Philip Dawdy’s post Texas Teen Commits Suicide After Taking Lexapro contains a link to a streaming video of a newscast. At one point in the news story, the dead girl’s father talks about how Kayla was going from highs to lows, typical of most teenagers. Then the newscaster’s voiceover says, “But when the highs became higher and the lows lower, a doctor placed Kayla on Lexapro.”

Now, it’s very likely he could have gotten this wrong. The media gets quite a lot of things wrong. But if he’s right, and Kayla was vacillating between abnormally low lows and abnormally high highs, then it’s not just Forest that her parents should be thinking of suing. Prescribing an antidepressant alone for someone who shows signs of being manic-depressive is criminally stupid, especially if you don’t provide them with adequate information and follow-up care.

I am tired of tragedies happening to families all because of people who should know better, or who should care, and don’t.

I’ve taken Zoloft on and off (but mostly on) for over eight years. If you’ve read the posts Philip Dawdy made last month or last week about an article in The New England Journal of Medicine, “Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression,” or read this news article about it, you know that this study shows that antidepressants aren’t effective in treating bipolar depression.

Okay, so you probably could have figured that out anyway.

At this point, I am taking Zoloft for two reasons:

1. I’ve mostly been feeling good since I started taking meds again, so I don’t want to screw with my medications in case Zoloft is helping me avoid depression.
2. Some medications have made me extremely tired. Since Zoloft does the opposite, I assume it is helping me wake up in the morning. I have trouble falling asleep, but I wake up and I can function. I think it’s balancing out any drowsiness that my Epival might cause.

I don’t know if either of these are valid long-term reasons to be taking Zoloft, but they’re good enough reasons for me in the short term.

Zoloft is the only SSRI I’ve ever taken, but I took Effexor in January and February of 2006. Three weeks starting on it, and then three weeks coming off it. See, I was taking it all by itself without a mood stabilizer or an antipsychotic. I had gone off all of my medications in the fall, felt fine, then got really suicidal really quickly and wound up in the hospital. The psychiatrist on the unit discharged me with a prescription for Effexor although I told him I didn’t think it was a good idea for me to take an antidepressant without a mood stabilizer.

He told me it would be fine, and I figured I might as well listen to the doctor, because stopping all my meds all by myself hadn’t worked out too well for me. I was also not thinking very clearly and it didn’t occur to me that this could have more dire consequences than a mild hypomania followed eventually by another depression.

So what happened? Well, I once read the phrase “rapid cycling/mixed state hell” on an online forum, and that describes it perfectly. I don’t feel like going into any detail today, but suffice it to say that I wound up back in the hospital exactly three weeks later. It wasn’t pretty. It was, in fact, really ugly. I mean the situation, but come to think of it, the hospital was ugly, too.

I’m sure my being bipolar rather than unipolar had a lot to do with that in my particular case, but we all know that you don’t have to be manic-depressive for antidepressants to make you flip out. So it’s nice that the FDA has finally ordered updated black box warnings on antidepressants “to include warnings about increased risks of suicidal thinking and behavior, known as suicidality, in young adults ages 18 to 24 during initial treatment (generally the first one to two months),” whereas the warning only applied to those under 18 before that.

Health Canada had already issued a warning about this:

Health Canada is advising Canadians that Selective Serotonin Re-uptake Inhibitors (SSRIs) and other newer anti-depressants, now carry stronger warnings. These new warnings indicate that patients of all ages taking these drugs may experience behavioural and/or emotional changes that may put them at increased risk of self-harm or harm to others.

The new warning for each of these drugs, which are listed below, appears in the information package received by patients and in the prescribing information available to health professionals.

Patients, their families and caregivers should note that a small number of patients taking drugs of this type may feel worse instead of better, particularly within the first few weeks of treatment or when doses are adjusted. For example, they may experience unusual feelings of agitation, hostility or anxiety, or have impulsive or disturbing thoughts that could involve self-harm or harm to others…

That’s from a press release issued June 3, 2004.

It’s a bit different, though — it applies to all ages, not just people under 25; it includes harm to others as well as self-harm; and it doesn’t include all antidepressants, just newer ones.

I’m just mentioning that this Associated Press article exists: Benefits trump risks for children taking antidepressants: study. I don’t remember reading about it before.

The authors of a new comprehensive analysis of antidepressants for children and teenagers say the benefits of treatment trump the small risk of increasing some patients’ chances of having suicidal thoughts and behaviours.

The risk they found is lower than the one the U.S. Food and Drug Administration identified in 2004, the year the agency warned the public about the drugs’ risks for children.

After the warning, U.S. youth suicides increased and some mental health experts said reluctance to try antidepressants might be to blame.

The new analysis includes data from seven studies that were not part of the FDA analysis…

The abstract of the actual journal article is here, but I don’t think I can read the whole thing for free and don’t really feel like commenting on the study results without having read it.

Anyway, more from the AP article:

“The medications are safe and effective and should be considered as an important part of treatment,” said study co-author Dr. David Brent of the University of Pittsburgh School of Medicine. “The benefits seem favourable compared to the small risk of suicidal thoughts and behaviour.”

Effective, when only Prozac worked better than placebo in depressed children under twelve, and none of the other antidepressants in the studies did? When overall, 61 per cent of depressed kids and teens in the studies improved on antidepressants and 50 per cent on placebo? (The data are better for OCD and other anxiety disorders, which I think we already knew, but I’m less personally interested in anxiety disorders.) I know that research-wise, you can define this as “effective,” but as a patient, it’s not good enough for me. So I at least appreciate that the article mentions the need for careful monitoring of the effects that antidepressants have on children and teens taking them:

Dr. John March, chief of child and adolescent psychiatry at Duke University Medical Center, welcomed the study as “the most comprehensive analysis of the data yet put together.”

He said the suicidal behaviour risk, although lower than that found by the FDA, demands that doctors and families watch for warning signs…

If I thought antidepressants were completely evil, I wouldn’t be taking them. I’ve taken them since I was a teenager. I have found them beneficial at times. I’m finding Zoloft beneficial now. But I think that even if this study is accurate and antidepressants will cause suicidality in only one out of 101 kids who take them (and I’m not saying it is accurate; I haven’t even read the thing), that’s still a cause for concern. And so do the parents of kids who are suicidal or dead because of antidepressants.

Is it wrong for me to be amused that one of the co-authors of the study has the same name as the incompetent boss from The Office? Probably, but hey, if it’s wrong, I don’t want to be right. No offense meant to Dr. Brent, I swear.

There’s a post at Furious Seasons today commenting on the Portland Identification and Early Referral programme in Portland, Maine and an Associated Press article about the program. My personal favourite part of the programme’s web site is the line “Mental disorders are diagnosed in the same way as asthma, diabetes and cancer.”

Ah, so mental disorders are diagnosed with a pulmonary function test? No? A blood glucose test? No? A biopsy? No? Is there any type of biological test that can conclusively prove someone’s particular psychiatric diagnosis? Again, NO.

I was in an early psychosis programme when I was nineteen. The psychiatrist I was seeing for depression when I was eighteen thought I might be schizophrenic, so she prescribed me Risperdal, only saying that it would “help my concentration” and not bothering to tell me that she thought I had schizophrenia. Six months later, she moved away and my GP referred me to the psychosis prevention programme based on whatever was in my file. The next summer, another psychiatrist I saw told me that my file said the first shrink thought I might be schizophrenic because I had told her that I was bullied in junior high school and sometimes I still worried that people might not like me. That was the basis upon which she had prescribed me an antipsychotic: she somehow mistook my occasional worries caused by past trauma for delusional paranoia. The best part is that the bullying was something I had mainly worked through and it bothered me so little at that point in my life that I didn’t even remember mentioning it to her. It was just something I’d said in passing.

During the psychosis prevention programme itself, I saw a psychiatrist and a psychiatric nurse and talked to them about my depression. I knew the programme had something to do with psychosis, but didn’t know why I was in it. Nobody told me that my previous psychiatrist thought I was psychotic. Nobody told me I wasn’t psychotic. Nobody told me they thought I might become psychotic. Nobody provided me with any education about psychotic disorders. Nobody thought they should take me off my Risperdal, so I stayed on it (and my Zoloft, which has been nearly ever-present in my life for the past eight years). I think I just quit seeing the psychiatrist and the psychiatric nurse on my own without them referring me elsewhere; I think my psychologist eventually referred me to my next shrink.

So I wound up in a psychosis prevention programme because I made an offhand remark about sometimes worrying that people might not like me. Even before I was in the programme, I wound up on an atypical antipsychotic because of that same remark. I was not schizophrenic then, and I’m not now, although I was tentatively diagnosed as such at the time. I was not psychotic then, nor was I showing any signs of psychosis. I didn’t get psychotic until years later. My worst psychotic episode was when I’d been off all of my medications for months, but I’ve been more mildly psychotic while on antipsychotics, too. I was misdiagnosed, unnecessarily prescribed heavy-duty medications, and kept in the dark about everything. I don’t believe AAPs caused my eventual psychosis (although such a thing is not impossible), but I sure wish I hadn’t been taking drugs with such serious side effects for years before there was ever any real sign that I might need them. In the long run, being prescribed antipsychotics at eighteen didn’t stop me from getting psychotic at twenty-one or twenty-two. I’ve also been off AAPs for over a year and a half without having any serious episodes of psychosis in that time.

Years later, I reread some old journal entries from the three weeks I was taking Zoloft but hadn’t yet started taking Risperdal. I seem pretty damn hypomanic in them, which I didn’t realize at the time. Although my behaviour shortly before being prescribed Risperdal wasn’t entirely normal, it appears that the only rationale for the prescription that my psychiatrist actually bothered to write down was that one comment I had made. Either that was her entire basis for considering me a possible schizophrenic, or she mistook my hypomania for schizophrenia and did a really sloppy job documenting it.

P.S. I should have knocked on wood while I was writing yesterday’s post. I didn’t sleep very well last night.

In the past few days, I’ve rediscovered what it feels like to get a lot of sleep. I’ve always had trouble sleeping, and although I’ve had the type of insomnia where you keep waking up in the middle of the night and the type where you wake up really early in the morning although you’re tired, usually I have sleep-onset insomnia, which means that it takes me hours after I’ve gone to bed to actually fall asleep. When I was a small child, I usually wanted to get up around 4 a.m. because I felt ready to start my day at that point (my parents did not think this was a good idea), but at some point in elementary school, I started having problems falling asleep.

The insomnia comes and goes, and it’s been present again for the past few months, but I haven’t found it very bothersome, partly because I’ve had much worse trouble sleeping at other times, and partly because I know that my chronic exhaustion and hypersomnia while on Topamax and Zyprexa were a lot harder on me than mild to moderate insomnia is.

The past few days I’ve slept considerably later than usual and I really haven’t wanted to get out of bed. I know it was a holiday weekend, but still, I slept a lot. Usually, not wanting to get out of bed means I’m depressed, but my mood was fine, so I only wondered very briefly if I might be getting depressed before dismissing that thought. Then I wondered if maybe I was anxious about the job interviews I have coming up and trying to avoid preparing for them… but I have been preparing for them when I do get up, and I don’t feel unreasonably nervous about them. (I’m allowed to be a little bit nervous. They are job interviews, after all.) My interview prep and increased sleep have also left me with little time to blog lately.

My conclusion: I am just enjoying this rare joy of eight, nine, or ten hours of sleep per night to the fullest, because who knows when it’ll happen again?

Holy crap, this is a boring post. Maybe it’ll have a soporific effect on someone else, though, and do some good that way.

Currently I take 50 mg of Zoloft and 500 mg of Epival (that’s Depakote to those of you not in Canada) per day. Actually, I have very little money and no drug plan and take generics rather than brand name drugs, but it’s easier to say “Zoloft” and “Epival” than “sertraline hydrochloride” and “divalproex sodium.” This is the least amount of medication I’ve been on in eight years, barring the times when I’d decide I’d be much better without the drugs and would stop taking them all.

I used to take 200 mg of Zoloft a day, not 50 mg. I was on antipsychotics for about six years. For about a year and a half, I took an antidepressant, a mood stabilizer, an antipsychotic, and an antianxiety med every day, some of them multiple times a day. I haven’t been on a lot of different medications (only eight) because usually when something didn’t work, my doctors would just increase my dosage rather than try something new.

The side effects from all these drugs were bad, particularly from Dope-a-max Topamax and the antipsychotics. I was lucky enough to be one of the few people who didn’t gain any weight from antipsychotics, but the pills made me completely exhausted every day for years. That is no way to live your life. So a few times I stopped taking my pills, things would go all right for a brief period, and then the really bad episodes would come. It’s not as if the medication ever really stopped my mood swings completely, but at least it made me less likely to be severely suicidal or psychotically manic.

For a long time, I thought, as a lot of people think, that my only choices were being out of control or being a zombie. But these low dosages of medication are actually helping me without making me tired and confused all the time. Five hundred milligrams of Epival isn’t even supposed to be effective for bipolar disorder, but it’s helping. I’m a bit hypomanic right now; I get that way in the spring. So far, though, it’s hypomanic in a good way, and I’m keeping a close eye on the way I’m feeling and acting. If I start feeling hypomanic in a bad way, I’ll call my family doctor and/or my therapist. I don’t have a psychiatrist right now, but that’s a post for another day, or probably several posts for several other days.

I’m not saying that drugs are all I need to stay healthy. Oh, HELL no. There are a lot of things I need to do. Plus, I’ve been taking these pills at these dosages for less than four months, so I don’t know if they’re going to keep helping me for a long time or just suddenly stop working. But for now, it’s good.