What to expect when your brain wants to kill you - excerpt from: SLEEP

Sleep is the fastest way to escape depression. When I feel overwhelmed, I go to bed, where I can drop the Mask and silence The Critic. The worse the depression, the more worn down I feel, the more tired I get, the more I want to sleep. Denial naps during the day, early bedtimes, and late sleep-ins help fill the time without confronting the worst of it. 

The better I am managing, the less I sleep.

What to expect when your brain wants to kill you - excerpt from: VIRTUAL MENTAL HEALTH CARE

 

I have been asked many times what I think about virtual mental health care. My experience over the last few years has been mixed. Technical glitches are frustrating, and the effectiveness of video calls is definitely not the same as an in-person visit, but e-health is the way of the future, so here are a few observations.

One of my psychiatrists used Zoom technology during conference calls. Our appointments were very short. Our sessions include him, his psychiatric nurse, and a psychiatry student. I found all three faces looking at me at the same time unnerving. With an in-person session, I can focus on talking to one person, or, if I choose, I can just look at the space in front of my shoes. In the Zoom call, I felt obligated to look at everyone and into their eyes, which I found overwhelming. I tried to figure out what they were thinking instead of focusing on sharing my own concerns. I always shut down the conversation as soon as possible.


Other distractions didn't help the situation, such as the clock at the bottom right of my screen and my own face in the upper right. There were no clocks in my therapist's office, at least none that I could see. I didn't worry about finishing up "on time" or if I had wasted too much time on a specific topic. Also, my therapist's office doesn't have a mirror. Seeing my face online was distracting. It broke my train of thought, especially since I was wearing noise-canceling headphones. I looked ridiculous.

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What to expect when your brain wants to kill you excerpt from: PETS

My first pet as an adult was Charlie, the cat. Shawna and I had been married for a few years and decided we needed a "real" pet (not a rodent). We went to the humane society and chose an older cat no one wanted. Kittens are adorable, and so are always the first to be adopted. I remember being nervous as they interviewed us to ensure we qualified as responsible owners. My wife had cats and dogs growing up, which helped our cause. Anyway, despite my anxiety, we were allowed to bring Charlie home.

I loved that cat. She was so calm and easygoing. I loved how she would jump up on me when I lay down. She would gently knead my chest with her paws for a couple minutes, then curl up and settle down. I could feel her purr against my heart. It was such a soothing sound. Charlie was the closest I have ever had to a therapy pet.

Then we got Sam. He was a rescued kitten. He was fun and a ball of energy and would cackle when excited. Unfortunately, he never really settled like Charlie did. He also was not as calm or cuddly. Later on, he developed a nasty habit of marking his territory. The smell was disgusting, so Sam became a source of anxiety. He was not affectionate with the kids and never let you pat him for any length of time. Sam lived a very long life. In the end, he looked like a zombie with skin and bones. Then, one day, he curled up in the shade beneath a table outside, closed his eyes and passed away. He didn't seem to be in any pain. Sam just knew his time had come. I hope I can do the same.

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What to expect when your brain wants to kill you excerpt from: THE MASK

"Were you bullied as a kid?"

I've been asked that question a lot, especially by Pdocs and therapists. I'm not really sure why. I know my dad was. Someone shot a firecracker at him when he was little. I know my friend was after he did a whoopsy in his pants on a Grade 6 field trip. I've seen people bullied my entire life, both adults and children, but I have never been the target.


I guess the Pdocs and Therapists were trying to establish if there was some childhood trauma that could inform my depression. I told them nothing was there. My childhood was happy with no need or want. My only fear was that of being bullied, and I took steps to protect myself.

I watched in silence as others were attacked. Empathy would surge through my veins, but never with enough courage to help. When they were bullied, I was too. I made note of the target, his tragic flaws and what made him so susceptible to abuse. Then, I made sure I never made the same mistake myself. I internalized what I saw and shared in the shame and tears, all the while doing my best to blend in so as not to be the next target. I'm sorry to those I let down. I should have been there for you. Instead, I ran away and hid behind my mask (figuratively, not literally). I adjusted my expression and manner based on whoever I was with. People saw in me what they expected. And it worked. I was never bullied.


Over the years, though, I became my own worst enemy. Behind my mask, The Critic was relentless in his criticism and ruthless with his words; he cut me down again and again, draining me of my worth and self-compassion (see chapter on The Critic). By trying to hide from bullies, I created my own, worse than I had ever witnessed.

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What to expect when your brain wants to kill you excerpt from: CHRISTMAS

When you only see some people once a year, it is natural that after the initial Merry Christmas greetings, you compare resumes. "So, what have you been up to?" What should I say? I took a ten-week course on Skills for Safer Living with six other people, all of whom have attempted suicide in the past, just like me? It's not a good way to start a conversation. Nor is telling someone you're trying a new anti-anxiety pill that seems to work well. Once I ignore my depression and SI, there is nothing over the past year worth talking about; at least, that is what the Critic tells me. (see Chapter on The Critic).  

It might sound counterintuitive, but once I have my drink in hand - usually a beer. (What am I saying? It's always a beer.) I try to stay with a group of people. This way, you can watch and listen without participating. Let others do the heavy lifting and carry the conversation forward. No one will notice that I am not part of the discussion. If they ask me something point blank, I just nod and agree. 

My favourite Christmas Eve - more of a construct than a memory - is sitting alone by the fireplace, with a lazy flame dancing on a log. The tiny coloured lights on the Christmas tree scatter a cozy, warm hue. In my hand, I am sipping a Baileys on ice. In the background, choral carols float quietly, blessing the space. Everything is calm. My mind is clear. Everyone else is already in bed. I'm the last one to turn out the lights.

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What to expect when your brain wants to kill you excerpt from: POETRY

 

 

I enjoy writing.  I like expressing my thoughts on paper or on my blog.  I wish I could get more people to read my stories and poems, but that's not why I write.

I have written a couple of novels.  They have been revised over many years.  I have been tinkering with one since university.  I have carefully sculpted the other over the last 20 years.  Neither has been published.  I have tried the Literary Agent route, which is very frustrating.  You wait so long only to get a form letter rejection.  I understand why.  The number of "writers" worldwide has grown exponentially since the advent of word processing programs and the Internet.  Literary agents are inundated with story pitches.  I'm sure they can barely keep ahead of the avalanche.  I'm not criticizing them, but rather just sharing my observations.

The non-literary agents in my life - friends and relatives - advise me to self-publish.  I am reluctant for a few reasons.  First, Literary Agents want to avoid handling spoiled copy.  They want the princess to be intact, so to speak.  If I self-publish, my novels will be sullied.  It is an all-or-nothing strategy.

Second, to self-publish successfully, you need to be able to promote yourself.  All authors do marketing, but if you have a Literary Agent, you have some guidance and access to tools unavailable to lone wolves.

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What to expect when your brain wants to kill you excerpt from: Major Depressive Disorder - A PRIMER

 

Major Depressive Disorder is a severe mental illness which affects 7.6% of the population or nearly 2.5 million Canadians (Statistics Canada).  It is a deadly disease which kills, by way of suicide, between 2% to 7% of those suffering from the illness.

The percentage of Canadians 15 years and over who have had a major depressive episode in the past year has increased substantially over the last decade.  In 2012, 4.7% met the diagnostic criteria, compared to 7.6% in 2022.  Young women between the ages of 18-24 were most likely to report suffering from MDD (18.4%).  Among males in my age group (45 to 64), the prevalence is 5.4%.

The most common symptoms of MDD are :

• Depressed mood

• Feelings of guilt, worthlessness, helplessness or hopelessness

• Loss of interest or pleasure in usually-enjoyed activities

• Change in weight or appetite

• Sleep disturbances

• Decreased energy or fatigue (without significant physical exertion)

• Thoughts of death

• Poor concentration or difficulty making decisions

My primary symptoms are a constant and overwhelming urge to plan and complete suicide, a feeling of being useless and worthless, being overburdened with stress and anxiety, being paranoid of the future, feeling hopeless in the present, and regretting my past. My mind is constantly fatigued by a barrage of destructive thoughts. I'm often exhausted by the noise in my head.

The diagnosis of a mental health disease is unique from other medical conditions. Since there are no objective tests that can be given, it relies on the skill of the psychiatrist or family doctor and the honesty of the patient. Don’t embellish your symptoms or dismiss them as inconsequential (as I did). The only way you will get better is by building trust and sharing how you really feel. By listening to your words and observing your behaviour, a doctor can provide an effective course of treatment.

 

I was first diagnosed with the PHQ-9. Pfizer released this screening and monitoring questionnaire in 2010. It consists of 9 questions, which are designed to gain insight into a patient's thoughts and feelings. It asks, "How often have you been bothered by the following over the past 2 weeks?" It covers 9 different symptoms of depression ranging from appetite to sleep patterns, from self-esteem to suicide ideation. Each answer is assigned a score. The total of all nine questions identifies the level of depression the patient is experiencing.

The first time I filled out this questionnaire, I was identified as severely depressed. Even today, with my depression somewhat managed, I score between moderate and moderately severe. 

 PHQ-9

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What to expect when your brain wants to kill you excerpt from: STRATEGIES

This Chapter covers many strategies I have been told over the years.  All of them are Therapist/Pdoc approved.  I wrote specific chapters on CBT, Exercise, Self-compassion, Therapists and Music because they are the most helpful.  For unauthorized strategies, see the Chapter on the 10 Rules of Suicide.  

All of the following are effective in some shape or form, but for them to be truly beneficial, you must make those that resonate with you part of your daily routine.  They must be deeply integrated so that when you need support, a pause or a break, or even just a distraction to get over a crisis, big or small, you will instinctively choose the right strategy for you at that moment.  Many of these I don’t embrace that tightly.  I hope listing as many as I can remember will give someone else an option they never considered.

Let’s start with ice.  Before I experienced modern psychotherapy, I equated Psychiatric Hospitals with 19th and 20th Century Insane Asylums and their notoriously harsh treatment of patients.  I have a vivid image in my head of a patient screaming and crying as they were forcibly put into an ice bath and restrained in place.  It was a technique used regularly as much as a punishment as a treatment.  As it turns out, though, ice baths significantly affect a patient’s physiology.  They are routinely used by athletes to reduce muscle soreness and inflammation and to enhance recovery.  For patients, if you put your face in ice water and hold your breath, it triggers the dive reflex, slows the heart rate, calms the nerves and makes your body conserve oxygen. 

I don’t like being cold.  The only ice I want is in a drink, so the idea of an ice bath is abhorrent.  Nevertheless, I’ve always been open to trying different strategies at least once, so one day, when I was agitated, I tried it.  I filled a large bowl with water and a couple handfuls of ice.  I then bobbed for apples, or in this case, ice cubes.  As expected, it was not pleasant.  Perhaps it would have been refreshing if it had been a hot day.  As it was, it immediately distracted my thoughts.  Bracing.  As a strategy, it was effective, but as a viable option, I would have to pass.  There was too much involved in setting it up.  When I told my Pdoc I tried it, he was actually surprised.  He rarely had patients act on his suggestions.  He was more inclined to trust medication, especially PRNs, in such situations.  (See Chapter on Medication )  I won’t dismiss this strategy out of hand, but if I ever use it again, it will be in desperation.  

...

What to expect when your brain wants to kill you: FAMILY DOCTORS

My father was a family doctor, so for most of my life, I never needed one. If I required any care, I was treated at home. I used to get allergy shots when I was a kid. Once a week - every Thursday - right after dinner, when he had finished his tea, my dad would give me my needle. If I had a fever or a bad cold, he would reach into his old black doctor’s bag and dispense antibiotics.


My dad was a minor celebrity in my small hometown. As a teenager, I was often introduced as “Old Doc White’s son.” I was not always thrilled by that moniker - especially when my high school history teacher used it - but as I’ve gotten older, I’ve learned to cherish such an honour. He was probably the last doctor in our community to do house calls and to visit his patients in the hospital. He set a very high bar for bedside manner.


I have lived a remarkably healthy life - at least physically and so after I moved away from home, there was no urgency to find a new family doctor. Then, one day, I was overcome with a visually impairing headache. I suffered a week before I finally gave in to my wife’s demands and went to a walk-in clinic. After an hour’s wait, I saw the doctor, who seemed less than interested. He poked a little, massaged my neck and then told me flat-out that I didn’t have meningitis. “How wonderful”! I thought. Too bad I still had a splitting headache.


I was then presumptuous enough to ask point blank what it could be, and the doctor proceeded to rhyme off a list of “don’t bother me” options, concluding with “God Only Knows.” He never even gave me any treatment options. I asked if I should take Tylenol, and he shrugged and said, “Sure. You could try that.” I was so frustrated. I could have made the GOK diagnosis myself. The agony lasted two more days before my head finally cleared. That’s my rule now: always wait 10 days before going to the doctor because chances are it’s simply a case of GOK and will clear itself up soon enough.


My father once told me that when he was in medical school, they said to always look for horses first, not zebras; that is, to look for common explanations for symptoms rather than exotic ones. Seems sensible enough, but in this day and age of advanced diagnostic imaging, the concern of missing a zebra is far more important than identifying a horse. Saving a life is what really matters. I’ve never been a zebra. I’ve never been diagnosed with a “real” disease.


I’ve been to a couple more walk-in clinics throughout my life with always the same result. I’m always told what I don’t have and made to feel foolish for wasting their time.


I didn’t have a family doctor until I was in my late forties. I probably would not have had one if it was not a prerequisite for a job I was applying for. To be an Educational Assistant. I needed a doctor’s note that said I could manage physical labour. I literally did a Google search and found a doctor accepting new patients. I didn’t realize how fortunate I was. More than one in five Canadians - 6.5 million people don’t have a family doctor they see regularly. (CMAJ April 24, 2023) For me, to find one first try was actually remarkable.


Our first appointment was fast. She asked why I was there. I said I needed a doctor’s note that said I was physically fit. (This was before I gained all the side effect weight. (see Chapter on Medication)) She looked at me and wrote the note. No blood pressure check. No blood tests. No little hammer on the knee. She didn’t take down any family history or medical history. I asked if I should have a complete physical at my age. She explained that they don’t do that anymore. She fit the modern mould of a family physician: quick and to the point. I was in and out in three minutes with my letter in hand. I was not overly impressed, but it didn’t really matter. I got what I needed.


A few years later, when my depression and SI became acute, I reached out to her for a second time. I’m not sure why - I barely knew her - but I’m glad I did. Right from that first mental health visit, her priority was to help me build a safe and supportive network. She encouraged me at each appointment to tell my wife I was struggling. I didn’t want to be a burden on my family, so I resisted revealing my condition. In the end, though, my family doctor’s persistence prevailed. I told my wife. It was an awkward conversation, but when it was over, it was a relief. I also told my closest friend, whose consequent support was limitless. He was with me every step of the way.


My family doctor also worked on expanding my safety and support network with specialized mental health services. She put me on waiting lists for psychiatrists, mood disorder clinics, and urgent care services. Most wait times were a year or more, and I was discouraged, but she promised to be there for me, to listen and counsel as best she could. Unlike other health services (see chapter on Therapists), there was no limit on the number of visits I could make to my family doctor. In those early days, my appointments were quite frequent. I cannot thank her enough. Without her help, I wouldn’t be here today.


At our appointments, I would rattle on about my rules of suicide. (see Chapter on 10 Rules of Suicide). I know she was uncomfortable with how close my safety plan was to action. At a loss for medical solutions, she relied on her compassion and encouraged me to keep coming back. She actually made my next appointment for me right there in the office, so I didn’t have to talk to reception. My anxiety at that time was as high as the SI. I went in once, twice and sometimes even three times a week. She knew it was not sustainable. She could see me struggling.


She then prescribed medications. I was at first taken back. Was I really that sick? She assured me I was. I hate taking any kind of medicine, but I trusted her judgment. (see Chapter on Medication). We tried, but there was very little relief.


After months of waiting, she finally got me an appointment with Urgent Mental Health Care at the hospital. It was an outpatient service. There, I saw a pdoc and a therapist. Ultimately, they were not particularly helpful, but it was a start.


My Family Doctor remained my primary care provider until I took it too far. I had been collecting crushed peach pits as a possible method of suicide. (see Chapter on Ten Rules of Suicide, see Chapter on Methods & Means). One night, I came home from tutoring to an empty house. In the moment, I consumed all I had collected. It was an SI impulse that didn’t have a reason. It was to no effect. I clearly needed significantly more powder. Anyway, I was relaying this story to her without really thinking about it until she asked, “You took it?” I nodded my head and was immediately upgraded from Suicide Ideation to Suicide attempt.


She issued me a Form 1, which is an application by a Physician for a Psychiatric Assessment. In Box A – Section 15(1) of the Mental Health Act – Serious Harm Test, she checked off: “has attempted or is attempting to cause bodily harm to himself or herself” And also: “I am of the opinion that the person is apparently suffering from mental disorder of a nature or quality that likely will result in serious bodily harm to himself or herself.


She printed it up on the spot and signed it. She then gave me the Form and told me I had to stay in the office until my wife could come and take me into custody. If I tried to leave, she would call the police. I waited in the examining room alone. I was terrified. I had no idea what would happen. When my wife arrived, she drove me straight to the hospital. (see Chapter on Hospitals) She said I suddenly looked very old. I felt it. Exhausted.


When I got out of that first stint at the hospital (see Chapter on Hospitals), I went back to my family doctor and relayed all the new meds and strategies I was on. (see Chapter on Strategies) I was definitely in a better place than I was before, though I still relied on my Ten Rules of Suicide to keep me safe (minus the peach cobbler). At that point, I had an excellent therapist through my wife’s EAP, whom I gave permission to communicate with my Family Doctor. They both knew I was still dangerous.


Everything stitched along until, at one of my Family Doctor appointments, I mentioned how I had booked a room at a hotel two weeks out. The strategy was I would set a date for suicide so that I was safe all the other days leading up to it, and then the day before, I would cancel the hotel room and book another date three weeks later. (see Chapter on Ten Rules of Suicide). She was very uncomfortable with my plan. After I had left the appointment, she had a change of heart and wanted me to check myself in at the hospital. She tried to call me. Unfortunately, I had gone out for lunch with my friend. She didn’t have my cell phone number, so she anticipated the worst and called the police to take me into custody and deliver me to the hospital. (see Chapter on Hospital.)


It was one of the lowest moments of my life when the police stood me up against the squad car, arms and legs spread wide, as they frisked me in front of my neighbours (see Chapter on Hospitals). At the hospital, all the other mental health patients in the psych ward were aghast at what I went through. Some had similar stories about a police interaction being a little ham-fisted. Others told me that I got off easy in that they didn’t handcuff me.


Most patients thought her actions were egregious and that I should get a new family doctor. But in the end, I didn’t really blame her. I felt that it was my fault that I had said too much. I didn’t hesitate to go back to her. She said she felt bad for calling the cops, but she was very concerned for my safety. She didn’t apologize, but I accepted her reasoning. I didn’t hold a grudge. She has since become less of a support to my mental health. I have moved on to more specialized therapies and pdocs and have been officially diagnosed as having a Major Depressive Disorder and OCD.


I was lucky to find a family doctor who was willing to give me the time I needed and who worked tirelessly to get me the mental health support I required. I think we both learned a lot on that journey. In fact, she is the one who suggested I write this book.

What to expect when your brain wants to kill you: MEDICATION

Prescription medicine is a subject of much debate among mental health patients. Some view it as an unnecessary addiction with zombie-like side effects, while others consider it a lifeline to calm and their only chance of recovery. I have been told that no one, including Psychiatrists, knows precisely how this class of drugs works. It’s not as simple as replacing a chemical deficiency in the brain, as we are sometimes led to believe. Moreover, each drug has its benefits and possible side effects.

Many people have managed their depression through lifestyle changes and natural remedies. If this works for you, keep doing it. I’m not trying to persuade anyone to take psychiatric pharmaceuticals.  Likewise, if you need medication, don’t consider it an admission of failure; that you are somehow less of a person because you need it. Medication has nothing to do with strength; it is more about symptoms and relief. Find what works for you.

I am purposely not going to refer to any drugs by their name. What has worked for me may have an entirely different outcome for someone else. You have to be open to change.

I have not taken many prescription medications in my life. In fact, prior to the last seven years, I had only ever been prescribed antibiotics. So when my Family Doctor first suggested medication to manage my depression, I was a little taken aback. Was I really that sick? I hesitated for a few weeks but quickly found my symptoms were becoming unmanageable. In the end, I trusted her judgment. (see Chapter on Family Doctor)

 

The first drug we tried didn’t go well. To make matters worse, I didn’t tell my family doctor about the side effects I was experiencing; I had terrible stomach cramps but did my best to persevere. I didn’t realize that had I reported my side effects right away, she would have changed the medication immediately. I thought I was being heroic when, in fact, I was just being stupid. 

Most Family Doctors and Psychiatrists have their favourite drug combinations, but there is no reason to endure a severe side effect and suffer in silence. For medication to be effective, you must be open and honest with the doctor prescribing it. Tell him or her everything you’re experiencing, even if it is nothing. Side effects are not consistent across all patients. You have to tell your doctor how the medication is affecting you. Don’t settle just because they do. Let them know.

  

Over the last few years, I have tried many different medications and experienced many different side effects, everything from dry mouth to a brain fog, from an insatiable appetite to stuttering. It took a while and a lot of faith in my doctor’s intentions to continue following a path of trial and error. Every new drug had to be started with the smallest dose and titrated. I would spend weeks slowly building up the amount of medication in my bloodstream only to decide the side effects outweighed the impact of the medication in question. I would not take it strictly for the sake of taking medication. It had to provide some relief with minimal side effects.

Most doctors informed me upfront of potential side effects. The worst was when Pdoc told me a known side effect was death. That makes you take a pause! He told me that when I was on the drug, I would have to have monthly blood tests to ensure that my white blood cell count remained robust. This is the most helpful medication I am on. I have prominent veins, so it makes for an easy routine of “bloodletting.” Even better, the specimen collection lab is just down the hall from the patient pharmacy. This side effect is easy to mitigate.

Another extreme side effect is suicide ideation. Ironically, some of the side effects of mental health medications are indistinguishable from the disease. Don’t let this apparent oxymoron deter you from trying. Keep in mind that a potential side effect of Tylenol is a headache, and Viagra may cause blurred vision or make it challenging to tell blue and green colours apart. Just because a drug has specific side effects does not mean that everyone who takes it will experience any or all of them. If your symptoms don’t improve or the side effects worsen, tell your doctor and move on to another drug or take a different approach altogether. (see Chapter on Therapists; Chapter on Strategies)

The following are the top 5 worst side effects I have experienced on my mental health medication journey.

5. Vivid dreams and brain sparks.  Whenever I lay down, I would instantly be caught up in an all-consuming, vibrant-coloured, hyper-realistic dream. And when I wasn’t asleep, there were random lightning flashes behind my eyes or, as I called them, brain sparks. While I found these side effects fascinating, I was worried they were a symptom of some hyper brain activity that, over time, might cause permanent damage.

4. Deep sleep.  This one was more of a nuisance than anything. I would sleep so deeply that I would frequently wet the bed. I also drooled on my pillows, experienced night sweats and snored. A real treat for my wife. I ended up sleeping in my own bedroom in the basement, separate from the rest of the family. It was embarrassing and depressing. My self-esteem plummeted. For a time, I wore adult diapers to bed and washed my bedding every morning. My drool would soak through my pillows and leave a musky odour. Eeew!

3. Loss of sexual desire.  This was not a performance issue that could be addressed by Viagra or Cialis. Believe me, I tried. Instead, it was one of desire or worse. Intimacy never even crossed my mind. Interest in physical contact vanished. I was chemically castrated. Provocative images, words or sounds no longer inspired me. It was as if desire had never existed. What made it even worse was that I didn’t even realize what I had forgotten until I purposely stepped back and thought about it. I feel cheated.

2. Overeating and rapid weight gain.  For my entire life, weight has never been a problem. I was very lucky. If I gained weight over Christmas from all the treats, chocolates and nuts, I could easily lose it all by mid-January by simply eating sensibly. I had never had to diet. But when I went on one particular med, I gained 25 pounds seemingly overnight. I suddenly had a middle-aged “beer belly” distending over my waistband. I hated what I saw in the mirror and felt embarrassed to swim. This side effect was devastating. It took me a long time to claw back half of what I gained. My body image still suffers. The Pdoc did warn me about weight gain, but considering my past experiences, I didn’t anticipate it would be a problem. I was wrong. The fact I am no longer on this medication (because it didn’t help) makes this side effect all the more disastrous. I still have to live with it.

1. Lethargy.  The worst side effect I experienced was when I was left sluggish and apathetic. Everything was heavy. Lead coursed through my veins. When I tried to speak, I could not find the words. My brain was filled with cotton batting. My short and long-term memory struggled. This side effect was worse than the disease. Sure, it stopped my emotional swings, anxiety, and suicide ideation, but all it left was a shell. It was not a side effect. It was replacing one disease with another. What was the point? I didn’t stay on this med for long.

I still live with some side effects in varying degrees, but none of them are debilitating. Am I cured? No. I’m still in therapy, and I still take my meds, but at least now, a somewhat normal life seems possible. The medication helps to calm my baseline emotions. 

There is another type of medication that is designed to help with acute anxiety. These drugs are called PRNs (Pro re nata - Latin for “the thing as needed.” My degree is finally worthwhile (see Chapter on Latin.) In other words, it provides immediate relief. I have never needed such medication, so I can’t offer much insight. I have always been more of a slow burn than a flash pan. I can manage my anxiety with CBT (See Chapter on CBT) and other strategies. (see Chapter on Strategies)

One of my rules of suicide (see Chapter on The Rules of Suicide) is that I can’t go off my medication. If I’m going to make an attempt, the decision must not be based on some sort of withdrawal. The one time I went off my meds was completely unintentional. I went away for the weekend and forgot to bring along my psychotropics. The first day and first night were fine. I barely recognized a difference. But on the second day, I felt off. My brain was light-headed. I had a mild headache. I lost my appetite. Nothing terrible, just off.

On the second night, when I usually take my strongest medication, the terrors broke free. Dark and shapeless shadows, long and stretched, chased me down a never-ending corridor. No matter how fast I ran, I couldn’t get away. Then they grabbed my feet and dragged me down the bed. I tried to scream out, but I couldn’t make a sound. I tried a second time. I screamed louder and broke through the dream. I found myself screaming in real life. My wife woke me up several times because I was so loud. 

It took a day or two after restarting my meds for things to feel back to normal. At least now I know what will happen if I suddenly stop all my medication. I suspect the third day and night would have been worse; the shadows would begin to pursue me in the daylight, and the demons would devour me beneath the moon.  

Whether you decide to use medication or not, remember it is not a panacea. I had one Psychiatrist tell me drugs are only 30% of the solution and that exercise alone has a similar level of impact on improving mental health (see Chapter on Exercise). Ongoing therapy (see Chapter on Therapy), that is, talking to someone who is willing to listen, is also crucial to recovery, as well as mindfulness, Cognitive Behavioural Therapy (see Chapter on CBT) and other strategies (see Chapter on Strategies).

Recovery will require more from you than simply taking a pill with water. Success is non-linear. There will be many setbacks. The key is to pick yourself up and keep trying. When I finally found the right combination of medications, the Critic settled enough that I could hear myself think. (see Chapter on The Critic) It gave me the strength to look beyond the current crisis and to even consider a happy life. It’s not enough, though. I know I need more help. The SI is still the default in my brain. Suicide is still my destiny. 

I just want someone to teach me how to lead a happy life.  

I’m sorry, but it does not come naturally to me.

What does is the constant bombardment 

of what I’ve done wrong, 

am doing wrong 

and will soon fail at.

You’ve given me the drugs to consider success 

but not the tools to succeed.  

And so I go where my thoughts always have, 

to the pull that promises relief.

What to expect when your brain wants to kill you: PDOCS

When you mention mental health services, the first provider that usually comes to mind is a Psychiatrist (Pdocs for us in the know, "shrinks" for those over 60). My experience with this profession is decidedly mixed.

First things first, get the traditional image of a psychiatrist out of your head.  There are no couches or notepads or ink blots or even a cigar, for that matter.  On your first visit, they make it very clear that they are primarily Pharmacologists.  Their specialty is medication, not therapy.  I have often heard complaints from other patients that psychiatrists are only interested in pushing pills.  I admit I said the same thing when I first started on this journey.  I have since realized, at least from my experience, that they are supposed to do that.  Complaining about a psychiatrist always prescribing pills is like complaining about a dentist who only cares about your teeth.  Psychiatrists are what they are.

If you’re looking for therapy, not medication, you must see a therapist.  (see Chapter on Therapists).  A psychiatric appointment does not typically allow for deep discussion.  I saw one Pdoc who started our first session by saying, “I only have 15 minutes, so don’t go into too much detail.” She wanted the current problem with no backstory, pronto.  I spoke as quickly as possible and brought up my mom’s Alzheimer’s.  The Pdoc stopped me right there and pointed out that we had already discussed this at a previous appointment.  She said it as if I had missed the obvious that talking about an issue once would make it magically disappear.  I learned to shut up at my appointments and just talk about the effects and side effects of the wondrous drugs she had prescribed.  The Pdoc was much happier that way. 

Another psychiatrist kept answering his pager during our session.  Clearly, there is a shortage of psychiatrists, but that doesn’t change the fact that he made me feel entirely unnecessary.  It was as if he already knew which medications he would prescribe me before I even sat down.  In his mind, he already knew “the story.” He didn’t need any details.  As I described my condition, he nodded his head and repeated vague validation statements such as “Oh my!” and “That must be frightening.” His frequency undercut his purpose.  The words were there, the empathy wasn’t.

Psychiatrists are primarily interested in compiling a list of acute symptoms, which they can then use to select the most appropriate medications.  Follow-up visits then focus on the side effects and the benefits of the chosen drug and whether or not there is a need for a dosage change or a different medication altogether.  It is like going to the eye doctor when he changes the lens and asks, “Is this better that this?  What about now?  It this better?” The only difference is you can tell the eye doctor right away which prescription is the most in focus.  A pdoc writes a series of scripts and then slowly titrates the dosage over weeks and months.  If there is no improvement, the Pdoc will recommend a different drug and start over with the smallest dose.  (see Chapter on Medication). 

I respect Psychiatrists for what they are, and I know that I would not be able to write this book without my current medications.  That said, there does seem to be a bit of alchemy involved in the prescription process.  No one really knows how psychiatric pharmaceuticals actually work, so selecting the right medication for a patient is not as simple as prescribing antibiotics.  I have had experience with several Psychiatrists.  In fact, I have seen a total of nine different Pdocs in my life, as well as two more student Pdocs, most within the past five years.  This was not by choice.  My hospital visits availed me of such variety.

I found it troubling that each doctor seemed to have their own drug preferences.  In fact, I often had to sit and listen as one Psychiatrist would tell me why another psychiatrist’s prescription was wrong.  One doctor, for example, saw no sense in breaking pills in half.  His attitude was to go up a full dosage no matter what.  He also guffawed when he heard I was on lithium.  He told me it was little more than a vitamin at a low dosage, and I was promptly taken off it.  I remember how he stroked his beard with satisfied confidence when he revealed which “flavour” of medication he thought was best.

The very next day, I saw another psychiatrist who prescribed a different drug altogether.  The most bizarre Pdoc interaction I ever had was when a Psychiatrist asked me what drugs I wanted.  He tried to prompt me, “How are you sleeping?  Do you want something to help you sleep?  What about anxiety?  Do you want something to settle your nerves?”  

How would I know?  Did I look like an experienced brain med user?  I just shrugged my shoulders and said, “I don’t know.”

The lack of follow-up was even more frustrating than the variety of medications.  I was monitored for benefits and side effects in the hospital, but once I was discharged, that was it.  Unlike my wife, who was given a very specific three-year appointment schedule for follow-up after her cancer surgery, I was discharged with a bottle of pills and no follow-up appointments.  I was instructed to see my family doctor, who readily admitted she didn’t have a strong knowledge of all the psychiatric drugs available and was uncomfortable changing my medications.  I felt like I had been pushed out, and the door was locked behind me.

I got no follow-up treatment until I was accepted into the mood disorder clinic.  On my first visit, I saw two psychiatrists who independently confirmed my Major Depressive Disorder diagnosis by asking me an encyclopedic-sized questionnaire.  They covered every phobia, trauma, and loss I had ever experienced.  I was impressed at how thorough they were.  It was exhausting, but at least we ended up with a label.

After that, I became an outpatient and regularly saw one of the pdocs.  Only then did my medications become consistent and more effective.  What I found particularly reassuring was that if a medication had a side effect I thought was too severe, we immediately changed it.  (see Chapter on Medication).  This Psychiatrist didn’t have a favourite drug.  Instead, he was interested in finding which one worked best for me.

He was the one I surprised with my last major attempt.  I had fooled him with my persona.  He didn’t recognize the Critic (see Chapter on Critic) nor understand the sense of satisfaction I got from being so unpredictable.  That time, I was taken to the hospital in an ambulance and was in the psych ward for two weeks and the psych hospital for 6 weeks more.  (see Chapter on Hospitals)  The Pdoc at the psych hospital was the best.  He prescribed the medication that has given me the most significant relief from my depression and anxiety.  (see Chapter on Medication).  I haven’t been hospitalized for 5 years.  I still see another pdoc every six weeks or so as an outpatient to ensure the medication continues to be effective.  I also have to have my blood tested monthly to ensure it is not damaging my white blood cell count.  

The Critic still lurks in the background, relishing the idea of surprising my Pdocs with a completed suicide.  (see Chapter on The Critic).  The Critic tells me they are arrogant and smug and that I can make them second guess their practice.  When my thoughts are distorted, this makes sense.

My perspective on psychiatrists is limited to those I could access free of charge.  My family doctor tried to find me a psychiatrist in private practice, but either the waiting lists were ridiculously long (years in length), or they outright declined my case.  Apparently, being suicidal was deemed too needy, and so I was turned away by at least one doctor, sight unseen.

My advice to those who want to access a psychiatrist is to have your family doctor put you on every waiting list available, whether that be urgent care, a mood disorder clinic or a psychiatrist in private practice.  If you want to see a psychiatrist immediately, the hospital ER is your only option.

Most pdocs I have worked with were arrogant and condescending.  Some were outright dismissive.  The same is true for regular doctors.  Bedside manner is severely lacking in health care today.  Perhaps it is the strain on the system, everyone being overworked and underfunded.  I have been lucky of late.  I have assembled an exceptional mental health care team with a pdoc, a therapist and my family doctor.

Despite my own success, I don’t believe you need a pdoc to overcome mental challenges.  Medicine is not the only source of relief.  I think finding someone you can talk to is more important.  (see Chapter on Therapists).  You can’t manage depression alone.