Nursing & Depression

abrenrn · Dec 21, 2002

The story about the reporters is true - I read it a long time ago in the back pages of a newspaper and more recently in a book about a woman with schizophrenia. The conclusion of the book, by the way, was that if the disease had been recognized early and treated aggressively, it probably would not have become chronic - but I forget the name of the book. One I do remember, is Eden Express, by Mark Vonnegut, son of Kurt. He had a very severe episode of schizophrenia in his early twenties. Lucky for him, it was treated aggressively with something that worked. I hear he went on to become a psychiatrist. Hope he's still doing OK.

I think much the same with depression. I know in many ways, anything I mentioned that a doctor did not like was labeled a symptom. Some were, most weren't. Had someone treated me appropriately and aggressively when I was 19 years old, I doubt I ever would have become a "treatment-resistent, chronic depressive."

I still hope for a cure. I think I'm on my way.

KarenKidsRN · Dec 22, 2002

I wonder the same thing about receiving appropriate treatment early. But I think I had my first episode at about 16, I am 48 now. Back in the 60s we didn't have the meds and treatment options we do now so treatment back then might have actually made things worse. I have an aunt who was treated with ECT in the 40s and she is missing a few brain cells, possibly as a result of that? no one knows for sure. So maybe not being treated early was a blessing in disguise.

BellaTerra2002 · Dec 22, 2002

I was mildly depressed (dysthymia?) for most of my life, beginning with puberty. Started to get real bad at 35. Was in a hospital for two weeks at 46. I was treatment resistent for 13 years until 5-6 years ago, at the age of 48, when a psychiatrist (the millioneth one I had been to) diagnosed me a "low-end Bipolar Type II" and put me on 1000 mgs. Depakote and 200 mgs. Serzone. (Yeah, I'd never heard of Serzone either.) For the past year I've been down to 500 mgs. Depakote and 100 mgs. Serzone with NO problems. In fact, aside from normal emotions (normal brief periods of normal depression -- who wants to be happy ALL of the time -- kinda one-dimensional!), I've been just fine.

I DO believe in telling the doctor what is not working for us. I DON'T BELIEVE in telling the doctor what to prescribe. So I don't say it lightly when I say try the Depakote and Serzone combination if all else has failed. My psych uses this combination (to begin with) for all his patients (who are experiencing clinical depression) who come to him and who have been treatment resistent. If it doesn't work, he tries something else. But this combination works on a lot of people.

Caution: For the first two weeks I couldn't drive a car. I was too dizzy. In fact, he started me at 250 mgs. Serzone. When we went down to 200 mgs. (rather quickly), I was fine. But Serzone, at any strength, takes an adjustment period. If you can handle the adjustment period, it's fine. Oh, and it took 8-10 weeks for me to feel better -- but he told me it would take 2-3 months. Not only did he not lie to me, he hit it right on the head.

abrenrn · Dec 22, 2002

Karen - with your aunt, I would say it depends. How depressed was she? If it was severe and ECT was all they had... Have you ever read the Bell Jar, by Sylvia Plath? An autobiographical novel, ECT saved the life of the main character - and its author. That's where the title comes from, something like - she had always felt like she lived inside a bell jar - everything around her seemed a bit distorted. After her first appropriate ECT treatment, she felt the bell jar lift, just a little. After a few, she could see the world clearly.

Sylvia Plath was a poet. After a "nervous breakdown" she graduated from Smith College, got all sorts of degrees then married another poet and stayed home to raise children. Apparently the bell jar descended upon her once again; in her thirties, she successfully committed suicide (using the oven method). It's especially sad since, from what I've read, it was almost a miracle that she survived her college "nervous breakdown" suicide attempt.

I recognized that something had lifted two weeks after I took the first med that ever worked for me (an MAOI of all things). My bell jar was never completely lifted until a more recent combination. Even in this day and age, though, I've seen cases where ECT was used as a last resort - e.g. an old person who would have died of starvation before meds kicked in. He was laughing - and eating again - after his first treatment.

I've never had ECT. But, if I ever feel the way I've felt before and that was all that could possibly help - I'd say yes in a heartbeat (if I wasn't too depressed to say anything). It is an extreme treatment that should only be used in extreme cases. There are still times when it should be used. I'm just glad I don't have to make that decision for anyone.

Bella - I don't believe in telling a doctor what to prescribe for me. I don't like it though when they don't listen to me tell them what has worked for me or hear my concerns about treatments they recommend. I always said no to Serzone - because of what you described. I couldn't afford to be a zombie - I had to go to work, I had to drive. If there was nothing else, I would have, but I knew there were other things to try. Hell, I took Parnate - talk about a dangerous drug - but it was the only possible drug at the time, TCAs never worked for me. If possible, I'll avoid Parnate in the future.

BTW, I learned a trick re prescribing antidepressants - start as low as you must to avoid the type of symptoms you mentioned. Then, go up to therapeutic dose. I've seen pts become exhausted on 25mg of Serzone - starting at 250mg would be considered irresponsible these days. Studies show that slow starts lead to better compliance rates at 6 months. True, but I don't have the reference at my fingertips. Easy to find though.

People didn't know this several years ago. They found out when a few psychiatrists started paying attention to patients, starting more slowly because of really difficult side effects, bringing up gradually. They were much more successful than those who always started patients at top doses.

I always try to listen to my patients. Even crazy ones. They know more about themselves and what they can tolerate than anyone else does.

Also, Parnate and all the SSRIs kicked in for me within two weeks, if they didn't they weren't going to. I needed an adjunct also. The one that worked for me wasn't one of the anti-seizures (from what I hear, neurontin works as well as Depakote and it's safer too, no blood level checking - you may want to ask your psychiatrist about it; it's more expensive for the med - but think of those blood tests!!).

In fact, a psychiatrist recently tried to put me on depakote. At first he balked when I mentioned Neurontin. When I pointed out that it was no more off label than Depakote, he relented. I decided against it, though. Fatigue has always been one of my worst problems. I'd try it if I trully felt I needed it. I don't. In fact, under the care of a regular PCP, I'm cutting back all my meds. Psychiatrists tend to get lazy after a while. They find one regimen that works and stop reading.

sphinx, BSN, RN · Dec 22, 2002

I had ECT. Of course, it's different now than it was so many years ago in that they give you muscle relaxant and put you out briefly. They also have worked to do the procedure in such a way to decrease the possibility of memory loss. I had like 8 sessions. I quit because it was only helping a little bit, and I couldn't handle the side effects anymore.......not so much the memory loss (at the time, I was unaware of it), but the exhaustion, the incredible dry, dry mouth, the sore leg muscles......and I hated the preparation......the injection to dry you out (a painful one), then when you go in, I got to really hate being put under......the smell of the pastic of the O2 mask, the incredible burning of the medicine as it goes up your IV. Waking up was weird, but not so bad, I wasn't as bad as this other woman who always had treatment right after me, who never knew where she was or even what ECT was. As soon as I was able, I'd have a drink cuz I was so dry. I'd have a killer headache. They'd call my husband who'd pick me up, and we'd pick up lunch and my mouth would be so dry everything tasted like sawdust. Then I'd go home all disoriented and sleep forever. If I'd noticed more dramatic results, I might have stuck with it, but I saw almost no improvment. The memory loss was moderate, and lots of stuff from that time is just gone. But ever since then, the way I process memory has changed too. My memory is way worse then it ever was. In a way, i think I'd do it all over again if I thought I'd help, but my husband says I'm forgetting how much I hated it. Maybe he's right.

As for meds, well, ya'll have heard my take on meds, so I won't bore ya with that again. I also have never felt comfortable telling a doctor what to prescribe, but I suppose if I were in a position were I was taking a med combo that was really working, and moved, I'd have to to make sure my new doc would agree.....I mean, why mess with what works? But in general, I may want to try something.., even mention it maybe, say no to things that haven't worked before or that I have a strong preference not to take......but I will try what he thinks will work, give it an honest try. I am now up to 75mg Lamictal, with a goal in the range of 200-300mg, depending on how it works for me. At that point we'll likely try to taper off the topamax and see how that goes. Meanwhile, I am much the same......nothing new to say, so I say nothing, rather than the same old stuff.

abrenrn · Dec 22, 2002

Sphinx -

One thing about meds, the results can be so gradual, it's hard to tell. To me, you sound better than you ever have.

As per ECT - like I said, extreme treatment for extreme situations. In the book. Sylvia Plath did not say much about headaches, etc. I'm sure she had the side effects - but they paled next to the results she had.

You had ECT and it didn't work. If I were you, I wouldn't consider it again unless I was totally suicidal and I was told it was the only chance I had. Though, I admit, hard to make decisions when you are in that state. It is for me, anyway. And I am not you. But I said yes to Parnate when it was presented as the only option and while I waited for it to work I would make little jokes (to myself) that now I could kill myself with a pepperoni pizza. I didn't try. After two weeks, I didn't want to.

Hard to notice small changes yourself. Believe me, Sphinx, you sound better to me than you ever did before.

BellaTerra2002 · Dec 22, 2002

AbrenRN, it was my understanding at the time I started -- and still is my understanding -- that 300-400 mgs. is a therapeutic dose of Serzone. Secondly, I take both the Serzone and Depakote at night before bed. I sleep a good 7-8 hours. I have no problem with daytime fatigue other than normal daytime fatigue after eating too big of a lunch or if I don't get to bed until midnight and then get up at 4:30-5:00 a.m. (my normal wakeup time, 365 days a year -- I'm a morning person). Both of these drugs took that horrible never-ending fatigue away.

I am familiar with Plath. Such a good writer. So tragic. When I realized I was going to kill myself if I wasn't restrained and because I knew suicide would devastate my three adult children, I handed my house keys to my supervisor (who was also a long-time friend and my neighbor), called my doctor, and I drove to the hospital where I checked myself in.

Interesting enough, when my psychiatrist took me OFF of the antidepressant I had been on, my suicidal feelings abated greatly within 24 hours. After 48 hours off the drug, they were TOTALLY gone. I know my clinical depression had nothing to do with the wrong drugs, but I'm positive that my almost irresistible urge to commit suicide had everything to do with that drug. Strange that I can't remember which one it was. On the other hand, I think that by the time I started on Serzone I had been on just about everyone there was up to that time.

Oh boy, just readin this board reminds me of how bad I was. I don't know how I ever got out of bed in the morning or how I got to work. I was in so much pain. I couldn't think. I would go home from work and go straight to bed. Spent whole weekends in bed. But I had to work. Well, 18 months later I couldn't work. I couldn't afford my meds; I felt much better; so I quit my doctor and slowly weaned myself off my meds over a 6-month period. Big mistake. And I was in a lot of denial. When it finally caught up with me, when I absolutely could not get out of bed, it took me four weeks before I could manage to go back to work and even then it was 8-10 weeks of 'light duty' before the medication kicked in.

I only have blood tests every six months. Which reminds me, I'm due for one. Thanks. I don't mind them. I get them done first thing in the morning so I don't mind fasting.

To all of you who are treatment resistent, I feel so bad for you. I remember 13 years of almost hell. I don't know why I should be so fortunate now (other than I divorced my husband and I think that helped tremendously). But I am so grateful that I am. And of course, I know that this combination I'm on could stop working any time.

abrenrn · Dec 22, 2002

Bella -

Given the shape you say you were in when you started the Serzone, the MD did the right thing for you - start high, not safe to wait. The slow start generally applies to people who are outpatients. In those cases, overall compliance at six months is much higher. The study did not look at people who were in the hospital.

Nobody who knew anything would take Parnate as a first choicemed these days. It is a very dangerous drug (all the MAOIs are). Since it was my only choice, and I did not want to be suicidal, I took it. Since I was depressed, I made silent jokes about now being able to kill myself with pepperoni pizza - if I had really wanted to die, it would not have been a joke. Look up parnate. Certain foods (including pepperoni and mozzerella) cause malignant hypertension, often fatal, when eaten with MAOIs.

As per the depakote, you are doing the same thing I do - if it works, don't fix it. I suggested the other to the MD because when starting, Depakote has to be monitored closely, why not try one that doesn't? Every six month blood tests - I wouldn't change either.

What I have to remember (and, sadly, many psychiatrists I've met don't) is that what works for one doesn't work for others. ECT worked for Sylvia Plath; it did not work for Sphinx. Nothing wrong with Sphinx - it was the wrong treatment.

I don't mind an MD STARTING me on a regimen that he or she has a positive experience with. It's when they want to stop one that is already working that I get upset.

Also, I know the bell jar can come down again on me at any time. I watch. I want a professional to watch. But, when a psychiatrist tells me I'm manic on the basis of a two minute conversation when I'm late for picking up my father, I do question his diagnosis.

I have found a family practitioner who listens, pays attention to the literature. He told me I seemed to be doing OK on my meds. When I told him I didn't want to get a mammogram he said "Bull....". Personally, I like someone who doesn't agree with everything I say. I don't like someone who never agrees with what I say. I'm a pretty experienced patient.

Yes, I empathize with those others who are treatment resistant. I've found something that works for me (after more years than I am willing to say), Bella found something completely different that works for her. It sounds like Sphinx has found something that works for her too. There is hope.

BTW. Besides the meds, I quit my last job. That's when the depression really lifted. I probably wouldn't have quit if the depression hadn't lifted as far as it had.

flowerchild · Dec 23, 2002

I found this web site to be informative and interesting.

http://www.teachhealth.com

I think that as nurses we are always under an incredible amount of stress and that it is difficult to avoid the stress related anxiety that leads to depression. I know that whenever I have had a position that required me to be responsible for up to 500 patients 24 hours a day, 7 days a week, that I'd loose sleep with worry and become anxious and then depressed. Too much for me, so now the s/s of anxiey and depression are totally gone and the only thing I did was change to a job where I'm only responsible for the patients when I'm there at the clinic. In peds, after they go home, Mom and Dad take over and I'm off the hook....so to speak. I sleep nice and sound these days. Love it and love life, but it wasn't always this way.

abrenrn · Dec 23, 2002

Thanks flowerchild.

Did you ever notice how hospitals, journals, professional organizations respond to this increased stress? They try to teach us relaxation techniques, stress reduction techniques. I agree they are useful. At a certain level, though, you have to try to reduce the stress.

They say they are trying but I'm not sure I believe them. It's a lot cheaper to teach a stress reduction technique than it is to hire more nurses.

Youda · Dec 23, 2002

Just a semantical addition:

It isn't stress reduction that is taught, it's stress MANAGEMENT that is taught. No reduction, just techniques to handle the same amount of stress, or more of it. I've had some success with stress management, but the best stress reduction is to go on Sabbatical. Sure hope that when I need a good nurse that they aren't all working at Taco Bell.

A few posts back someone mentioned fatigue. Of course that is a large part of depression, and fatigue can be caused by things other than depression. I don't feel depressed anymore (at least it's manageable now), but I still have the crushing fatigue. It isn't caused by the meds, because the low energy level has plagued me most of my life . . . yes, all the usual tests have been done. So, I guess my question is: is there anything to do to help the fatigue part of it? (I'd love to be bi-polar because I've already got the depression part of it, and it would be nice for a few days of energy!)

cargal · Dec 23, 2002

Youda,

I have been a victim of fatigue for most of my life too. That is my daughter's main complaint, and with the stress of being in a pressure cooker academic environment, the MD's treat her for depression. I am wandering however if it isn't something else. Our family MD stated he had a mild case of narcolepsy- can be treated w/ritalin, provigil, etc. He also stated there was a blood test for it, but I did an internet search and found that the blood test was not a good indicator, but I forget why. The site was a good edu site. It may have been Cornell or Stanford. I am definitely going to look further into it so HER life insn't ruined too.

Nursing & Depression

Nurses and Depression/Anxiety