This is something I need to explore further.

The second reason is that I’m not sure whether group therapy of any kind is the best approach for me, or not as the main mode of treatment. In the past one of the things I’ve really valued about therapy is that it’s a space just for me, where I can be ‘selfish’ and talk through whatever I need to talk through, without having to worry about other people’s needs or whether I’m monopolising the conversation. In a group I don’t have any of that. Arguably, group therapy is the ideal place for me to learn how to get my own needs met in a mutually supportive environment, how to get the balance right between giving and taking, but it can feel like a catch 22 in that to get the therapy in the first place I already have to resolve the issue to some extent. I don’t talk about my own problems as much as I should, both for this reason and the one below, and that may be one explanation for why I’m pretty sure the recent improvement in my mental health has little to do with therapy.

The third reason has to do with the psychoanalytical orientation of the group and the NHS service, and it’s the hardest to pin down. I guess I can sum it up by saying that for a long time I’ve been preoccupied by the following questions:

  • There are many areas of my life that I think I’m reasonably happy about when I’m well, but when I’m depressed they not only get me down, but I view them as a likely cause of my depression. Is this just the ‘depression talking’ (distorted thoughts and beliefs) and me grabbing at straws to make sense of things, or are these real problems that I’m refusing to tackle and which do indeed make me ill?
  • The psychoanalytical therapy I’ve had so far has been known to stir up difficult and painful stuff and I have subsequently relapsed into depression (I’m thinking in particular of the individual assessment sessions with Group Therapist here). Is this stuff that needed to be addressed, and would have made me ill sooner or later anyway, or is dwelling on things which don’t bother me in my day-to-day life unhelpful and misguided?

What I would really like is to be able to talk these questions through in a safe and non-judgemental environment. The problem is, I don’t feel Group Therapist is a safe person to discuss this stuff with, not only because he’s implicated, but because psychoanalytical theory (to the best of my knowledge) has set views about this. It’s all about the importance of the subconscious, of issues we’ve pushed out of our minds which continue to affect us, and of the need to stir up difficult and painful stuff and for things to get worse before they get better. From my perspective, though, I don’t think these are questions that can or should be answered easily. I don’t think there can ever be a ‘one size fits all’ answer that applies to every person and every situation, and I also think the answer in any one situation is unlikely to be black and white. It’s quite possible, for example, that when I see myself as well I am brushing a particular issue under the carpet, but that at the same time it’s not as big a problem as I think it is when I’m depressed, and is only a minor factor in me relapsing. I don’t know, I might be doing Group Therapist a disservice here (trust issues, much?) but I’ve seen him work very hard to persuade other group members of things and I don’t want to put myself in a situation where I feel pressured into accepting a particular explanation or belief. Another thing I’ve really valued about the therapy that’s helped me most – which was all person-centred – is that I did have the space to come to my own conclusions. Even if Group Therapist is right about everything, I feel it’s more likely to ‘stick’ if I have that opportunity to realise things for myself and not feel as though they’re being forced on me.

I became disillusioned with the NHS approach to CBT because I didn’t feel it was flexible enough – I was taught helping coping techniques, and the practical side of things was good, but there wasn’t the opportunity to talk about painful childhood experiences if I needed to, nor anything else to try if a thought record / behaviour experiment didn’t help with a particular issue. The psychoanalytical service seems to be just as inflexible, just at the opposite end of the spectrum (I know I’ve made the comparison with communism and fascism before). :P Now that my mood and energy levels are fine, what I really want to do is focus on the practical stuff – make sure I’m taking good care of myself, make sure I’m not pushing myself too hard. Since the fatigue went away, I’ve been doing a lot of that. I read a self-help book about body/eating issues and am implementing the ideas in that which are really helping. I’ve admitted that on mirtazapine I really do need nine hours of sleep most nights and am making sure I go to bed early enough. I’ve acknowledged that getting overwhelmed can be a big problem for me and so prioritising is vital, and I’ve found a prioritising system that seems to work. I’ve recognised that the long days teaching in another city were really draining me last year so this year I’ve arranged to only ever teach one workshop in a day, not two. But this is all stuff I’ve done and figured out on my own, because my therapy group is emphatically not about taking practical steps.

What are the reasons for staying in group therapy, then?

1. As I said above, I can’t be sure that the group hasn’t helped. I’ve left a lot of therapists in the past and I don’t want to cut and run again for what may be the wrong reasons.

2. I can’t afford to see someone privately at the moment, so the group (or individual therapy at the same service) is my only option for a long-term talking treatment. I could access shorter-term counselling through a local charity, but with my mental health being so changeable and cyclical, and with one of my main goals being to understand why I relapse and whether it can be prevented, I feel I really do need something long term.

3. I really like some of the others in the group and can relate to them a lot. Contact outside the group isn’t allowed and I would very much miss them.

4. The idea of having to discuss my issues with the therapy and reasons for wanting to leave in front of the whole group – a place which still doesn’t feel safe even after seven months of treatment – is extremely daunting. I’m worried that Group Therapist will pressure me and the other patients will be upset or think they’re to blame. OK, this isn’t a good reason for staying but the group does feel a bit like Hotel California sometimes…

5. I’m worried that if I leave the group and decline the option of individual psychoanalytical therapy – especially if I’m not arranging my own counselling straight away – I’ll be viewed as ‘non-compliant’ and this will cause problems accessing NHS mental health or fertility treatment in future.

6. I’m also worried that if I leave the group, then relapse and need more support, I won’t be able to get it and may really regret my decision.

According to WordPress I’ve written close to 2,000 words. I will leave this now and allow the dust to settle in my head, but any comments or feedback would be welcome.

P.S. If you follow me on Twitter you may know that I recently suffered a bereavement. I’m not blogging about it publicly for privacy reasons but I do really appreciate all your support. The death was expected and I’m coping with it well but it’s still a sad time for me and my family.

Health at Every Size

My relationship with food and my body has always been a difficult one. I spent my teens binge-eating, and my student years borderline underweight and terrified of gaining. Then I was prescribed an antidepressant that happened to cause rapid weight gain (a rare side effect), and to my utter amazement, I developed boobs. I had been convinced that I would be flat-chested at any weight and therefore needed to stay as skinny as possible, but in fact putting on a stone or so gave me enough cleavage that I was less worried about the size of my waist. For a while, I was relatively relaxed about my weight. More pounds crept on, but my BMI was still in the healthy range and I was now a DD cup. I wasn’t entirely happy about my apple shape, but if I chose my clothes carefully, I thought I looked all right. Eventually, though, I reached the point where I was classed as overweight and it may not be coincidence that around the same time, I started to think I looked fat in any outfit. It was time to lose weight.

My first diet was a success, or so I thought at the time. I got details of the WeightWatchers points system from my partner and once I’d learned which foods would fill me up and which treats I could ‘afford’, I lost the weight fairly painlessly, stopping half a stone or so below the maximum ‘healthy’ weight for my height. I kept the weight off for a good while too, following WeightWatchers’ plan for maintaining weight. But then, a year after I’d started the diet, several traumatic events and life stresses had me turning to junk food for comfort again. Slowly but surely, I started to regain weight until I was back where I’d started.

I tried to diet again, and this is where it all went horribly wrong. I was now a vegetarian, limiting my options, and I was on a higher dose of antidepressants which are known to cause increased appetite. The situation with my mental health had also gone from ‘in remission from depression for several years’ to ‘frequently relapsing’. Whether because of all this, or for some other reason, sticking to a calorie-controlled diet in any kind of sensible way seemed almost impossible. Every time I tried, I either gave up because I was so hungry all the time, or a switch seemed to flick in my head and I would start starving myself. I have spent the past couple of years yo-yoing from overweight to my target weight and back again. I most recently dieted in May-June last year and by December I had gained two stone. I now have a BMI of 27, which is the highest it’s ever been, and I’ve been feeling deeply unhappy about my size.

When fatigue stopped being my biggest problem, I knew I wanted to do something about my weight and body image, but what? I didn’t want to start another diet, get sucked into an eating-disordered mentality and end up larger than ever, so I eschewed the usual weight loss resources and tried to find something aimed at people like me. People who might not have a full-blown ED, but do struggle with eating-disordered behaviours. This led me to a book called Getting Better Bit(e) by Bit(e), which has a chapter specifically for people with a history of binge eating or bulimia who are overweight.

What I read shocked me. I had assumed that, as my BMI is ‘unhealthy’, I needed to lose weight and should just find a more sustainable way of doing so. Instead, the authors – both psychiatrists who specialise in eating disorders – told me that the health risks of being overweight have been greatly exaggerated, especially for people who are in the ‘overweight’ rather than ‘obese’ category. That it’s far more important to be physically fit, and above all that repeatedly losing and gaining weight does a lot more damage than simply being overweight.

Not long after this, purplepersuasion published an excellent blog post about her own cycle of dieting/restricting and bingeing/regaining, and one of the commenters recommended the Health at Every Size concept and Linda Bacon’s book. I bought a copy and devoured it. What Bacon says (I’m loving the potential for food-related puns :P ) makes so much sense to me and has already made a huge difference to the way I feel about my body and food.

In a nutshell, HAES is about being healthy irrespective of how much you weigh or what your BMI is. It’s an approach focused on intuitive eating, physical activity and self-acceptance rather than dieting or weight loss. The book provides a lot of scientific evidence that backs up what I’d learned from Getting Better Bit(e) by Bit(e), and shows that:

  • Diets don’t work in the long term. Over 99% of people who diet regain the weight.
  • People with a BMI over 25 are more likely to develop certain health conditions such as high blood pressure, cardiovascular disease and diabetes, but there’s no proof that being overweight or obese causes these things. It’s more likely that the causes are other factors which often go hand in hand with being overweight, such as a poor diet, not getting enough exercise and a pattern of losing and gaining weight. (The exception is osteoarthritis, which is directly caused by obesity.)
  • There is some evidence that people who are overweight, as opposed to obese, are healthier and live longer than people towards the lower end of a ‘healthy’ weight range.

Why don’t diets work? Bacon argues that everyone’s body has a ‘setpoint’, a weight range of about ten pounds which is natural and appropriate to them and which their body will try to maintain. If you go below your setpoint, your body will do everything in its power (increased appetite, cravings for calorie-rich food, lowered metabolism) to regain the weight. If you go above your setpoint, your body will also try to lose the weight but it’s not as efficient at doing this, because our bodies aren’t really designed for a modern environment where we don’t have to go out and hunt our own woolly mammoths – or whatever it was that cavemen ate. When you diet, your body assumes that food is scarce and it may even increase your setpoint to better protect you against the next ‘famine’. As I understand it, the stuff in this paragraph hasn’t been proven beyond all doubt yet, but there is a lot of evidence to support it.

Instead of dieting, Bacon recommends:

  • Eating as much as you need to satisfy your hunger, stopping when you’re full.
  • Choosing ‘real’ foods over processed foods where possible, and eating a wide variety of different foods (this is a good way to make sure your diet is nutritious without becoming a slave to nutritional facts and figures).
  • Allowing yourself the foods you crave, but eating them mindfully and stopping when your body’s had enough.
  • Regular (but not excessive) physical exercise.

(There’s a lot more detail on how exactly to do all this in the book.)

I’ve been following the HAES approach for a couple of weeks now and I think it’s brilliant. I haven’t totally got the hang of mindful and intuitive eating yet, but what’s incredible is that all my urges to binge and overeat have vanished. I really didn’t expect that to happen. I didn’t think I was prey to the “I’ve blown my diet anyway, I might as well stuff my face” type of thinking – I’ve done CBT, I know that’s neither rational nor helpful – but I hadn’t realised just how much the shame I felt about my weight and my eating was triggering me to turn to food. The idea that there’s nothing wrong with being fat (Bacon deliberately uses the term ‘fat’) and that I can be healthy at this size is very liberating. HAES is supposed to help your body return to its setpoint and I have to admit I am hoping my setpoint will turn out to be lower than my current weight – I’m also encouraged that I’ve had to tighten my belt by one hole since I started HAES. :D But the focus on self-acceptance and on health is more important and is what’s really helping me.

It’s all a bit shit

I am low and exhausted. I’m struggling to get through the day almost every day. My life is work, choir and rest (at least I have choir, which involves socialising as well as singing). At work, everything seems to take longer than I would expect and I don’t know whether this is because I’m underestimating the difficulty and complexity of tasks, or whether I’m ‘slowed down’. I frequently have to cancel medical appointments at the last minute because I don’t have time to fit them in. Housework is kept to the bare minimum and the clutter is really starting to stress me out.

I can’t not work because my debt has been steadily rising since last December – a combination of overspending, poor budgeting and the sick leave I took in the summer. With my partner about to become unemployed, I’m determined to reverse this trend (this month it’s finally gone down by a whopping £27.02). I could perhaps reduce the amount I work slightly but whenever I plan to, it doesn’t happen because I’m so worried about money. When you’re self-employed and you turn down a project, you never know where the next one is coming from.

I saw my psychiatrist on Monday and she gave me two options: increase the mirtazapine or switch to a different antidepressant. I decided to increase the mirtazapine, because I’m worried about my mood (and ability to work) dropping further during the switch, about the replacement med possibly not working at all, and I didn’t feel up to being assertive about which antidepressants I am and am not willing to take. But now I’m worried that it’s been the wrong decision, especially as she also wants me to come off my baby dose of citalopram to see whether that helps with the fatigue. And especially as, on the advice of a friend who’s a GP, I actually sneakily re-upped my mirtazapine a few weeks ago. It seemed to be helping but as of yesterday the self-loathing and intrusive thoughts are back with a vengeance. (One good thing: my psychiatrist emphasised that I should phone her before my next appointment if I feel I’m going downhill. Although I always knew I could do that, the fact I’ve been given ‘permission’ makes it much easier for me.)

Therapy is making me increasingly aware of my role in causing my own problems, yet this awareness doesn’t seem to help me change, so I feel trapped. In December I’ll have been in the group for six months and I think I’m going to decide it’s not for me, that I need individual therapy, but that means either a long time on a waiting list or trying to arrange something elsewhere (counselling through a local charity if I’m lucky, otherwise paying to see someone privately. See financial problems above). And here too I’m worried that I’m not giving the group enough of a chance or trying hard enough to make it work for me – that my problems with trust and attachment are actually making it impossible for me to make further progress with my mental health.

On Saturday I went out and spent a lot of money on healthy food – fruit, vegetables, lean proteins, herbal teas. My hope was that upping these things and cutting back on sugar, saturated fat and caffeine would improve my energy levels as well as my weight problems (I’m still gaining weight), but in the heat of the moment I’ve found myself reaching for sugary snacks and ‘proper’ tea. I think I may need to accept that I just don’t have the energy to prepare ‘real’ food for myself, on top of trying to hold down a full time job. :(

My partner’s depression is worsening and she’s spending increasing amounts of time tearful and in bed. Although she’s been on sick leave since August, she’s not really getting any meaningful help or treatment; she does take medication but this has not been changed since her relapse. She saw a GP last week who finally agreed her meds should be reviewed and has referred her to a psychiatrist again (last time the referral was refused). I have suggested she might benefit from some counselling to help her come to terms with everything that’s happened, but that has to be her decision and she doesn’t know what she wants. In the mean time she needs a lot of emotional support from me and needless to say is not exactly gung ho about helping around the house either.

Our government seems determined to shit on the long-term ill and disabled and make us bear the brunt of the austerity budget. It’s not just the cuts that are upsetting me – yes, cuts need to be made and they have to come from somewhere, though I personally feel the pace is too fast and will worsen, not improve, the economy – but the sheer hatred the government and most of the press seem to have towards people who are too ill to work. The ‘scrounger’ rhetoric and the number of people who seem to agree with it is really getting to me. The assessment for ESA – the new sickness benefit for self-employed or unemployed people – takes little account of mental health problems, fatigue, fluctuating conditions or the adverse effect working might have on health, meaning it’s unlikely my partner or I would ever be granted it, should we need it.

On Friday I am singing at a 19-year-old’s funeral. I didn’t know her personally but I know her younger brother and sister, and her parents by sight. I keep thinking back to when I was 19 and how exciting life was then, how I had my whole future ahead of me. K has been robbed of all that and I feel guilty that I have wanted to throw my life away – with one suicide attempt and countless thoughts and urges. I feel almost as though it should have been me, not her. It’s incredibly sad.

With the exception of K’s death, all this has the result of reinforcing my feeling that I can’t rely on others for help and have to struggle on alone. The government don’t care, so I have to work even when I’m ill, and work enough to financially support my partner as well. My partner is emotionally supportive (she was lovely on Monday when I thought I’d lost my annual bus pass and had a panic attack) but not so good at the practical stuff. When she’s not working, I bear her share of the mortgage and bills, but she’s never been able to do the same for me, as her credit cards are perpetually maxed out. When I first became self-employed, and when I was ill last summer, I shouldered the burden by getting further into debt. And of course I don’t trust anyone enough to let myself rely on them anyway so it’s all my own fault. (Qualification: I know I am not responsible for government policies, Evil Employer’s… evil or my partner’s illness, but I feel I should have some control over my own issues and therefore be able to reach out for support more, and I’m beating myself up that I can’t.) I feel so alone and almost unloved, although rationally I know I am loved… it feels like I’m re-experiencing the pain of being that bullied and abused child who had nowhere to turn for help.

I do feel better for getting all of this out and now I feel I want to take some time out with a cuppa and cake, then come back and look for solutions. But my current therapy has me questioning whether finding my own solutions is a good move. There’s so much in this that can’t be easily solved, and it seems I’m always patching things together, only for them to fall apart again. Thoughts?

The medical model and psychotherapy

Over the past few weeks I’ve been thinking a lot about the idea of my depression as an illness. It’s a concept I struggle with a lot, for various reasons. At times, it really doesn’t suit me to think of myself as ill or disabled – I’d rather bury myself up to my neck in work and denial. Then there’s my transient core belief that, rather than experiencing a valid mental health problem, I’m just fundamentally flawed as a person. Add in a hefty dose of therapists telling me my issues are a ‘normal’ response to childhood trauma, and doctors (in the past) using the fact I’ve been bullied as an excuse not to treat me, and you get a lot of confusion and anguish.

The thing is, when I look at the facts from a rational perspective it doesn’t make any sense not to think of myself as ill. My experience of severe depression is not just about feeling sad or low. I suffer from extreme fatigue that sometimes leaves me struggling to get out of bed (it’s not just a question of motivation) and feels comparable to having glandular fever. I lose my ability to concentrate to the point that I often have no choice but to take medical leave from work. It’s not unusual for me to ache all over. The physical symptoms are significant enough that every time I relapse I have to have a batch of blood tests to check I’m not anaemic/hypothyroid/etc, and my GP mentioned the dreaded words ‘chronic fatigue syndrome’ for the first time this week – though she thinks depression is the correct diagnosis. Add in the fact that, over the past ten years, it seems medication has been the only thing to lift me out of an episode (more on that below) and I hope you can see where I’m coming from. Of course childhood trauma and some of the issues it’s left me with make me vulnerable to depression, but if this is a normal response, it’s normal in the same way that lung cancer is a normal response to smoking. Is a smoker with lung carcinoma somehow less ill than someone who gets it for no apparent reason? No, of course not, and I feel exactly the same way about my depression.

This realisation is a helpful one in that it allows me to reconcile the different beliefs I have about my depression (that childhood trauma probably caused it, but that it is an illness requiring meds). It’s also a frustrating one because I feel the professionals involved in my treatment don’t really agree with it. Recent comments have left me worried that, now I’m in therapy, no one thinks sorting out my meds is that important. Hopefully I’m reading too much into things and next month my psychiatrist will be only to happy to switch me to another antidepressant, but… this is what I’m worried about.

When I last saw my psychiatrist and we decided to try reducing the mirtazapine to see whether that helped with the fatigue (it’s a known side effect), at first she wanted to increase my citalopram to compensate. Then she remembered that even 20 mg of citalopram messed with my prolactin before. She asked whether I was experiencing any other symptoms of depression besides fatigue, and I had to admit that I was, though not to the extent of actually qualifying as depressed. She ummed and ahhed for a bit then decided that, as I’m in group therapy, it would be all right to just decrease the mirtazapine.

At the time, I was pleased about her sudden show of faith in Group Therapist. In the past my psychiatrist has wanted to refer me for NHS-style ‘one size fits all’ CBT despite the fact I was already being assessed by GT with a view to beginning treatment. She was also not happy about me seeing a private counsellor in the past because said counsellor was not doing CBT with me. So it’s wonderful that she’s come to recognise other types of therapy can be perfectly valid… isn’t it?

Unfortunately, reducing the mirtazapine has made me depressed again, and the fatigue is worse. Off I went to see my GP who’s done the requisite blood tests, but doesn’t want to increase my meds again behind the psychiatrist’s back. I can understand that, but it’s frustrating given I’m only just managing to keep going at work. I’m scared of slipping further, and with my partner likely to become unemployed in the near future, I simply cannot afford more time off work. But what worries me more is that my GP pointed out I keep relapsing, that that’s one of the reasons I’m in therapy, and that therefore it might not be appropriate to change my meds anyway.

It’s complicated.

I do very much hope that therapy will help stop me relapsing. I hope it will help me deal with the issues, and stop the behaviours (like pushing myself too hard and not letting other people support me), that leave me more vulnerable to depression. If I’m really lucky, I might end up not needing meds at all. But even if all this is true, psychoanalytical therapy is not designed to be a quick fix. It’s not going to help me now, while my serotonin levels are dwindling from a lower dose of meds. It is instead painful and difficult, and it seems to me more important than ever that my meds are optimised so that I’m able to cope with therapy and get the maximum benefit from it.

The counter argument would probably be that only when I’m depressed can I truly work on my depression in therapy. The problem with this view is that it makes a number of assumptions I’m not yet ready to accept. Lisa wrote a great reply to my Core Beliefs post where she described how unhelpful core beliefs she had resolved in therapy came back when her thyroid went out of whack – and I think that just shows how these things are not necessarily purely psychological. It’s possible my more recent episodes of depression would have lifted anyway without meds tweaks, and I’m trying to keep an open mind on that, but I do also have in my history two very protracted episodes of depression (three years and one year respectively) that did not respond to therapy, did not respond to self-help, did not respond to the many other things I tried, and only lifted when I was prescribed the right antidepressants (trazodone and mirtazapine respectively). You can argue that the therapy I was able to access at that time wasn’t particularly good, which is a fair comment, but the fact remains that it’s meds which have a track record of getting me out of episodes.

What’s more, I don’t yet know whether the group is the right type of therapy for me. There are advantages to being in a group, but I don’t feel I’m getting as much out of it as I did from the individual assessment sessions with GT. For the past few weeks – ever since we came back from the summer break, actually – I’ve been finding it frustrating because GT has a bee in his bonnet about us all walking on eggshells and not challenging one another. I can see we’re all being very polite to each other, but I don’t actually feel as though there’s anyone in the group I need to challenge right now. If I did, I think I would do it – tentatively, perhaps, but I do have those skills. The problem for me is that I’m walking on eggshells in a different way, by not telling the group when I’m struggling and need their support, and to have GT constantly harping on about a different issue leaves me feeling alone and forgotten. It also feels as though whenever we start to open up with each other, and a meaningful conversation begins, GT interrupts it by trying to link it to his own agenda and that makes it harder for me to grow to trust the people in the room. I think it’s normal when you’re first getting to know people to want to focus on the things you have in common rather than your differences, because that’s how you forge links.

Have you spotted the elephant in the room here? The person I really want to challenge is Group Therapist, and I could never, ever do that. He, after all, is the expert on psychotherapy and who am I to say he’s doing it wrong? At the same time, I know therapy can be different because I’ve experienced different types of psychotherapy and that leaves me questioning what the best approach for me is.

I’m not in a hurry to conclude the group isn’t working for me, because it’s a really unique opportunity I probably won’t get again, and I really want to give it my best shot. The fact remains, though, that I’m far from certain it’s the thing that’s really going to work, so I don’t think it’s appropriate to abandon other types of treatment just yet. And while I have a range of options for accessing counselling or therapy, there’s only one place I can get meds.

Mirtazapine reduction and fatigue

In recent weeks, I’ve noticed a clear pattern to my energy levels. I make it through the working week, but on Saturdays I find myself too exhausted to function and spend most of the day in bed feeling rubbish. By Sunday I feel a lot better, but losing half of my weekend every week is preventing me from fitting in activities I enjoy and means housework and gardening get neglected. We’re talking about the kind of extreme fatigue that makes even getting myself a cup of tea difficult – not something I could or should push through. It’s no way to live.

So it was with excitement that this Saturday I tweeted:

Guess what? It’s a Saturday & I feel normal! as opposed to too exhausted to function as I have been for past few weeks :)

I went on to have a great weekend. I met up with an old schoolfriend, got on top of the housework, mowed the lawn (despite being terrified of the lawnmower :P ), took advantage of the Heritage Open Days to visit a castle and a cathedral, then sang at the first evensong of the new term and went out to the pub afterwards. Unfortunately, I woke up (or rather didn’t wake up…) on Monday morning to find the exhaustion had just shifted by 48 hours. My work deadlines were such that I could afford to take most of the day off – it just means getting a bit behind with my uni marking, which is virtually normal for academics – and if I only crash every nine days instead of every seven that’s progress, but still… I am beyond frustrated.

I saw my psychiatrist on Monday afternoon and we’re going to try reducing the mirtazapine to 45 mg to see whether this helps with the exhaustion. It’s hard to be certain whether it’s a symptom of depression itself or a side effect, so a lower dose could make things worse rather than better, but I feel it’s worth a try (and may also stop me wanting to eat everything in sight). I am getting some other symptoms of depression, but these are very transitory, and my psychiatrist reckons they’re a job for Group Therapist rather than meds. I was pleasantly surprised that my choice of psychoanalytic therapy seems to have gone up in her estimation since she found out that Group Therapist is doing it – he seems to be very well regarded, even among professionals who would normally recommend CBT. My GP Dr Right also thinks he’s lovely* and I’ve trusted her opinion ever since she told me she “couldn’t bloody stand” a particularly blinkered, arrogant and unhelpful psychiatrist.

Fingers crossed that the dose reduction makes a difference (so far, I haven’t experienced any withdrawal symptoms) and that I’m feeling a lot more energised soon!

* Personally, I think Group Therapist is bloody annoying, but that’s usually because he’s being right about something I’d rather not acknowledge, and only occasionally because he’s resorted to an embarrassing psychoanalytic cliché.

Ten years

On a Tuesday lunchtime ten years ago, I headed into town after telling my flatmate I was going to a medical appointment. I dropped enough hints that he would think it was for a smear test and not ask too many questions. In fact, I was going to my first ever counselling appointment and my first attempt at seeking help for my mental health problems. I was not currently depressed, but the episode I’d had the previous year – when I was living abroad and didn’t have health insurance – had scared me enough that I’d promised myself, when I returned to the UK and the NHS and the university counselling service, I would seek professional help.

That first counselling session was not a success for many reasons. The counsellor was in her late 50s and I worried she wouldn’t be able to relate to me, which made it hard to open up. She resorted to a few too many counselling clichés which made me cringe. At one point, she tilted her head in what I’m sure she thought was a sympathetic manner, adopted an obviously staged ‘sad’ expression and said, “I’m just feeling your pain now.” What? I told her how I’d had to leave an internship two months early because of my depression, that I’d known the bitchy atmosphere, stress of working full time and grey weather weren’t helping so I’d moved further south and enrolled as a part-time university student for the remainder of my year abroad while I convalesced. She told me that sounded like a very healthy decision and, when she found out it was the first time I’d ever turned round and said “no” to something that was making me miserable, focused on what a positive step that had been. Although ostensibly she was right, I saw my recurrent depression as an illness that was disrupting my life and when she didn’t acknowledge this perspective, I felt unheard and invalidated.

But perhaps the biggest reason I didn’t go back was what happened towards the end of my session, at 13:46 in the UK, although I didn’t know about it until a couple of hours later. You may have guessed that this was not just any Tuesday in 2001. It was 11 September 2001 and, after a trip to Ikea, my housemate’s brother got a text message saying, “Have you seen the news? This is fucking scary!” When we learned that terrorists had crashed planes into the World Trade Centre and the Pentagon, when we got home and watched the footage of the towers collapsing over and over without it really sinking in, I made a decision. There were Real Problems in the world. 3,000 people killed, with probably millions injured or traumatised. I did not have Real Problems. I would take the counsellor’s advice, put the whole thing down to a toxic work environment and get on with my life.

I didn’t get very far with this outlook. Within a month I had relapsed, first into anxiety, then depression. By the end of October I had seen my GP and was on medication. But that first counselling appointment proved to be the start of a pattern of years struggling to get my illness taken seriously, by myself as well as by the professionals. I think there were several factors at play, all interlinked. I’ll try to list them:

  1. Although I knew I was depressed, I didn’t want to accept that this affected my ability to function. I felt I should be able to push through it, but trying to do so only made me more ill, as did beating myself up when I ‘failed’.
  2. Many of the counsellors and therapists I saw, like that first counsellor, viewed my depression and other issues as a normal reaction to having been severely bullied and emotionally abused as a child. They encouraged me not to think of myself as ill. Although I’m sure it wasn’t their intention, this fed into #1.
  3. The CBT I had, while teaching me useful techniques for challenging my negative thoughts, also encouraged me to ‘get more active’ and behave as though I wasn’t depressed. (I’ve written more about this in my second What’s wrong with CBT? post.) What’s more, to help prevent relapse, I was advised that when I developed the early warning signs of depression I should ‘look for alternative explanations’ rather than seek help. This also fed into #1.
  4. The medical profession first failed to diagnose me with depression (I was initially told it was ‘normal final-year stress’ and prescribed beta blockers and sleeping pills), then wrote me off when the second antidepressant they tried didn’t work. I was actually told by one GP that as I’d had a traumatic childhood, medication wouldn’t work for me – but I couldn’t access effective therapy (see #2 and #3, then add in NHS waiting lists and limits on sessions) or crisis support either. The fact that they didn’t seem to take me seriously fed into #1.

When you take into account the fact that antidepressants have been the only thing to lift my depression (and I don’t think I could handle proper therapy without them), you can probably understand why I have a thing about being taken seriously, and why being viewed as ‘ill’ when I am depressed is important to me. To this day, I can’t read Dorothy Rowe’s Depression: The Way Out of Your Prison because she argues that depression is not a medical illness. So many people have recommended it to me, and intellectually I recognise that her viewpoint is (a) one valid perspective among many and (b) probably not the main point of the book, but it’s just too triggering. Even if my childhood has caused me to develop or be more vulnerable to depression, I need to believe that brain chemistry is involved, whether because there’s an endogenous side to it too or because trauma has changed my brain chemistry. You might think that’s an entirely logical conclusion since the meds work (even if they haven’t been able to stop me relapsing), but I think it goes deeper than that.

What does it mean to be ill? What does being ill mean to me? These are the questions I’m pondering and I think it comes down to two things. Firstly, being ill means medication can be appropriate, that treatment from GPs and psychiatrists as well as counsellors and therapists is appropriate, and that’s important given what I now know about what works for me and my depression. But secondly, being ill means it can be appropriate to take time off work and time out from responsibilities. If I am ill, I am allowed to cut myself a break. I’ve probably mentioned before that I’ve become good at taking care of myself when I’m clinically depressed, but I really struggle with perfectionism and pushing myself too hard the rest of the time, making relapse all too likely. My current therapist – thankfully in a way that makes it very clear he does take my problems seriously – says that depression for me may be a healthy response, a way of getting the rest I need. Ill yet healthy. It’s a strange dichotomy, but I’m starting to suspect that deep down I feel it’s only OK to take care of myself when I am ill. The rest of the time, I have to prove my worth.

Today my thoughts and prayers are with the victims of 9/11 and everyone who has been affected by the tragedy, but I’m also looking back on ten years of my own mental health treatment. I hope it won’t take another ten years for me to truly believe that I have worth just by being who I am.