Wednesday, July 29, 2009

Meds - Pt 2

Every evening I take between three and six pills --invariably two of Lamictal and one of Zocor (a cholesterol-lowering drug), to which I often add one or two Klonopin and occasionally one Ambien.

Even after all these years, I still find this a little strange. From an early age I disliked the very idea of taking anything stronger than the occasional aspirin or cold medication. I didn't begin taking psychotropic medications on a consistent basis until my mid-thirties, and I somehow doubt I will ever get used to it. I've just learned to accept it as a fact of life.

Little in my civilian background equipped me to deal with bipolar disorder. Within my family a taint of shame and weakness, usually covert but hard to miss, attached to it with regard to my mother. It was not much different when I was diagnosed in 1986. Most of my friends just sort of fell away, as if my life were over and I was no longer worth the investment. Many years later, when my life was on track and the bipolar disorder obviously in hand, I became reacquainted with one of these friends and asked what had happened. "We just didn't know what to do," she replied. Which was slightly odd coming from a devout Christian as well as a registered nurse.

Within academe scarcely anyone ever inquires about the disorder. I think it makes them feel awkward. And as I've written elsewhere, a common reaction is to consider it "inappropriate" for me to openly discuss it. Almost no one has said this outright, but an academic generally has a lousy poker face. Over the years it has been increasingly difficult to find a plausible alternative explanation. And of course I live in a society that still prefers to see mental illness as a character disorder ("Snap out of it!") or as an all or nothing proposition (you're either normal or you're abnormal).

Almost the only thing that has equipped me to handle the disorder is my experience with the Army. Back in basic training the Army drilled into me a vital core principle: You do what it takes to accomplish the mission. The aesthetics don't matter. You don't need to look like John Wayne. A manly attitude is irrelevant if it doesn't translate into effective action. It doesn't matter what other people think. The mission is everything.

A second thing the Army did for me -- as it does for most recruits -- is to show you that you are stronger than you think you are.

Even so, the need to be "normal," to be like everyone else, is powerful, particularly in young people who have not yet realized that no one is normal, that no one is like anybody else, and that we all carry wounds. Initially I took medications -- lithium and Imiprimine (an early antidepressant) -- for perhaps nine months, and even then without much conviction in their efficacy. It was tough on me psychologically. Taking the pills always seemed like a bizarre eucharist, a daily acknowledgment that I was now as broken as my mother had been.

Then for over ten years I took nothing. It took not only a brush with an unmistakable hypomanic episode to bring me to my senses. It also took the maturity that comes with being older and the basic confidence that comes with having securely established myself in life.

To my surprise, the first psychiatrist I consulted prescribed nothing stronger than a sedative to help me sleep. "You've had the disorder for eleven years," he pointed out, "and during that time you've gone to graduate school, gotten your PhD, succeeded in getting a faculty position, published a prize winning book, and gotten tenure a year early. Clearly you've been able to manage the disorder. So until I know more I'm not in a big hurry to put you on psychotropic medications."

Within a couple of months, however, the hypomanic episode had been succeeded by a depressive episode that seemed unrelated to anything in my day to day life and was sufficiently debilitating that it became difficult -- though not impossible -- to function normally. Certainly, though, I could not function at my usual level and on top of that, life seemed flat and meaningless. Small reversals suddenly loomed large. The memory of old failures and regrets constantly tugged at my thoughts.

So I consulted a second psychiatrist -- not because I disliked the first but because the second one was in my health care network. The first had not been. I wanted an antidepressant but I knew enough to recognize that an antidepressant alone carried the strong risk of vaulting me into a manic episode. Consequently I would have to take lithium as well.

In July 1999 -- precisely ten years ago, come to think of it -- I had a manic episode that simply blew through the lithium, and when the second psychiatrist somehow refused to accept this fact, I got rid of him and found the psychiatrist I continue to see to this day. I'll call her Jennifer -- it's hard to call her "Doctor" since we both have doctorates, although mine is merely PhD. Jennifer put me on depakote, which worked fine except that, as I mentioned in Part 1, it had the effect of ratcheting up my weight. When I discontinued it, I was startled by how rapidly my weight returned to normal.

As I indicated earlier, we substituted Lamictal and gave it the dual role of antidepressant and prophylactic against mania. But in the depakote years we tried and discarded any number of antidepressants after experimenting with different dosages of each over a period of months. There were so many I can't recall them all. Looking over a list of antidepressants, however, I recognize at least four: Celexa, Lexapro, Effexor and Wellbutrin. I'd bet money there were at least one or two others. [Update: Seroquel and Neurontin, though in both cases quite briefly.]

None of them, as far as I could tell, worked worth a damn. We finally hit upon Lamictal (even when I was on depakote). Lamictal is interesting in that you start with a negligible dose and it takes over a month to gradually ramp up to therapeutic levels. That's because in rare instances it has an undesirable side effect, namely a severe, life-threatening rash that from descriptions sounds practically like spontaneous combustion.

Fortunately I had no problems with it. It seemed to mitigate, though it did not eliminate, the depressions, and gradually we came to suspect that the depressions were often triggered and / or exacerbated by environmental factors, of which (perhaps) more in a future post. This past spring, however, although I was here at the Army War College, an environment in which I have thrived, I experienced a series of depressions in which the reprieves were so fleeting it was basically a single continuous depression lasting almost three months. We responded by doubling the Lamictal (from 100 to 200 mg per day). I've been fine since then.

Part 1 - Part 2


Barb said...

I'm glad the Lamictal is working for you, but I'm surprised you haven't gained weight, though I do know you work out regularly. When it was prescribed to me several years ago, I ballooned quickly, gaining about 45 lbs. A friend of mine who is currently taking it has also put on considerable weight. However, she and I are women, so maybe there's the difference.

Mark Grimsley said...


I experienced no weight gain at 100 mg / day. After doubling the dose to 200 mg / day, however, I rapidly gained about 15 pounds. During the same period I was traveling a lot and as a result eating at restaurants, grabbing meals at McDonalds drive-throughs, etc., so it isn't clear to me if the weight gain is causally related to the lamictal or merely a coincidence. Still, 15 pounds is a lot of weight to gain in a few weeks.

I did some checking, of course, and found that between 1 and 5 percent of persons taking the drug for bipolar disorder experience weight gain. This side effect does not seem to occur in persons taking it to control seizures. I've seen no data re men and women. Nor have I gained any insight into whether a person who experiences no weight gain at one dosage would experience substantial weight gain at another. (With depakote the weight gain occurs even at low doses.)

My solution has been to hold the lamictal dosage steady and carefully monitor my diet and exercise. That's the principal reason I recently joined WeightWatchers, which has a good system for doing both. Even before then I ramped up my exercise and was more careful about what I ate. So far I've lost 5 pounds, which is suggestive but not yet definitive. It'll be several weeks before I know for sure.

Thanks for writing.

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