Wednesday. Tabitha has her own PNP practice just a couple miles from my house, a small office with a couch and an easy chair. She sits on a large exercise ball and types into her laptop as we talk. She’s serious, but in a friendly way.
“So tell me why you are here,” she says.
I tell her I’ve been on psych meds for maybe 16 or 17 of the last 20 years, and although I’ve often functioned at a fairly high level, I’ve rarely felt well. I have been doing worse than usual since at least the middle of 2014, with ups and downs. I’ve about given up on meds and was thinking maybe I should come off entirely, although I was still willing to discuss other options as well.
Tabitha takes my history, mental health issues in my family, suicides? Birth order, well-being of my siblings. When I think about it that way, I realize I have one sister who lives in deliberate denial (“I don’t like to reflect on my life.”), one with an obvious anxiety problem and possible eating disorder, and a brother with depression and PTSD. I hadn’t really thought about our collective struggles that way.
She goes on, physical health, medications. She is impressed because I was able to bring her a list of all (well, maybe most) of the psych meds I have tried since 1995 and my reactions to them. Yes, I’m a researcher, and I collect and organize data on everything; it’s my nature.
It feels easy to answer her questions. She’s low-key and reacts to things at most with a sympathetic murmur. I realize how much it helps me to have psychologists and psychiatrists not show too much reaction to what I tell them. That way I don’t have to worry that I’m shocking, upsetting or disgusting them.
She’s surprised I am on such a high dose of venlafaxine (Effexor). She thinks it could be part of the problem. “You started it in October 2014 when things were getting hard, but it doesn’t sound like it’s helped.”
No, though I’d never thought to link it to the fact that the past couple of years have been worse than typical. I did, however, ask for a second opinion back in October of 2015 because I didn’t feel things were going well. And Sue, my previous psychiatric nurse practitioner, had dismissed that doctor’s suggestion that the venlafaxine wasn’t a good idea. I show Tabitha the results from the genetic testing that second opinion doctor conducted.
She glances at it and says she will review further. She would also like me to have adrenal and neurotransmitter testing. She says some people with treatment resistant depression don’t get a benefit from SSRIs because their bodies aren’t able to make the neurotransmitters in the first place, so working on the transmission is not sufficient. She talks about eating protein and vegetables, limiting even fruit. She talks about diet and supplements as a way to affect the way my body uses amino acids.
It all sounds very scientific, but I don’t have the background to know how to evaluate it (I’m a social scientist, and my knowledge of biology is not very sophisticated, unfortunately.) She says we’ll start with the adrenal and neurotransmitter tests (not covered by insurance) and some blood work (probably covered by insurance). I am to cut the venlafaxine by 20 percent starting this week. First goal is stabilization (getting out of bed before noon, eliminating suicidal thinking). Then we’ll work on building energy, adding in exercise, and further tapering off the venlafaxine. It’s a hard medication to come off of, she tells me. We’ll take it slow. I’ll see her every two weeks for a while until we know we’re moving in a positive direction. Over time we can think about different anti-depressants. Lamictal has been great for some people, but there are other options too.
“I’m hopeful things will get a lot better for you,” she tells me as I leave.
I raise my eyebrows skeptically, but I have to admit, I leave the appointment feeling that perhaps she’ll be helpful. She did radiate knowledge, professional confidence, and stability.
Friday. Two days with a lower dose of venlafaxine, and I’ve had some strange dreams but otherwise don’t notice much difference yet.
I realized yesterday that I’d not mentioned self-harm during my intake with Tabitha. It wasn’t a deliberate omission. She didn’t ask about it, and it slipped my mind. I wonder whether that makes a difference in how she thinks about medication.
I still want to be hopeful about Tabitha. On the other hand, she told me she would send me an email with a list of the blood work she’d like me to request from my primary care doctor. It’s Friday afternoon, and there’s nothing from her in my inbox. She said she’d send me a receipt from the appointment, and that hasn’t arrived either.
Maybe she will get to it over the weekend; she might be the type who does her follow-up paperwork and messages at the end of the week. Or maybe she is the kind of person who talks well in appointments with people but doesn’t have good follow-through. I’ll delay judgment a bit longer.