I don't want to think that my parents are old, or mortal

Pneumonia is an old man's killer, and my dad just got admitted to the ICU with pneumonia. My stepmother is there and I will go in the morning. So much for yoga I can't help thinking- I was on a roll with getting myself there... I can't help thinking this is a really bad weekend, I need to get so much done. And I can't help wondering how severe it is, and how he will do, and what this will take from him. He has had two cardiac surgeries in the past few years, and both took him a very long time to recover from and to be himself. I am worried.

Normally he is a pretty amazing 84-year old who works out with a personal trainer and is sharper than I am. But he is still 84, and no one gets out of here alive.

If I don't die an early death then I will outlive my parents. I will be an orphan. Someday. But not today.

I quit therapy

I left a message on my therapist's voicemail. I didn't think I had been seeing him long enough that I had to do it in person, and I was glad that it went to voicemail and I didn't have to actually talk to him.

I tried to be very pleasant. I guess I still have memories from the time I left an angry message on my psychiatrist's voicemail and the police and an ambulance show up at my door. I didn't want anything like that happening! I didn't even want a return phone call, and I didn't leave my phone number deliberately. He hasn't called back. I don't know what therapist etiquette is- if someone quits over the phone, are you supposed to call them back? I don't know.

I have thought a little about going back to my last therapist- but even if I had the money I just can't imagine spending $125 a session when I no longer have any out-of-network benefits. So I think I will go without for now. I don't have the patience to keep trying out therapists.

I think I was in a better mood today. Still struggling with anxiety/agitation, but not nearly as much as on the 100mg of Lamictal. I am taking little bits of klonopin- so tiny that I think half of the effect is placebo, and that is enough to take the edge off of things. I feel more awake, more alive. It is good. I am not feeling despair. I did not wish to be dead today, and that is an improvement.

Latest interest- winning the New Yorker cartoon caption contest

I wasn't going to say obsession- that is so in these days, to say something is an obsession, just because you are doing it. And I am not quite obsessed. Just determined to find something funny to say once a week no matter how difficult it seems.

My half brother is a writer and does the New Yorker cartoon caption contest. Then my brother started doing it. So I decided that I had to start doing it. I have just submitted my third entry. And it was good, except that I put an unnecessary "that" in it. I wanted to redo it but I can't. I am still impressed with myself that I managed to find something funny to say with this one, because initially I wa stumped. But as with all that I have done so far- I just pull from current events.

I wonder if, between the three of us, any of us will ever win? A lot of the winners aren't even funny- although the last winner was very good, in fact pretty perfect.

I really wish I could redo my entry. I did it so fast- not thinking I should take the time to edit a one sentence entry. But I am wordy, so I need to. It will never make it as is. I will take more time next week.

Mood swings and decisions

I decided I'm going off the Lamictal, although not all at once. I'm taking my night-time dose but didn't take the daytime one this morning. And most of the day my mood was just awful- although I did feel more alive. But then by evening my mood switched, and I started feeling good. Better than I had in days.

Yesterday I saw my therapist and it just wasn't useful- he doesn't get me, he is wrong about things. Like when I was telling him I can't do anything after work because I am so drained he thought it was low blood sugar and that I should eat an energy bar. Really, it is not that. Just like my racing thoughts are not ADD. And I am not irritable because I am feeling better and therefore expecting more of the world.

There were so many things that he didn't understand- like my trouble taking showers and grocery shopping when depressed- that I started to wonder how many depressed patients he has treated. His attitude is that you just have to make yourself do it, and eventually it will get easier. Well, I don't need a therapist to tell me that. But I beg to differ on the it will get easier part. The next depression I think that taking a shower might be just as hard.

I am going to quit therapy. I will call him tomorrow- I get out from work earlier tomorrow. I just don't think it is going to help. I don't feel understood nor do I feel like I am learning useful skills.

When you don't know whether to go up or down

I am halfway through my titration up on the Lamictal. I'm at 100mg, going to 200mg. You have to do it slow because there is a small chance of getting a very dangerous skin reaction- but this chance is lessened if you go slow.

But recently I have been miserable- and I think more miserable than I was before I went on it. But it is hard to remember. I should track my moods more often, especially when I am making med changes. I should create a program that would let me graph mood, meds, and the number of hours of daylight!

As bad as my moods have been, my sleep has been worse. I can't sleep at night- which means that all I want to do when I get home is sleep- and even if I make myself stay up I get nothing done, I have no life. If I take klonopin it is awful- klonopin on top of the higher Zyprexa dose really has me knocked out the next day.

Plus I have been really irritable- which I seem to remember being an issue with Lamictal before. Of course it could be the fact that it is the longest day of the year... my psychiatrist wants to raise my lithium, but I won't. It would just make me too numb. The dose that I am at- it isn't too bad in terms of side effects. I have been on high-dose lithium before- and that was almost enough to stop me from ever trying it again.

I did somehow make it out and to my dad's to visit with family. It wasn't easy, and taking a very necessary shower seemed like an Olympic sport.  I can't say that once I got there I felt fine and all was well- I still was really fighting with the darkness inside of me. But I'm glad I went. It was better than staying home with the darkness.

Tomorrow I see my therapist and I don't know what I am going to do. Sometimes I think I stay in therapy because it seems like I am doing something, and that to give up on therapy means to give up on me- although that isn't true.

My last therapist I felt understood me fairly well, if only because of the length of time I saw her and the need I had to tell my story at times. So my current therapist is at a disadvantage. He doesn't get what I struggle with. And I don't want to do the type of therapy that he likes the best: schema therapy. So is there any reason to stay?

I'd like to give DBT another try. I could do it with him, maybe. He does list it as something that he does on his website. I don't think I have the energy to drive an hour each way to the nearest skills group. But maybe I could do it on my own with a workbook. Aren't you ever done with therapy?

What to do about therapy?

I think I may have to break up with my therapist on the grounds that he is too mentally healthy and he is very good with his paperwork. He doesn't understand how much I struggle, and it is hard to explain. Even just the paperwork part.

I'm sure if I stayed for months he would understand more about me- but do I want to give it months?

My insurance company has messed up my deductible and I am paying full price again. I had to charge my last session- and I think that, trying to be helpful my therapist scheduled me for two week's time as I was doing better. But once I go down to every other week it never seems helpful. Or perhaps I just have more time to question why I am going.

Today my mood crashed, which is not surprising given that I got up at 3am to go into work early and do notes. Perhaps it is just as well that I didn't have therapy after work as I have been dizzy and light-headed since the afternoon. I just wanted to go home and watch the Game of Thrones finale.

It is my obsession. But I feel like it is at least one "normal thing" that I am into. Something that gets me out of myself. But now- how will I manage until the next season? Maybe I will need therapy for that! Fortunately I have the books to read.

I am not sure where my therapy is going right now. At least I felt like my last therapist knew me. I would like to do a DBT program, but there is nothing near me- it would be quite a drive, and I just don't have the energy for that with work. Plus I would have to change my work hours. And if they required me to see a therapist there it could be even more time consuming.

What I think my therapist doesn't get- because he hasn't seen me that long- it that if I have a week or two in which I get more things done- it isn't because I have had some kind of breakthrough. It is because my depression is a little less. And when the depression comes back I might just lose anything I seem to have gained and be back to square one.

Of course that doesn't mean don't try, don't fight. But it means that if I keep trying with the expectation that things will eventually get easier, I am likely to be disappointed. I try not to have that expectation, but I can't help it. I do.

Today I was so weary of life, so weary of trying. It just seemed too hard. I hope a good night's sleep fixes that.

I'm thinking of all the money I would save if I quit therapy. I could get new glasses next month- I'd have enough money in my health savings account. And I am wondering how to fight my insurance company for messing up my deductible.

Made it back to yoga

I went to yoga at a new place but with the same instructor I had previously had- she opened her own studio. I haven't done any yoga in a long time, and it was the perfect session- mostly stretching, and not too demanding. Just what I needed to ease me back into it.

And yet I came home tired and napped- but perhaps that is because I didn't sleep well last night. I tossed and turned and woke up a lot and then got up early. I also woke up grinding my teeth really hard- harder than I thought possible.

My dentist told me that I grind my teeth, and a part of me didn't believe it. I never had the sensation that I did this. But this morning I was really doing it- it is the first time I have noticed it. I wonder if that is because I am no longer taking klonopin regularly. Next I want to try to get off of the Ambien- but I'm not going to hurry that too much.

I want to ask my psychiatrist for Ativan instead of klonopin as a prn. I'm hoping I don't need it much- but if I do, I'd rather have something with a shorter half life. When I take klonopin I can feel it the next day. Then again, perhaps that is what stops me from taking more of it.

I'm down to 5mg on the Zyprexa. It is the one medication I have "permission" from my psychiatrist to titrate- although I don't think I need anyone's permission! But I realize that sometimes I will be able to get by with 5mg, and hopefully most of the time- and sometimes I will have to go up to 7.5mg. And I will probably go back and forth. When I am really depressed or agitated, I am more functional at the higher dose. But if I am not, the costs of being at the higher dose are too great. But that is what is good about Zyprexa- it can be adjusted quickly and works quickly, much faster than a conventional antidepressant.

Healthcare reform

At my job we try to be "efficient" and try to see the patient for as few visits as possible. This makes us look better with insurance companies and most patients have high co-pays these days anyway.

But there are always those patients who need more- who I keep on for a while. They might have had a CVA, RSD, a tendon repair, or just a really stiff hand because of an injury with swelling and weren't sent to therapy in a timely manner. And some hand surgeons want their patients seen more often.

Well we have a new policy at work. When a patient reaches 15 visits, 20 visits, and then 25 visits, I have to discuss their case with my supervisor. (I wonder what happens if I reach 30!) And it has me really mad.

First, I feel like my clinical judgement is not being respected. If I can convince an insurance company to let me keep a patient for 20 visits, I don't know why I should have to convince my supervisor. Secondly, I feel like we are being pressured NOT to give the harder cases what they need. And finally, what happens if my boss thinks someone should be discharged and I do not? Do I tell my patient that I am discharging them because my boss says so?

Perhaps we should tell patients up front, on the phone, when they call to schedule an appointment- if  you are going to need more than 15 visits you should look elsewhere. This seems to be the way that healthcare is going. The difficult cases require more care and make you look bad to the insurance companies and Medicare, so you can't take on too many of them. The insurance companies might cut you out of their network if you do. Medicare might audit you.

I tell myself that if healthcare becomes too awful I will become a massage therapist.

The best cognitive rehabilitation

One of the therapists where I work has started doing cognitive rehabilitation where I work. I don't think we have the best setting for it- but some people don't want to go to (or can't get to) a formal cognitive program that is further away.

Well, I have found the perfect activity, because it is really straining my brain. I am reading the "Game of Thrones" books, and I am having the hardest time keeping track of names and relationships. Who is that person? What house are they from? Who are they related to? There are just so many characters to keep track of.

But I am enjoying the books. They give a depth to the story that the TV show just doesn't have time for. I'm just reading them slow, bit by bit- which makes it all the harder to remember who is who.

Tomorrow I am signed up for a yoga basics class. I haven't gone to yoga for a long time- it will be good to get back. There was a time I was going twice a week regularly- until my next depression hit. I want to get back to that. Unfortunately the Monday class that I used to go to no longer exists. There is a later one that might be okay- except that it isn't until 7:45 and I get out of work at 4:30. Even if I stay to do notes, it is still pretty late.

The good news is that my neck is feeling better. I really worked on it two nights ago- hanging my head off the side of the bed and doing gentle mob's. Plus I had to take klonopin to sleep that night- and it is a muscle relaxant incidentally. It hasn't hurt since. But I already scheduled a massage for the weekend, I don't think I'll cancel it. Maybe that is why things got so bad, I haven't been getting my monthly massages.

Tomorrow I up my Lamictal dose. I'm still titrating up. I hope it doesn't make me too spacy.

Some good news

I had to have a follow-up mammography for my right breast today as a 6 month follow-up for my breast biopsy. It was fine. I really wasn't worried about having cancer. Instead I was very worried that they would find something- again- that would require biopsy to determine is benign. And I started wondering how many biopsies I will have in my lifetime- and remembering the patient I had who had a mastectomy due to repeated (benign) biopsies. I guess at some point you would either need to stop having mammograms or have a mastectomy if it got that bad.

Of course I could get breast cancer- but dying of heart disease is much more likely with my risk factors and family history. Unfortunately there is no law saying that you can't have both breast cancer and heart disease. Or breast cancer, heart disease, and bipolar disorder... There is a part of my mind that thinks having bipolar ought to give me a pass on having a serious medical condition, at least until I am "older." Like god/the universe wouldn't be that cruel to strike me twice. I know that this is a very irrational feeling. All the studies, in fact, show that moods disorders increase your rate of just about everything it seems- and if the mood disorder doesn't, then the meds do.

At work I was playing "Dr. House." I was diagnosing (in my head) an undiagnosed patient with neurological symptoms and it isn't good. I hope I am wrong. I'm often right about these things- and with the last patient I was right about it was ALS. If I had gone into medicine- which I considered very, very briefly for about 1 semester in college (before organic chemistry and before the psych hospital), I think I would have become a neurologist. Even though being a neurologist is pretty depressing- because the brain has limited ability for regeneration, plus many of the illnesses are progressive- there is a limit to what you can do to help your patients. But still, I thought about neurology.

Today I might be more interested in hand surgery. But I have lousy fine motor coordination, I'm lucky I can take out sutures. And I have poor spatial skills. So really, hand surgery would be a bad fit. I'll stick with neurology for my imaginary medical career.

Disability?

No, not that extreme. I just might need PT for my neck. What I really need is to do less paperwork. On my vacation, on long weekends, I have no neck pain whatsoever. The more time I spend doing notes the worse it gets- and now I am starting to get that tingling/electrical pain in the back of my neck at times- but fortunately no radiating. Or at least not yet.

My hope is that when we get to electronic medical records it will be better because we will have laptops and I will be looking up at least a little bit instead of straight down at the desk. For now I am doing my chin tucks and back extensions and cervical ROM. And I should probably go for another massage- I haven't been in a while.

I was looking at my computer at my desk today- and it is an ergonomic nightmare! There are no pull-out keyboard trays in the staff office and the monitors are just sitting on the desks- way too low. I have to bring in some books to put under my monitor. And to think that I give my patients ergonomic advice... I had better not let them into the staff office. Of course our office wasn't designed by an OT.

I see enough patients with really messed up cervical spines- I have to fix this. But I realize that it may not fully resolve until we stop doing paper notes. And I don't know what to do about PT- I'd love to go where I work (plus it would be a lot cheaper). But I don't want my co-workers knowing my medical history.

What goes up must come down...

This was a rough week and towards the end my mood really crashed. I did go to acupuncture this morning, however, and I hope that it helps. It seems to, more than last week's did. I go to a really neat acupuncture place- it is a community acupuncture place. Everyone is in one room, lying in recliners. And it is sliding fee scale, $20-$40, pay what you can. They don't ask your income, it is up to you. I have been paying $30. But it really makes acupuncture more available to more people.

Unfortunately the hours are mostly during the times I work, except for Saturday mornings. But it is good to get me out of the house on a Saturday morning, so I don't stay in all weekend. And while I am there, lying with the needles, I practice my diaphragmatic breathing- so I come out extremely relaxed.

I am so relaxed right now that I think that I have to nap. And then I have to figure out how to contact my insurance company, because they have really messed things up with my deductible. First they charged me things I didn't owe- and never got back to me when I questioned it. But they finally realized I shouldn't have paid it- and subtracted it from what I have paid towards my deductible- and they have not sent me a check for it. So I am down $1200 towards my deductible again, instead of having met my $2500- which was very nice to be just paying co-pays finally.

Tears at work

I have a patient who I have treated several times- a really nice guy- and I found out that he is in the hospital and it doesn't look good. It is sudden and very sad. But that is what happens when you work in healthcare with people who have a lot of medical issues. And some people touch you more than others, they just do.

It's funny- sometimes when I cry I feel relieved that I am crying- that all the meds I take have not made me so numb that I can no longer cry. Sometimes I wonder.

And sometimes I wonder if I drank if I would need less meds! No, I don't mean if I were an alcoholic- just if I came home to a glass of wine. I wanted one today. I had the busiest, most hectic day at work and even during lunch I had to go to an infection control inservice so I couldn't do the other things I needed to do. When I went home, I thought I'd really like a glass of wine. But I just don't like the way I feel the next day when I drink- plus with all of the meds I take I really shouldn't, if only to save my liver. So I didn't. Even though I do somehow have 3 bottles of wine. At least one was a gift from a patient.

Fortunately I do feel relaxed now- with no wine or no klonopin either. But if I had to pick wine or klonopin after a hard day at work- I'd definitely prefer wine. But I'd really prefer neither.

A very busy work week

Work is good- interesting patients, good OT therapy moments, etc. And also too busy- I'm double booked, my patients can't get times that worked for them, I can't find a moment to write my notes. It is hard. We could use another OT. Except that in a couple of months we will probably slow down when all the hand surgeons go on vacation- August and September are usually very light.

I'm feeling very American- I came home late both nights this week and wanted nothing more than to eat dinner in front of the TV. Monday night I watched Game of Thrones and tonight I watched the pilot episode of Mr. Robot- which was really good. So now I have three shows to follow- Last Week with Jon Oliver, Game of Thrones, and Mr. Robot. I haven't really been keeping up with the Daily Show recently because I find it is so hit or miss.

The past two days of rain and dreariness have taken a toll on my mood and energy. I just want to sleep. I hate how much my moods are controlled by the seasons and weather. I try to fight it, but it is really hard.

One of these days I will actually get to the gym again. Hopefully soon.