On Medication: Managing with Mental Illness - Part 2 of 3

Talk Therapy

I don’t refill my Xanax prescription when it runs out, relying instead on weekly counseling. The counselor works out of a converted two-story house at the bottom of the hill on the periphery of Ithaca’s downtown. Driving through what looks like a residential neighborhood, I pass signs for a dentist and a chiropractor before finding street parking near the counselor’s office. She’s a serene, reserved woman with short salt-and-pepper hair and a sincere smile. She introduces herself and invites me to sit where I like. I pass a patterned yellow club chair and take a seat against the right armrest of an ornate Victorian-era couch of deep brown wood and aged, crinkled crimson velvet.

She seats herself across from me in a generic office-style desk chair, a hefty and austere coffee table sit between us. It supports only a box of tissues. This is going to be great (sarcastic font).

“Hello, Derek, it’s so nice to meet you.”

“Hello. Nice to meet you, too,” I reply.

“Tell me about why you’re here.”

I tell her about my recent mental health history, adding context from further back as necessary. Before delving further, she says, “Vet school, huh? What are they doing to you kids up there? I see a lot of your classmates.”

“Really?” I ask.

She raises her eyebrows, “A lot. Teachers too.” She shakes her her head with concern and adds, “It’s such a pressure cooker.”

I tell her about the hazing comment from my professor. Incredulous, she says, “That doesn’t seem productive.”

I snort, too loudly, and she gives me a quizzical look. “I agree.”

I’m reassured to learn that I’m not alone. Anxiety is insidiously isolating. I wonder just how many of my classmates and teachers are silently struggling as well, feeling uniquely broken when they aren’t alone.

                                                                               Illustration by Mink Ratcliff, www.hypercarnivore.com

Strengthened by the insight, I move forward with the appointment and we agree to meet weekly for the foreseeable future. It’s expensive, even with insurance, and every penny is borrowed. I cringe to think that I’ll be paying twice: once now, once later when I pay it back plus interest as part of my planned student loans. I console myself with the mantra that there’s nothing more important to spend money on than my mental health.

Burnout

Therapy alone turns out to be entirely insufficient. By the end of Block I, I’m a sparking electrical wire of anxiety and depression. Finals week proves to be among the most difficult 7-day periods of my life. I go through the motions, but I feel alone and impossibly heavy at the bottom of an emotional crater.

Illustration by Mink Ratcliff, www.hypercarnivore.com

At my lowest moment, the night before the last day of exams, I arrive home to find an envelope addressed in my mother’s handwriting. The return address says only “Nick” in a childish scrawl. I open it to find a dozen or so small pieces of construction paper labeled with random numbers and dollar signs. No message, no explanation.

I walk onto the porch and lean my elbows against the weather-worn rail. It’s autumn, but still uncomfortably warm. Holding the envelope in one hand, I pull out my phone with the other and dial my mom. While it rings, I stare absently into the distance, feeling a numb melancholy. She picks up.

“Hey mom. I got a letter...er, some mail today with Nick’s name on it. What is it?”

My mom runs an in-home daycare, originally started so that she could also provide care for her own aging mother and for my older brother, Jeremy. In his teens, Jeremy was intermittently housebound due to surgery and illness resulting from autoimmune disease and our father’s abuse. She’s grown into the job, and some clients describe her as a co-mother rather than a daycare provider. Nick is five years old and splits his time between his home up the street and what he considers his home with us. Having helped raise him and his older sister, we have become brothers.

“Nick came by the other day, unscheduled. Just popped through the front door and gathered some art supplies and told me ‘I don’t want you to see what I’m doing.’ He set up at the kitchen table and worked like the dickens. He covered up what he was doing whenever I came close. He looked very serious. When he was done, he gave me those pieces of paper with the numbers and said ‘I need to send Derek this.’”

Irritably, I say, “Okay...but what are they?”

Mom replies, “Nick told me ‘I hear you on the phone with Derek and I know he’s hurting and I want to help him and he keeps living too far away in Hamsterdam and Cornell and I can’t help him and so I want to send him money to help him get better.’”

I go still and have the sensation of being pulled out of my own internal world and see my context in an entirely new way. The love in the gesture wraps itself around my inner self and makes me feel warm, and light, and safe. I’m so deeply touched to be in someone’s thoughts. To matter to a child - my brother - thousands of miles away. I’m not alone on an island of unending personal pain, I’m a loved person having a very difficult time. I sit on the bare wood of the porch and weep.

Every time I talk about this experience in the future, I weep.

The day after finals week, I meet with the Associate Dean and ask how best to facilitate taking a year off from veterinary school, starting immediately if possible. She listens for a long time while I pour out what's been happening to me. 

Illustration by Mink Ratcliff, www.hypercarnivore.com

“I see that you’re overwhelmed." She wrinkles her brow and presses her lips together and her empathy is genuine. "Unfortunately, there’s no clean way to interrupt your curriculum except from summer-to-summer. Let’s try and work out a way to get you through this academic year.”

We work through schedule and elective options to give me the lightest possible academic load through my first year. There isn’t much wiggle room because the entire class is expected to hit certain benchmarks at the same time. She’s right - the non-traditional structure has no opportune breaks except summer.

We conclude that I’ll stick it out for the current term, take a light load of electives in the spring, and take the summer completely off (many vet students spend summers building their resumes).

She wraps up, “If, after the summer, you aren’t able to start back up, we can talk about the possibility of a year-long sabbatical.”

Diagnosis

Having a plan fortifies me, but it’s become clear that I need to take an additional step to manage my mental health. I speak with my counselor, who agrees that what I’m experiencing is above and beyond what talk therapy alone can address. I ask, “Am I really, really the kind of person who needs long-term medication to function?” (Spoiler alert: Yep.) I get a referral to a psychiatrist and make the appointment.

Illustration by Mink Ratcliff, www.hypercarnivore.com

One afternoon after Block II lectures, I drive back down the hill into the heart of downtown Ithaca. I enter a small office building through heavy glass doors with heavier brass handles. The psychiatrist’s reception area has a mural covering one wall. I take a seat opposite. It’s a tree painted in soothing tones and I count the branches several times during my wait. There are 27 tree branches.

I’m eventually invited to cross the hallway to the psychiatrist’s personal office and take a seat on that same sorta-comfy mid-century modern client chair that mental health professionals seem to always have. The psychiatrist is a trim, dark-haired, middle-aged man with a sensible tie and a neutral bearing. He sits opposite me and opens my medical record.

“So...” he pauses, references the record in his lap, “...Derek…you’re a veterinary student?”

“Yes.”

“I see a lot of your classmates.”

“That’s what I’ve heard,” I say. “Any thoughts on why? Nature or nurture?”

He replies without pausing, “There’s no data, but I’d bet it’s both. The selection process favors the most intense people. It’s rare to compete that intensely for only healthy reasons. Then, when you get there, it’s a pressure cooker. It’s as damaging as hazing.”

I snort, too loudly, and he gives me a quizzical look. “I agree,” is all I say.

After asking about my symptoms and making a few clarifications, he says, “I think we should try Lexapro first, it tends to be really useful for Generalized Anxiety Disorder.”

“Generalized Anxiety Disorder?” I ask. “Is that my diagnosis?”

“Yeah, GAD. It’s a mood spectrum disorder. Anxiety disorders are fairly common mental illnesses.”

Illustration by Mink Ratcliff, www.hypercarnivore.com

The labels rattle me. I’m relieved that what I’m experiencing falls into a known category, which means lots of other humans experience it and therapies exist. It also perfectly encapsulates my experience of constant anxiety aimed at nothing in particular. I suddenly realize, however, that I’m only comfortable with the terms “mental illness” and “disorder” in the abstract. When they affect other people. They hit me like hot darts and I’m not sure I hide a wince. Do I really have a mental illness? (Spoiler alert: Duh.)

“Geez! Feels weird to use those words about myself!” I say, putting on the fake-cheer mask.

The psychiatrist looks at me like he’s seen this mask at this moment many times. He says, gently, “Prescriptions treat disorders and illnesses. Those terms just mean things aren’t functioning normally. There’s no shame in a cold or arthritis, and there’s no shame in a malfunctioning brain. Knowing what we’re dealing with helps us address it. Lots of people blunt their anxiety with alcohol or more dangerous drugs; you’re taking a healthier approach and I applaud you for it.”

This helps. Still, the sensation lodges in my chest and stubbornly beneath my thoughts as he explains. “The key feature of GAD is excessive worry about multiple different events or issues for more than 6 months. For you, everyday events trigger a fear far out of proportion to reality. There’s some overlap between diagnoses. But, your anxiety isn’t focused on specific things and you don’t have any repetitive thoughts or behaviors, like in OCD. Also, even though you suffered mental and emotional abuse as a child, you don’t seem to be suffering from PTSD. Your triggers change over time. Does that feel accurate?”

I barely muster, “Yes.” The boxes are checked. My personal experience fits a recognized pattern. I don’t share that this dose of reality makes me feel alarmingly exposed. Luckily, he seems to see it anyway.

After a pause, he continues, “You’ve tried all the non-medical anxiety treatments: education, talk-therapy, and cognitive behavioral therapy. For folks who try those things and still can’t achieve a manageable quality of life, medication is the next step.” He leans forward, “The next healthy step.”

I nod, stare absently,and keep nodding. My mind is racing as my self-image shifts unsteadily beneath me. I tell myself to focus and say, “Lexapro, you said. How does Lexapro work?”

He answers, “It’s a selective serotonin reuptake inhibitor. SSRI’s elevate mood at lower doses and reduce anxiety at higher ones.”

SSRI’s cause serotonin to stick around longer between neurons in the brainstem, amplifying happiness and feelings of well-being. Selectively tinkering with serotonin without affecting other neurotransmitters reduces side effects. Lexapro also has a longer duration of action than Xanax. These features make Lexapro a better choice than Xanax for managing my anxiety long-term.

The doctor continues, “One rare side effect when starting an SSRI is serotonin syndrome.” I’m familiar with the term because we use an appetite stimulant in cats, mirtazapine, that can induce the same problem. “Serotonin syndrome is basically a serotonin overdose, so we’ll be starting you at a low dose and working up over several weeks. I’m going to refill your Xanax prescription to use in case you notice the symptoms: increased heart rate, shivering, sweating, dilated pupils, involuntary jerking or twitching. It should take six to eight weeks for the Lexapro to reach peak effect, so don’t give up if you’re not noticing any changes at first.”

I’m preoccupied as we wrap up. We make an appointment to check back in after two weeks and shake hands. As I walk back to my car, my mind churns, furiously re-negotiating my identity.

Again.

See Part 1 of 3

Part 3 of 3 out next week!