Little things

I went out to say hello to a new neighbor who is moving in. That is not much for most people, but for me it is an effort. And then I signed up for the next Sci Fi book club- which is an hour's drive away, but it is on a Wednesday night and the next day is a late day for me at work, so I can do it. The book looks good, I wanted to read it anyway.

I caught up on my back episodes of "The Strain." At the end of the last episode- it really got weird! Although I have a theory. Why do I like shows like this? It really borders on what I can watch at times. I think I have gotten more timid when it comes to horror. I went through a phase when I loved horror movies.

This morning I did my meds and vitamins for the week. And I realized, I am set with my meds for a while- well, except maybe that last bit of klonopin... But otherwise, I have figured out what works for now. And even if in some very distant long term I might be better off of certain meds- I probably won't live long enough to benefit! I have to do what works for now.

I think my supplements are pretty set, too- except that sometimes I think I want to add more coQ10, or investigate DHEA. But taking DHEA means working with a doctor who will test your level- I doubt mine will- and it just gets too complicated. I don't want to find another doctor.

Eventually I will have to figure out what to do about menopause. I need to find out what my options are for hormone replacement- I have been hoping they would figure it out by the time I got there, but they need to pick up the pace! I think that, mood-wise, I will be much better off taking some kind of hormone replacement. And if anyone gives me a hard time about prescribing it because of risk factors, etc., then I will tell them that Zyprexa is a much riskier drug and I have been taking that for a long time.

Time travelling, as my therapist would say

There are times my mind goes to the past when things were really bad- and hangs out there for a while. My therapist calls it time travelling. This latest episode was triggered by my psychiatrist visit. And I was thinking of previous (very bad) psychiatrists, and of the times that I was very badly medicated, etc. Even just getting my script for half a milligram of klonopin- I mentioned that the first time I was put on klonopin it was 10mg/day during a manic episode. And so my mind went there.

It is wonderful that I am no longer in that place. And it is wonderful that people who meet me would never guess my past. And yet, sometimes it feels like there is a part of me that is not acknowledged. I think maybe that is why I haven't given up my therapist yet- there is someone who knows that part of me and where I have been.

Today has been a quiet day. I didn't have a real weekend last week because I was out of town at a course, and by Friday I was extremely tired. So today has been a lot of lying in bed, napping, reading, watching TV. Tomorrow I will be more productive. It is a three day weekend- I wish that they all were.

He said it so nicely that I didn't get mad

I saw my psychiatrist the other day. I told him about my various adventures lowering meds- with the only  one that worked out being going down on the Zyprexa from 7.5mg to 5mg. He told me that it was okay that I adjust my Zyprexa between 5mg and 7.5mg as needed, but that I shouldn't adjust my other meds without discussing it with him. And then he said that I pay him for his advice, so I should probably take it.

Otherwise he raised the Synthoid to 75mg because my free T4 is still low. I have had more energy since going on the Synthroid. I had been writing off my fatigue as being overweight, not realizing it was thyroid. Everything else is still the same. I do get the feeling that he doesn't really approve of the Provigil- in fact a couple of times he even offered to prescribe an amphetamine in its place. But I have had too many bad reactions to amphetamines- although I think that I did tolerate Ritalin OK in the past. What I would really like to try is Nuvigil- because then I wouldn't have to take a pill in the middle of the day like I do now- but financially that is not possible right now. I can barely afford the Provigil, which is generic. And my insurance company is not paying.

Filling prescriptions has gotten too confusing. I really should have gone to Walmart to fill my synthroid- it would have been 10 dollars for 90 days, instead of 34 dollars at my hospital pharmacy. I am in a high deductible plan, and haven't met it yet- and my insurance company prices for drugs often are worse than Walmart. Although- then there is no paperwork for my claims to count towards my deductible and my meds are all at the same place. Except for my Provigil, which I fill at Costco anyway.

Today was a better day

I need to remember this- don't go down on my Effexor. It won't hit me immediately, like lowering an antipsychotic, but eventually it will. Yesterday was still pretty hard, but today was much better. I even stayed late to do notes.

I think I have tried twice before- and one of those times it was because the doctor wanted me to- and the same outcome. Although, I did successfully get down from 600mg to 450mg. And I could still be at 10mg of Zyprexa instead of 5mg if I didn't keep trying. And  I got myself off most of my klonopin myself. It is hard to know what you really need, and what you can reduce or stop. Sometimes you can't know that answer until you try.

I think I am pretty okay with my meds now. I've tried to go lower on the Zonegran twice, but it didn't work. Same thing happened- it didn't happen all at once, but after a couple of weeks I started thinking my life was over and I should be dead and how did I get here.

The only things I'd like to reduce/get rid of are ambien and klonopin, but there is no rush. I think that my doctor will raise my synthoid at me next visit as my T4 was still low- I don't know if I should care becuase I take T3 as well and my TSH is good. But I do think I have more physical energy since I have gone on the synthroid. I think that is why I didn't notice so much that my mood was dipping- my energy was better. So if he wants to go a little higher, I guess I will.

Pretty soon I have to start the light box. Usually I start on Labor Day, although I had 2 doctors who said that I should start it sooner. But I haven't been eating my lunch in my car much- I have been spending my lunches inside trying to do notes, and that isn't good for me. It is like starting SAD early.

Civilization tells me to stay inside during daylight hours, spending many of those hours sitting at a desk, doing paperwork that I hate. How has civilization advanced? We are not doing what evolution designed us to do. No wonder there is so much mental illness. In a preliterate society, it wouldn't even have mattered that I am dyslexic. There would be no such thing. Maybe in a thousand years- when we all do voice and video and no one reads anymore- there will be no such thing again.

I hate to admit it- but things are getting bad again

My mood is just awful today- it wasn't that great at the course and I tried telling myself I was just lonely. And the week before I struggled.

It could be as simple as the fact that I have been off my birth control pill for over a week and a half- I forgot to pick it up the day I left for my course, so so I have been off of it a while. That pretty reliably makes me feel crazy. But I also have to admit- although I don't want to- that ever since I went down on the Effexor I have been having trouble concentrating. Maybe my brain just needs that norepinephrine stimulation of ultra-high-dose Effexor. Especially after all of those years on it.

Today I made myself leave work in time to get to the hospital pharmacy before it closed- which was a sacrifice because I was doing notes. I hate the way I have to use the hospital pharmacy with my insurance to get the lowest deductible and copay. It has lousy hours and I don't work in the hospital itself- which makes it really hard to get my meds. I never had this problems with running out of meds at other jobs when I could fill my prescription at any drugstore that was open weekends and evenings. It is only at this current job that I am having this problem.

But I did get my BC pill today, and have already taken one. Plus an extra Effexor. Plus a crumb of a Zyprexa. Because I really have the "I'm going crazy" feeling.

There was a time- when I was on disability and didn't have to go to work the next day- that I would feel like this and knock myself out with meds. There are times I took so much I am surprised I woke up. I didn't care if I did or not at the time. Whenever I hear about a celebrity overdose, I always wonder why they died and I lived. But I think it is because I don't drink. A lot of drugs, like benzo's really aren't that dangerous except in combination with something like alcohol. So I always woke up.

I don't want to feel what I am feeling right now. But I guess I will wait to a more reasonable time before I try to go to sleep- because otherwise I don't sleep or don't sleep through the night, etc. It is sad to say, I am looking forward to the oblivion of my nighttime meds. Hopefully tomorrow will be better.

Back home, survived my trip

I went to a three day course out of town- I had to go the day before because I took the train. It was kind of lonesome. I didn't stay at the couse hotel- I missed the deadline and it sold out- and I didn't go with anyone or know anyone there. I was surprised to find myself lonely. Usually I am a pretty solitary person.

It was a good course, it really was. But I am finding that I am starting to learn less in these courses as I know more. Still, it is good to repeat and reinforce what I know- or that is what I tell myself.

But I found myself thinking- again- that maybe I should be doing some kind of clinical research. The main instructor was talking about modalities, and pretty much debunking low level laser. Except that there are now higher power class 4 lasers on the market- and we have one of them. And the laser research meta-analyses generally do not control for the power of the laser or the dose received. And I think that our 10 Watt laser really work. I was very skeptical when I started- but I really see it work. And I said this. And so the instructor said that I should do the research to show that it works.

So I have to think about this and what it would involve. A case study wouldn't change anyone's mind. and you can't do a double blinded study, because you can feel the heat of the laser. The patient will know. So I have to look at some research designs. The thing is, we don't have a huge number of patients and I am the only full-time therapist- so I will be administering most of the treatments, which means that I won't be blinded either.

Actually what I have in mind is a randomization to either ultrasound or laser for some condition that we get enough of in a year that we could get a study out of it. But I don't know if it is worth doing if I, the evaluator, is the one doing the treatments and the evaluations and is not blinded. Would anyone publish it?

And then there are probably a lot of hospital regulations, research proposals and clearances, etc. It all gets very involved. The collecting of data and the data analysis would be easy (I was a statistics teaching assistant). Everything else would be hard.

When not thinking about research my mood was up and down. But- I was able to ask one of the docs teaching the course a clinical questions which put my mind at rest about a post-surgical patient I was very afraid I had pushed too hard the day before- it turns out she was in the safe zone (as I had thought but needed reassurance). Sometimes I really am too neurotic to be a hand therapist- I worry too much.

Can't concentrate

I don't know what is wrong with me recently but I can't concentrate. I don't know if it is too much meds, too little meds, just me... I just don't know. I don't know what to try to fix it. I think about trying to lower something, but I don't know which med to try first. Last night I tried to lower that last quarter of a milligram of klonopin that I take at night to an eighth of a milligram- but after two hours of trying to sleep I gave in and took more. I have no willpower. But I think I am on the right track- the klonopin can't be good for my concentration.

But I am also having trouble sleeping- because I am having joint pain. I think I am getting old. My right knee hurts when I sleep and it is not completely straight- if there is any lateral stress on it. This has meant that I can no longer sleep on my side, as I prefer, but I am sleeping on my back. But then I toss and turn- and sometimes still wake up with pain in the middle of the night. I am also having a lot of finger pain- but that doesn't keep me awake.And my back hurts whenever I wake up in the morning- but doesn't usually wake me up at night. But anyway, this can't be helping my concentration either.I am falling apart- but bloodwork was all normal, perhaps it is all osteoarthritis.

Interestingly when I went to give blood my temperature was 99.4. They said that the cut-off is 99.5. More medical mysteries.

I need to get more strict about my eating. When I went to visit my brother I ate wheat, and have been eating a little bit ever since- and it seems like that is when this episode of joint pain started.

Jumping to conclusions

I sometimes hear people say that getting old is not for sissies. Well, Parkinson's Disease is no walk in the park. And it may have been a walk that Robin Williams did not want to take- and that may have been the main reason for his death. The early reports all jumped on his history of mood and substance abuse disorder.

I often hear it said that suicide is never a rational choice. But I think it can be- even for someone with severe, recurrent, treatment-refractory depression. Maybe you just don't want to deal with that kind of life anymore. Most of our actions are not 100% rational, anyway.

For someone as expressive and emotive as Robin Williams, Parkinson's seems like a particularly cruel fate. And yet, I have many patients with Parkinson's disease with good lives. The medical therapies are getting better and there are some new rehabilitation techniques as well. But in its later stages, it is a savage disease.

I don't know what I would do if I got the diagnosis. To have to deal with that on top of the depression- that would be a lot. My biggest fear is dementia, as a result of both my illness and my meds. Along with tardive dyskinesia- although my doctor thinks we could spot this early.

A death, amongst many

People are dying of Ebola. In skirmishes  between resistance fighters and the army in Ukraine. From ethnic cleansing in Iraq.

And Robin Williams killed himself. Surprisingly, that doesn't touch me very much. My step mother called to ask me how it affected me. She said that some of her friends with depression were affected- or felt validation- that this showed the world how bad depression can be, and how hard it can be to hang on.

I think I put Robin Williams in the "celebrity realm" and it doesn't touch me. They inhabit a separate world in my mind. And I am not a part of that world. What celebrities do- it never seems real. Even this. If my neighbor did this, I would be terribly affected. But an actor/comedian? It doesn't seem real. Which is probably not being fair to celebrities. I'm sure their lives seem very real to them.

And I was never sure I liked Robin Williams. I liked a couple of his movies- but most of them seemed too tame, not him. And yet his standup comedy was both genius and uncomfortable to watch at times. He went too far into that strange place. Too far for me.

I'm sorry things were so bad for him. He must have been in a lot of pain.

Fortunately my thoughts have not been that dark recently. In fact, I did something life- affirming today. I gave blood. I used to- but after I moved several years ago I got out of the habit. It turns out that none of the drugs that I take are contra-indicated for blood donation.

I always have this image in my mind when I give blood: A depressed person is in a car accident, needs emergency surgery, and gets a transfusion of my blood (with all my meds in it). And then the person wakes up feeling better than they have felt in years!

It is funny- I am normally fine with blood. I do wound care, change dressings, watch surgeries, etc. But when I give blood, I cannot watch the blood going out of my arm into the tube and into the pouch. I feel like it is my soul that is leaving my body. So I just don't look.

A good weekend

My mom and I went to visit my brother, sister-in-law, and niece this weekend. It was great. In my recent visits I really haven't felt that great- I felt better this time. Maybe the med changes are good.

Or maybe it was the good news. They are having another baby. Yea! Niece does not not yet- it will be a shock. She is so used to being the focus of their attention. But I hope she will step up to the role of the big sister.

All of which made me think of moving closer. As I often do, I looked at the job ads on the two websites for hand therapists- and saw an ad for a job at a neighboring city. It is at a very prestigious hospital and hand center, and might even involve work with the hand transplantation team.

And I don't know. Is that just too much pressure? Or is that what I need? I don't know. Sometimes I want more of a challenge. But not yet. I need to get my meds settled first- then maybe figure it out. Plus, my pension- what little of it there is before they froze it- isn't vested for another year. Maybe another 14 months, because I took 8 weeks off for disability. So it is too soon to be going anywhere.

And I couldn't quit now anyway- I think we might be losing one of our therapists who just had a baby. If I left now- I couldn't do that to my boss. But I am not ready to leave. If I even want to leave. I don't know. I have it pretty good where I am now.

I just know that I have a very delightful niece. And I have an amazing brother who came out shockingly normal in some ways. I think that marriage and fatherhood have been good for him.

Rough day

Yesterday I felt so depressed that today I am back up to 300mg of Effexor. I don't even care what my dosage is- I just want to feel not depressed but not so numb that I lose my motivation and ability to act. I don't know how to get there. 

Today I had taken the day off- I thought I would go tubing on the river with my mother who is still here. She opted out due to concerns about her osteoporosis. I would up doing pretty much nothing today, and feeling in a terrible mood. I think we keep clashing in small ways, over and over again. We are such different people with different lives, and there is too much history between us. If I am not in a good mood to begin with, I cannot handle her. 

She also has to talk constantly. I need quiet. When I walk out of the room for some quiet- she follows me. There is no subtlety with her. She doesn't get hints. How can I be related to someone who talks so much? And yet, I think my mood problems come from her side of the family. There is a big component of her in me.

Tomorrow we go to visit my brother and family. I am looking forward to that. It will be something good. I get to see my niece!

Still in a strange place

I am feeling better in some ways, but very sad too- and like I am on the verge of tears much of the time. I'm not sure it is a bad thing. It will be if I get stuck here, but not if I can pass through it eventually.

This week I am desperately trying to get caught up on paperwork, but there are only so many hours I can stay at work. I did get some big things done but I am still behind. I think it is getting better. No, it is getting better. But it is taking so much of me that there isn't time for anything else- yet. When I get caught up- and I will- I think it will get better.

My IBS continues to be to be better- just some stomach pain occasionally, but no diarrhea. I am continuing to eat the modified diet. It is a pain sometimes- not so much when I cook but when I just want to grab something to eat out of the house- but it is doable.

My obsession right now is the Ebola virus and the Americans who have been brought back to the US and given the experimental serum. Will they live? Was this the right thing to do? Will we learn anything from this? You are supposed to do clinical trials with any new drug- you want to know how effective it is- and the only way to determine that is to give it to some and not to others. You need a control group. If we decide that the serum is helpful- no one will ever agree to be in a control group. You will never be able to do a clinical trial. If you believe in clinical trials- this should be very worrisome. And yet, it is very understandable what was done.

Supposedly the serum cannot be mass produced. Neither could penicillium, initially. If it works, they will they will eventually find a way to make larger quantities- if there is a financial incentive. A big if. The satire magazine "The Onion" had a great headline: Scientists Estimate Ebola Vaccine 50 White People Away.

Living on the edge

It has been good to cut back on the Zyprexa and the Effexor. I feel more alive, I don't struggle quite so much with initiation- it is easier to act. It is even easier to do my paperwork. And yet, I can see the specter of depression starting to appear at times- although nothing very serious yet. I just know it is there, waiting. And I think that if I go lower on meds, at least for the moment, I will go into that depressed place.

And then I think, maybe it is not depression- maybe it is just sadness. I have a lot to be sad about. Maybe decreasing my meds is just letting me feel that sadness, and that is not a bad thing. Maybe I have to go through that place.

But mostly I am just tired. I am tired of trying to get caught up on paperwork at work from the times I couldn't do things- and didn't know what was wrong with me. I am tired of this messy house that I have been too apathetic to clean- and I am trying to fix that. I have so many things I am behind on- and I just want a clean slate. I want to start my life over again. I wish I could be my pre-Zyprexa weight again. Now if I ever get there I will need a tummy tuck or such.

And when I came home late from work tonight, I wish that my mom had cooked dinner. But that would be expecting too much. I should have brought food home. I was disappointed. I continue to expect things of her and I shouldn't, I just get disappointed.

I remind myself that I am going to see my brother, and my niece, this weekend. That will be good. And I have Friday off- even if I go in to do notes in the morning. Maybe I will get a pedicure. My last one was in January. And then mom and I will go river tubing- it is a 3 hour trip. Life will be good- I think if I can get through the next couple of months, life will be good. But it is going to be hard.

If I could handle today without klonopin, I should have it made!

I spent the day with my mom here, and it has been stressful. I am not sure this visit was a good idea. I feel like she sucks the air out of the room- but I know that I am just very sensitive to her. Plus this apartment is way too small for company. I can get any distance.

But, I managed the day without klonopin. I can't say I didn't have a minute or two when I thought about it, but it really didn't get so bad that I felt that I had to have it, so I didn't.

I am still taking my quarter of a milligram at night to help with sleep in addition to the ambien. That is next on my list- after the Effexor. To get off of that. But not too many changes at once.

Tomorrow it is back to work, and we are meeting with some kind of efficiency expert tomorrow. The word is that the higher ups want us to see more patients per hour. But the irony is- that doesn't mean that we will make more money- because we see a lot of Medicare patients and Medicare doesn't let you double bill- if you are seeing multiple patients and one of them is a medicare patient, you have to split the billable time between them. So if I were seeing three patients per hour instead of two, it would be even more likely that one of my patients that hour would be a Medicare patient, and I would have to splint the billable minutes three ways instead of two.

I have treated three patients an hour before- it is doable in hand therapy- except for some of the really complex patients- but the billing becomes really complicated. I really hope we don't go that route. It is also going to make our patients unhappy. We are really able to give a lot of personalized attention right now. And the paperwork will be worse- and I can't imagine that they will give us more non-patient care time to do notes.