Hinterland

Bad night’s sleep.

They all are, at the moment. I’m sleeping too much, going to bed too early, forcing me down. In a strange hinterland between hypomania and depression, occasional bursts of brilliance, usually in mornings or afternoon, but a low tone of anhedonia rising in the evenings. Jittery but bored.

The skin around my eyes is tight, I couldn’t be bothered to moisturise last night even as I was scratching at my eyes and watching flakes peel off. Fucking lamotrigine, I think. I’m glad I have the drug and it’s hardly S-J, but I’m fairly certain this sudden rush of psoriasis is because of the lamotrigine, fiddling about mysteriously with my immune system. Last night I found it was spreading, too. Doesn’t help that I reckon I need an increase.

This all sounds grim. I’m not grim. Just in a hinterland.

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The promise of lust

Partial list of side effects from citalopram information sheet I don’t know exactly when it shifted, and I definitely don’t know why. I tend to put a definite cut off around 2008, since the 2008-09 episode was so profound, lasted so long, and smothered me; like sleep, under morphine.

At first I blamed the drugs. That was comforting and easy, because after all a side effect of SSRIs is loss of libido. It also held out the promise that once I was off the drugs, I’d be up and running again. I was willing to put up with a flatlining sex drive for a while, for the relief the antidepressants gave me. They were only temporary, after all.

And then I came off the drugs, and I looked forward to the promise of torrential lust. Being young and gay in London with no strong desire for sex is… frustrating. I wanted that part of my life back. So I waited, and I waited, and it never came.

Oh sure, I could get drunk and horny. But that’s missing the point, isn’t it? Drunken lust is clumsy, grasping and loose. Temporary, and soon forgotten. Being young and gay in London with no strong desire for sex is more than a little alienating.

I still blamed the drugs, or maybe I blamed the depression, or both. Blamed some kind of permanent rewiring of the circuits of sexual desire. Maybe they’d burned out? Maybe they’d atrophied? We live in a culture saturated by sex – gay subcultures especially are sodden with it. But for all that, we seem to have little real regard for it. For most of us, sex is important, beyond hedonism and lust and beyond even passion. It’s important for contact, for happiness. For relationships and belonging and feeling a broad and deep range of emotion, sensation.

And I wasn’t getting any.


“Loss of libido” is thrown away in the patient information sheet which details side effects of SSRIs, alongside “failure to reach / maintain an erection (in men)”* and “Anorgasmia (failure to reach orgasm)”. I guess in the grand scheme of things, these aren’t profoundly worrying side effects – the other drug I’m on, lamotrigine, lists Stevens-Johnson syndrome (a potentially fatal loss of skin) and disseminated intravascular coagulation (DIC, AKA Death Is Coming) as it’s potential side effects. Yes, I’d rather have no sex drive and shit orgasms than die horribly from my skin sloughing from my body. Still. Hardly a fair comparison.

Sex is important. And when you’re prone to depression, not having a full – or any – sex life, and thus no romantic life, is dangerous. It denies you a source of pleasure, emotional soil in which to grip your roots to the world. “Protective factors”, in the dry but honest language of a psychiatric consultation. The fewer roots you have the more likely you are to wither. The easier it becomes to simply take the hand you’ve been dealt, and fold.

Sex is important. I really, really don’t think the wider psychiatric community appreciate just how important it is, largely oblivious to how antidepressants can deeply wound a life.


Of course, I’m human, and humans excel at making simple things complicated. Maybe the depression led to a plummeting libido. Maybe SSRIs turned down too many switches inside my head. But people are more complicated than just brains. After so long without a shag, the whole issue takes a life of it’s own, entwining with sexual confidence and body confidence, until it becomes impossible to know if you’re not having sex because you don’t want to, or because you’re afraid to.

I hope this problem is nice and simple and neurological. I hope my bottomed out libido can be blamed on a zapped out reward pathway, or a scrambled endocrine system, or anything other than high level psychology. Because if it’s up to psychology, I really can’t see it being resolved any time soon. Sex is important. Without it I don’t meet guys, I don’t date. I must be the only gay man in London who has never met anyone off Grindr. Seriously. My last online hookup was in 2008. This. Is getting. Tiring.


“Would you be open to a mood stabiliser?” The psychiatrist asks.

I’ve been rumbled. They want to take the hypomania from me.

“Which one?” I ask. They know I study neuroscience. It’s in the file. An awful lot is in the file.

“Lamotrigine”

I’ve heard of it, but beyond it being a mood stabiliser I know nothing. I don’t want the sluggishness that can come with some psychiatric meds (paroxetine destroyed me with sleep; and I’ve seen the effects of olanzapine – an antipsychotic – second hand). Will it place a final nail in the coffin of my libido? I’m wary. I want to know it’s mode of action, I want to know if…

“Like I say; I think the SSRIs work because they make me slightly hypomanic. If you take that away… What’s left?”

He reassures me; “just a trial”

It’s ultimately up to me. Naturally I go online and look up the mode of action (voltage gated sodium channel blocker, calcium channel blocker, glutamate modulator). I look up personal experiences.

Rise in libido.

Not everyone, not all the time. And sometimes the reverse – maybe it could be the final nail in the coffin. And sometimes the rise is due to activation of mania, sometimes fades after a few weeks. Still. It hangs there, glowing on my iPad screen. The promise of lust. Rise in libido.

I say yes.

I take the pill.


*Seriously, this is how it’s phrased. I love the fact they felt the need to specify.

Always be beautiful

I feel…

I feel. You don’t know, you can’t know. How this feels. I feel.

Like…

Like the world…

No.

Like my heartbeat… Like my soul…

I feel the world, my heartbeat, my soul. I see this majesty, this glorious, wild, passionate world. I want to grab, to pull, to claw the world. To kiss. Deep. To leave my marks, red and raw and burning. Bloody, primal, rare.

To devour. This world dripping with promise and passion and fury and chaos and love, and love, and love, and lust.

I step from the pharmacy, holding a blister pack of lamotrigine in my hand, and look to the sky; a sunset glorious and impossible and free. A breeze teasing and sensual, and playful, and exultant. Clouds, golden, blazing.

I step from the pharmacy and look at the blister pack in my hand. Do you know how it feels? You can’t know. To feel so miserable, to feel to wretched and useless and bleak and ruined, to then see the world blossom out in breathless beauty; to move so swiftly from putrid misery to… to…

To this.

To glory.

And to be told this glory is folly, to be told to swallow these pills to take the fierce, untamed beauty from the world. To be told you must turn down Nirvana. Attenuate Heaven. You can’t know.

I walk, I smoke a cigarette. Catch the tube.


You can only hide so long. I suspected, ever since 2008, that the reason SSRI medication worked ‘so well’ for me was that they pushed me into a kind of hypomania. Paroxetine threw me into wild abandon – true mania, light speed and ecstatic and frightening and free; Sertraline, giddy and loose, the time I decided I needed to start dealing shares and learn Latin. Citalopram… Citalopram, like the bed of baby bear, just right. Citalopram, not too wild, just wild enough.

And yeah, sometimes I felt so free I could fly. Sometimes, even without the drugs, I could embark on wonderful new ideas and projects and schemes and it would always, always be beautiful. And I could dance in the street and dance in the gym because honestly, honestly, sometimes I can hear the music and feel the music, feel the music like a kiss. Not the gentle kiss of romance but music lustful, electric, abandoned; which grabs your neck and your body and pulls you in, devouring, devouring, hard and dangerous and fierce.

You give too much away, eventually. The records they keep are surprisingly detailed. “Would you be open to a mood stabiliser?” the psychiatrist asks. I say yes, eventually, for my own nefarious reasons.


Hypomanic episodes have less than ideal long term effects. Cognitive decline, possible neurological disruption. Still.

Still.

You can’t know how it feels. To be told this has to be taken from you, for your own good. The blinding brilliance of hypomania, when the world makes sense and you make sense and everything, oh everything is glorious, to be told everything that is glorious is a lie, the real world is a watery reflection, the real world a muted song. Take this pill. Save yourself. Turn down the world.

Would you take the pill?


I get off at Waterloo.

I take the pill.

Gravity

No milk for tea.

I’ve been sunny, these past few days. Birthday of Brother #2, tea with friends (I’m cutting back on coffee; besides, tea’s nicer. Amazing, how habit often overrides pleasure). Uni has been going well.

For one reason or another, or several reasons interlocking and which nobody really understands, SSRI antidepressants take 6-8 weeks to kick in. For me, the worst of the side effects – chattering teeth, sweats, anxiety – pass after two weeks.

The world comes back and I come back – not gently, but in strobe light; a jitter-jugger, lurching to life. This all takes time to settle. it’s been sunny, these past few days. But deep down I’ve known I’m yet to settle.

One mistake. One dumb and daft mistake I make yesterday, and I’m crumbling inside, my mind whips ups both fears and rage, rage at myself. I know I’m going nowhere so I go home, the world all sunny and me longing for the comfort of rain. Walk from the station – this is why I’m useless, this is why I’ve failed, this is why I should never, ever try; this is catastrophic thinking, this is the ‘all or nothing‘. Arguing with myself, wishing I’d just shut up. Frustrated; a few more weeks on the citalopram and I’d have been fine.

But right now I’ve been standing unsteady, and a trip leads to a fall. That’s just gravity.


 

When it’s just a trip, when I just get grazed rather than broken, sleep often works. I force myself under and wake in the morning, strangely reset. Get on with the day, with life.

But all sleep brought was a nasty, choking paralysis which I screamed my way out of, and a morning too sharp and tender.

Forgot to drop by Tesco yesterday. No milk for tea.

Problematic

I turned up to the GP, the other week. New GP, same old spiel; history of depression, not feeling great, suicidal ideation. Yes, there’s something of a family history. Tend to respond well to citalopram. Can I have some?

Of course, the GP says, and has me fill in a PHQ-9 while he taps a prescription out.

(The ‘Patient Health Questionnaire – Section 9’ is the standard test they give to – I think – anyone turning up to a GP’s office with suspected depression. It’s somewhat similar to something called the Beck Depression Inventory, which is used in research. It’s ten questions about your mood and thoughts over the past week, each scored 1 – 5, which map roughly onto the DSM-IV and ICD-10 definitions of major depressive disorder. I’ve filled in more PHQ-9s than I’ve had hot dinners)

Problematically, I don’t look depressed.

I know, I know – those twee fucking jpegs that do the Facebook and Twitter rounds, ‘Spot the depressed person OMG THEY LOOK JUST LIKE NORMAL PEOPLE’, as if those experiencing depression are some kind of alien stealth attack force. But by the time I make it to a doctor’s office, I am usually in a bad way. For weeks I will have been failing to claw my way out of this hole even as the ground crumbles beneath my feet; I’ll have gone from unremarkable, to tired-looking, to vacant and miserable; unshaven, matted hair, somehow smaller. I finally get into the doctor’s office, away from the eyes of the world, and I sink into whispering, eyes bobbing like dead fish in water. Mouth closed, open. Closed. In those moments I do not look just like anyone else. I look like one profoundly depressed bastard.

When you turn up looking like that, sounding as I do when I’m bad – slow, quiet, halting – then GPs are happy to fire anything at you. When you turn up obviously, profoundly depressed, and say you’ve been here before and say you’ve been helped by drugs before, doctors have no problem in handing you a script and also – in my experience – will ask what dose you’ve previously been on.

So, I don’t look depressed; I’m sat straight, speaking and gesticulating easy, eye’s maintaining contact; bright. Because I’ve been sensible, and this time I’ve gone to get drugs before I get really, really, really bad.

And this is problematic, because I get to the pharmacy and see I’ve been prescribed half my effective dose. This isn’t a huge issue in the moment, since I can simply double dose. This becomes an issue later on, when I finish the script early and have not arranged a further appointment to sort it out because – hey, depression, mind scramble, strobe light impulsivity.

It becomes an issue now, when I’ve run out.

Saved

Last week The Guardian asked readers to write in with their experiences of using antidepressants, and of course I had to take the bait.

Here’s my two penn’orth, where I speak about my 2008-09 episode. Writing this brief piece has made me realise I have quite a bit to say about that period, so I might go into more detail in further posts. It was a hellish time and has left me with some permanent scars.

You can find the original here.


 

Antidepressants and me, like depression and me, go back a long way. I’ve been on them, on and off, from being a teenager (Prozac), through university (paroxetine, citalopram), and into my working life (citalopram, sertraline).

The first few times are undramatic and, I suspect, uninteresting – as were my depressive episodes. Often, once I’d got better, I’d convince myself there was nothing really wrong with me. I’d just been silly, I had been lazy, I just needed a bit of positive thinking and self help books and I could be on my way. Each day is a gift! Every day in every way, I am getting better! Happiness is yours to have if you just reach out and seize life!

(An aside – high neuroticism is a personality risk factor for depressive disorder)

2008 put an end to that.

It’s a curious feature of depression, how much is fills your world with static and gauze and paints gargolye expressions over people’s faces. Looking back, I see how worried colleagues were for me, how concerned my weekly counsellor was. She suggested a visit to the GP, and I came back with a prescription for citalopram. I swallowed them, 20mg, once a day. I had no hope. You don’t, when you’re depressed.

“Can you remember being happy in the past”, she asks.

The question’s a cruel joke. Everything’s a cruel joke. I must have been happy once, rationally, I know I must have been. But I can’t remember. The idea is absurd.

“What do visualise in the future?”

“Grey mist. Nothing”

I go to sleep each night, wishing I could just die peacefully, no morning, no more. And wake each morning, howling inside; I’m still here, it still hurts. Cruel joke. I take the pills. I have no hope.

Sometimes, blissfully, I stop. Just, stop. One morning, stood half naked and holding a sock limply in my hand, I just stop. Half an hour maybe, maybe more. Stopped. And it was peaceful.

I’m seeing the counsellor twice a week now, taking the pills every day. Nothing’s happening; only the pain increases, I have to stop it, I know only one way how. To the extent that I can think, I think about suicide; to the extent I can feel, the thought is tantalising, terrifying. My counsellor knows how to spot the transition from thought to action, sees my howling desperation one morning. I’m sent to hospital, who order me off work but are reluctant to have me as an inpatient. I have good friends and good family, who can watch me. My plans involve jumping, not overdose. Keep with friends and don’t go near bridges.

I go home. I take a break from London and return to my parents, who do a fair job of hiding their frantic worry, their wits-end desperation for a son they can’t watch over any more. Me, face a permanent grimace, my mum trying to help.

“And what about affirmations?” she asks. “Every day in every way I am getting better”

I hate her. I hate her stupidity and her ignorance. I hate how lonely and isolated she’s made me feel. And most of all I hate myself, some cruel, selfish bastard of a son who’d put his own mother through this, some ungrateful wanker who could feel such hate to his own mother, because I love my mum, and I hate her, that she’s made me hate myself. Cruel joke.

I keep taking the pills. I am not getting better, in any way.

My GP, notified of the hospital visit, ups my dose. 40mg, every day. I have no hope. I am going to die, soon. If not this year then the next. Each morning, howling inside. I’m still here. Why am I still here?

I return to work. I’m not ready but people will be talking about me, they’ll hate me even more now that I’ve been off sick, being lazy. I must return.

The increased dose makes my teeth chatter and my body sweat, my eyes shiver in my skull. My mouth dry. Three weeks, this fades.

I cry at work, often, looking at photos of my family on my phone, smiling faces. They tried so hard for me to be happy, I’m not happy, I’ve failed them, I’m so sorry, I’m so sorry. I’ll be gone soon, it’ll hurt you but it’s for the best, it’s better than having me as a son, a useless wretch. I’m sorry, I’m so sorry I couldn’t be better.

I’m fine.

Cruel joke, I know not to trust this. I wake one morning and I’m not howling, and it doesn’t hurt. It looks like it’s going to be a beautiful May day. Cruel joke, I know not to trust this. I go to work, go to bed, fearful for the morning.

I’m fine.

I keep on being fine. A week, I’m fine. I sing in the shower, baffled, delighted, joyful. Happy. It is a beautiful spring day.

A month.

“Can you remember how you felt, when you spoke about suicide?”

But I can’t remember. The idea is absurd.

Well done there

Leaving aside the fact I’m off to Birmingham Pride this weekend, my alcohol intake (i.e regular slovenly insobriety) has slumped back to normal levels – well done there.

And aside from several large slabs of chocolate, last night’s Deliverance burger, chips and chicken wings extravaganza, an upsetting number of impulse detours to McDonald’s, and whole 6 pack of breakfast muffins the other morning, I’ve not had any self control problems at all.

#FML

(Note: Again, this is one of those occasions where the ‘physical’ side effects of my medication – in this case, reduction in hunger pangs – is easily overridden by the ‘mental’ side effect of impulse disinhibition. This doesn’t happen with my sex drive, where I’d actually ENJOY it; because biology and psychology both have a wicked sense of humour)

Slogged

So, just over a week into citalopram; the nausea has subsided, the strange yawning-stretching-crawling pulses are becoming more infrequent. My teeth still chatter, slightly. The turbulence of takeoff.

Sleep. Sleep is one of my two big sticking points with SSRI medications. I’m naturally a lark, one of those insufferable early-to-bed, early-to-rise people, up by 8am at the latest on weekends, unable to lie in. Except while on meds.

Antidepressants increase bed gravity like you wouldn’t believe. And this is the first time I’ve taken them when I’ve not had to get up first thing (to get into work), which has allowed me, for the past few days, to lie, just lie, and bob on drifts of sleep. Which means this is the first time I’ve realised – this is a terrible thing for me to do!

If I can’t get started first thing, turns out I can barely get started at all. I climb out of sleep and bed hazy and befuddled, clunk aimlessly downstairs and muddle about for a few hours, until I can no longer put off going into the lab and into the gym; shove myself, sulking, out the house. Wonder what the point of it all is.

This morning I forced myself up; I need to get to Dean Street for a checkup anyway, I’ve got shopping to do and then (obviously) lab and gym on top of that. And it’s not as if I’ve nothing to do – a mountain of study which I’ve been ignoring, my room is a tip (a few weeks worth of depression will do that). And Jesus, I feel better for getting up. Must remember this. Must try harder. It’d be absurd if a side effect of the antidepressants I’m taking made me more depressed…

Mirtazapine, intense as in

Peaches! It's a visual metaphor, maybe.So last week I asked for my prescription to be changed.

I’ve been on citalopram for about a year now – it’s is a common-or-garden antidepressant which has a very similar cellular action to Prozac – they’re both what you may or may not know as ‘selective serotonin reuptake inhibitors’ (SSRIs). I won’t go into the nuances of SSRI treatment here, save to say they work to an extent, and for some people more than others. I’m fortunate – citalopram seems to work very, very well with me. So why change?

Side effects.

The side effects of SSRIs are usually not too bad – the worst I’ve ever had, or seen anyone have, is an immense tiredness, which can be enough to lead people to quit. But the tiredness I experience on citalopram isn’t anything troubling to me; I need an afternoon nap and that’s pretty much it. Given how profound and dangerous the depths of my depression can be, a few piddling side effects really aren’t worth worrying over, not in the heat of the moment (or, rather, the depths of the dark).

After a while tho, when all is sunny and well, what had been niggling side effects take on a change in character; specifically, the rock-bottom libido I’ve lived with for a few years now, notwithstanding alcohol inebriation. SSRIs are known to sometimes muck about with sex drive, and after mirtazapine was brought to my attention I thought it worth a punt.

Even so, I don’t have great hopes for this ‘working’; that is, delivering some miraculous return of my sex drive. Libido is complicated and impacted by a whole range of factors, from depression itself to past sexual and romantic history, confidence, self-perception, all the way up to culture and subculture, and perception of one’s own role within that wider context. Even if my predicament was initially brought on by a simple chemically-induced neurobiological change, it will be far from simple now. Brains are complex, and people even more so. Still, this is low hanging fruit (fnar), and you have to make a start somewhere – this is a start, of a kind.

And what a kind! My GP looked surprised at my request, pointing out that mirtazapine is usually prescribed for more anxious-depressive types, those filled with a worrying energy. The drug, he explained, can have quite profound sedative effects. Take at night. You might have difficulty waking. Dreams may come.

Dreams did come, and they’re still coming, though I’m told they’ll eventually, probably, fade. Some claustrophobic, some vertiginous, some icy and frightening, all suffocating, intense. Intense as in seeming profound, only to tatter away with a moments thought. Intense as in teenage crush, primal and primary, confusing. Intense as in shrooms, hilarious because, hilarious because hilarious, because. Haunting, and like ocean waves dragging you down as you wake, as you surface, only thrashing and gasping and drowning again into dreaming, and again, and again into dreaming.

The first day, my eyes opened and I got up, I drank strong coffee and more strong coffee but never really awoke, napped for hours before exhausted went to bed, another twelve hours, awoke to dreaming, awoke to dreaming, awoke.

The second day – strange and a world full of echoes and space, but more awake. I think I’m lucky – the tiredness fading fast and swift now, even if the dreams still boil away at night; while waking is still a confused surfacing it’s getting easier. During the day I can write, read, I can even talk and think, and it’s been less than a week. That’s some quick neuroadaptation!

Maybe I’ll even get my libido back.testosterone