Sunday, January 6, 2008

When three out of four IS bad

My doctors and counselor have emphasized that there are four necessary components to my success in coping with depression and anxiety:

  1. Consistent medication
  2. Proper nutrition
  3. Regular exercise
  4. Adequate sleep

I suppose I could add that a positive attitude helps, but that's just not always possible, and I don't want to sabotage myself by requiring a positive attitude when depressed because that will just set me up for failure.

I'm consistent with the medication. I'm still taking generic Prozac, still at 50mg/day. I know that my ability to cope with each day is due in part to my staying on the medication; forgetting or missing a dose for whatever reason will impair my near future, and I'm the one who has to live with me.

I'm doing better with proper nutrition, in part because my husband is taking better care of himself and is therefore better able to help me with grocery shopping, meal planning, fixing healthy meals and so forth. If it were not for his contribution, there are many times I'm not sure I'd eat at all, much less eating healthy. Keeping kosher usually makes it easier to eat healthy. Sometimes it makes it harder, or at least demands more creativity. It is possible to make a fleishig (non-dairy) chicken pot pie from a treif (non-kosher) recipe, and have it taste good.

I noticed today, in fact, that I have lost some weight and the only major change I've made is eating better. Plus, I like how it feels and that buoys my mood too.

I am not a couch potato but I could do better about getting aerobic exercise. Cleaning house and chasing after children helps but is not quite the same as a workout. If only I had the room and the money to blog on a treadmill. Our health insurance now offers us a reduced membership at the local Jewish Community Center if I exercise some number of days each month. Time will tell if it is incentive enough for me.

And then there is sleep. Or no sleep. Like last night when I finally fell asleep at 5am and woke at 7am.

The Prozac, even when taken in the morning, will disrupt my sleep. It makes my already light sleep practically non-existent. My doctor tried me out with Lunesta, Ambien CR, and Rozerem, and only the Lunesta had positive results. Over the past few months, I've very gradually needed to increase my dose of Lunesta from 1mg/night to 4mg/night. Until recently, it has helped me get to sleep within less than an hour and sleep through the night, waking if I need to without feeling drugged or drowsy. It has brought dreams back into my nighttime, something that has been missing for over a year.

But within the past few weeks it has not been working as well. It's taken me longer to get to sleep and then I wake at 3am or some other middle of the night time and cannot get back to sleep. So I thought last night I would try going without it. Unfortunately, that meant going without sleep, too.

I know that Lunesta, like many sleep aids, does have a risk of dependency so that going without it may cause a few nights of interrupted sleep before the body's own sleep cycle takes over again. That appears to be the case with me. I don't see my doctor for another week, so I'm not quite sure what to do. What I know for certain is that I need my sleep. I need that REM sleep. I need more than 2 hours a night.

I'm doing pretty well on the 50mg/day of Prozac and there's no indication at this time that last year will repeat itself, despite my worries to the contrary. But staying out of the depression by using medication is resulting in less sleep, which increases my risk of depression, which might cause another meds increase, which will result in less sleep, which increases the risk....

It is enough of a challenge to live with the depression and anxiety/OCD, knowing there is no cure, only management. Why does treatment have to be so challenging too?

It maks me really wonder what G-d wants me to learn from this.


Keli Ata said...

I can empathize with you on dealing with chronic sleep deprivation. I have a number of endocrine problems which have contributed to my sleep problems; and I also have Restless Legs syndrome. For the RLS I take Tegretol which works pretty well.

For the chronic insomnia I take Ambien CR 6.25 mg, which helps. The regular Ambien upset my stomach too much. I have thought about Rozerem but I can't take it since that increasing your prolactin level and mine is already high because of my pituitary tumor. The last thing I need is more endocrine problems.

At first I wasn't crazy about the idea of taking any medication, especially for a sleep problem. But then I had a sleep study which showed I only got 90 minutes of sleep, had 7 comlete awakenings and zero REM. All of that was only contributing to my anxiety and depression.

Am I crazy about taking medication? Not really but my quality of life is important to me and without medication and not sleeping I could barely function. With the Ambien at least I can (usually) get five or six hours of sleep.

Keli Ata said...


Leora said...

What helped me the most with my many years of on-and-off depression was externalizing my angry feelings. At first, my therapist would just try to get me in touch with my anger. I don't know if you were raised as I was, to believe that anger was a bad emotion. I was certainly taught to be a good little girl. Anyway, I knew I was making progress when I was able to express some anger at a cashier; this sounds awful, but I did feel some release.

For health reasons, I carefully watch what I eat, but I've never found diet to make much difference with my depression. Lack of sleep definitely, definitely makes it worse!

Have you done any work with a therapist on getting in touch with deep, buried emotions? Has this ever provided any release for you?

Rivka said...

Keli: yes, it is difficult on many levels to accept that medication is necessary or good or possibly lifelong. At least for me. But I try to think about it the way I would want others to think about it.

I would never tell someone with diabetes that insulin was just a crutch and she should buck up and get over it. I would never tell someone with cancer that chemo is keeping her in a "victim mentality." Why should medication for a professionally diagnosed biological brain disorder be any different?

By the way, I did wind up taking the Lunesta last night. My body was exhausted but by midnight my brain was still wide awake. Not racing or anxious, but calm and observant and not interested in sleep. After 4mg Lunesta, I was asleep in less than ten minutes and slept six hours before waking.

Rivka said...

Leora: I was raised that anger was a terrifying emotion because when my mom got angry, I wound up anywhere between fearing for my safety for hours at a time to bruised and bleeding. I became afraid to express anger for fear I'd become like her.

There was so much going on with me as a very young adult that I had years of intense therapy, including dealing with the anger issue. It was only when much of the environmental stuff had been treated that it became clear there was an underlying chemical issue. Not to say that everything else is done and gone, but I am much healthier than I was even ten years ago.

Diet makes a difference in my mood especially if I eat something high in refined sugar. Or caffeinated beverages. Staying awake for Shavuos with coffee and cheesecake, for instance, is not always in my best interest.

Leora said...


It is so refreshing to hear the comparison of diabetes to mood disorders from someone else. My version is-- you wouldn't tell a diabetic: 'I can manage my blood sugar without insulin, so why can't you'? Actually a very good comparison, because some diabetics have managed to control their diabetes with diet, whereas others need the insulin.

I was diagnosed with a mood disorder around the same time that I started therapy. I find depression to be very intertwined between the environmental (how we were raised and deal with emotions) and the biological. My experiences with meds and moods would be a long post, so I'll leave this as is.

Have you ever read the
Igguret HaRamban
? I've always had a hard time with this letter (since I learned it quite a while back).

Keli Ata said...

Rivka: That's eventually the conclusion I came to. That medication was to treat an illness not unlike diabetes. Not a sign of personal weakness.

BTW, has Lunesta worked better than the Ambien? I am thinking of asking to try something else, perhaps with a quicker onset of action.

Years and years ago I was given a prescription for Dalmane and it worked wonderfully. Rapid onset and I got about 10 hours of sleep and awoke completely refreshed. Unfortunately because NYS institute that stupid law requiring benzodiazepines prescriptions be filled out on triplicate forms no doctor wants to prescribe it.

Ambien and Dalmane are both schedule IV controlled substances but Dalmane requires triplicate forms and Ambien does not.

Rivka said...

Leora: I have not seen it before but I looked at it now. I sense what it is trying to do, to guard against arrogance, which never did anyone any good. Where I have trouble is that one can take humility too far, as I'm sure many of us know. How do you guard against taking humility too far into self-degradation?

I'm sure when I am in a better space, I could find substantial support in halacha for not degrading oneself, but arrogance is so much greater a concern we don't hear about the other so often.

Rivka said...

Keli: My doctor tried me on Lunesta, Ambien CR (smallest dose), and Rozerem. The Rozerem did nothing. The Ambien CR worked too well and knocked me out for the better part of 48 hours.

Lunesta started out at 1mg/night would get me to sleep quickly but I still woke in the middle of the night. I kept at it, though, and gradually it worked well, though as I increased the Prozac, I had to increase the Lunesta as well (now at 4mg/night).

A few years ago I was also tried on Trazedone, which just left me dazed and groggy all the time.