Purple neon lights in concentric triangle shapes

Familiar Themes: Ketamine Troches Part 2

Listening to music during ketamine infusions usually helped me generate a flow of images connected by associations that were often mysterious to me when the infusion was over. Sometimes, I would be faced with settings or items that had made recent appearances in my life, and other times, the things I saw seemed entirely random. It was always different.

However, there was one commonality between many of my infusions. I often felt as though I were sinking in deep water. It was peaceful but also evoked a feeling of hopelessness, which is what I wrote in my posts at the time. Some of those infusions gave me the sense that water held some significance to my subconscious. I tried to draw some meaning from it – to spin it in a positive way or discern some kind of symbolism. I could only guess that the unsteadiness the ketamine made me feel was connected to the sensation of being underwater, and that my day-to-day sense of hopelessness was intruding on me during my infusions. It made me feel like I was drifting down through a vast body of water, and there was nothing I could do about it.

At some point, the water-based visions stopped, only to be replaced by a similar experience in which I was buried in sand at the bottom of an empty well. I concluded at that time that “my perception of depression [was] manifesting itself as unbeatable natural forces in my ketamine infusions. In my visual experience of ketamine, depression feels like sinking alone in the dark, open ocean. It feels like being buried in sand at the bottom of a well while people far away can only watch.” I don’t know for sure why I had so many experiences like those, but I felt the comparison was apt; depression was pulling me down, and it would be easier to not resist.

I found myself in a similar place when I took the ketamine troche the other day. Deciding which playlist to start proved to be difficult, so I removed my earbuds for the first half and just listened to the sounds of the room around me. Allowing my thoughts to wander on their own without the influence of music might not be the best option for me. Although my mind touched on dark topics during infusions, the progression of one song to the next helped keep my thoughts moving, and frankly, the intensity of the ketamine made controlling my thoughts difficult. They floated from one image to the next automatically. With nothing to pull me along and just enough mental control of myself to not get distracted by random stimuli when I took the troche, I became stuck. Eventually, I found some music to listen to, but my mind was already trapped in a negative space and it seemed to be too late to change it.

I’m planning to find a guided meditation or an audiobook to listen to next time. Perhaps if I begin with a positive intention and impose a framework of some kind, I can herd my thoughts toward something more helpful.

So far, the dissociative effects of ketamine have been limited to a roughly one to two-hour window. Thankfully, it seems that the extended visual and auditory hallucinations that I experienced after a few infusions (notably, this one and this one) were due to the combination of ketamine and Emsam, which I’m no longer taking. I haven’t noticed any giddiness or restlessness after taking the troches, either, which troubled me toward the end of my time getting infusions. That may have also been because of Emsam.

The plan is to increase the dose and continue taking them twice a week. Hopefully I’ll start to notice something positive.

View of milky way in night sky

Renewing The Ketamine Chronicles: Troches Part 1

I wrote in my last post that my ill-advised attempt to get off my medications is not going well. Not much of a surprise, I suppose. My psychiatrist suggested I try an oral formulation of ketamine, known as troches (pronounced “tro-keys”). These are dissolvable tablets that you take home and administer to yourself on a schedule. I’m doing it twice a week for two weeks.

One of the main drawbacks of troches is that the ketamine is less bioavailable compared to IV ketamine, which makes precise dosing a challenge. The risk of addiction can be minimized by carefully monitoring patients’ responses and prescribing ketamine troches in small batches with limited or no refills. An Osmind article written by a physician notes that the ketamine doses that are commonly prescribed are much lower than typical recreational doses but that doctors should have carefully outlined plans for restricting use and halting patients’ access to ketamine troches if necessary.

I got ketamine infusions fairly regularly for two years and then stopped with no problem, so I’m not very concerned about my own risk of becoming addicted. However, a cautious approach seems prudent.

An article on RX Insider describes ketamine troches quite positively, saying that they are a more affordable option than infusions and that they offer relief for patients who may not have access to other forms of ketamine due to logistical constraints or COVID-19 safety concerns.

Even with the experience I have from ketamine infusions under my belt, I was nervous about trying troches. In general, I’m uncomfortable with the idea of not being in control of myself. I managed to let that go when I did ketamine infusions, but the medical monitoring involved in that alleviated some of my anxiety. The uncertainty about what to expect when taking ketamine at home put me on edge, but it has turned out to be fine so far.

What Do Ketamine Troches Feel Like?

I’ve tried two ketamine troches and had very different results each time. Having some idea of what to expect based on my experience with ketamine infusions, I tried to set myself up for a smooth ride. The dog had been walked, my curtains were closed, and I had no obligations waiting for me. I wore comfortable clothes, arranged my weighted blanket on my lap, and chose some gentle-but-compelling instrumental music to listen to.

The first time, I put the troche under my tongue, waited until it dissolved (about 10 minutes), and then waited about 5 more minutes before spitting it out. I may have felt something, but it passed quickly, and I felt completely normal about 5 minutes later. It was so mild that I wasn’t even sure whether I felt it because I expected to or because the ketamine actually had some effect on me. I’d been advised to spit the ketamine out to minimize nausea, but when I reported feeling pretty much nothing, my psychiatrist told me to wait ten minutes after it dissolved the next time and, if I still didn’t feel anything, I could try swallowing it the following time.

A few days later, I tried it for a second time and waited longer than recommended. I think the ketamine that was absorbed under my tongue gave me a very mild dissociative feeling, but it again passed very quickly. This time, I took notes on my phone so I could keep track of the timing. I started at 2:45 and didn’t feel anything until 3:04. I felt a very low level of spatial wobbliness – a lot like how I feel when I’m a little overwhelmed in a busy grocery store. It felt like things were getting a bit hard to track with my eyes, and I felt ever so slightly floaty. By 3:15, it seemed like the effect had already peaked in a mild way and worn off. I felt pretty normal, so I swallowed the ketamine, and a second wave came a few minutes later.

At 3:30, I noted that my fingers felt a little numb and that I was going to close my eyes. Seven minutes later, I wrote, “Music too intense. Felt like being carried on a river of sound.” What does that mean? I no longer know. You might think that I was completely zonked, based on that tidbit, but only one minute later, I held a brief conversation with my mom and managed to seem totally coherent. Compared to ketamine infusions, troches seemed to create a more fragile dissociative state. I was much more able to pull myself out of it when under the influence of troches than I was when I got infusions.

I think my anxiety about what would happen had me coming back to the room frequently, which resulted in a very fragmented experience. I would get sucked into a song for a couple minutes and then reorient myself and write a quick note on my phone about what was happening.

When I closed my eyes, my sense of where my body was and where certain parts of my body were in relation to each other was distorted. It’s a feeling I also tend to experience when I’m on the edge of sleep or when I sit still for too long. Sometimes, it’s only a small discrepancy, such as the difference between whether my hands are resting on my lap or next to me.

The sensation is cranked up on ketamine. This time, it resulted in me feeling like my head was somehow directly connected to my knees. I experienced this kind of bodily confusion frequently during ketamine infusions, so I knew it was nothing to be concerned about. I tried to let go of my desire to organize my body in a certain way and just float along in whatever form I had taken.

Every time I checked back in to the real world, I was surprised to find that only a few minutes had passed. It felt more like 20 or 30.

What I was seeing and feeling during those few minutes was nothing so detailed or bizarre as what ketamine infusions created, but I have the sense that if the experience had not been so fractured, I might have approached a similar level of immersion.

I remember one song evoking an image of the night sky as viewed from a very dark place, with the vast swath of the milky way stretching out overhead. Another song made me feel as though I were standing in my old house as it burned down, sparks and ashes falling around me. The wind had begun to howl outside in earnest, which makes me nervous these days.   

At 3:48, Stella decided to sit on the window seat. She found the break in the curtains and pushed her way through, light streaming in behind her. The light held my attention for a few minutes, but by 3:53, I wrote that I was feeling more normal but also rather sad. I had a bit of a cry, noticed that time was jumping ahead in small increments, and then got up to go to the bathroom at 4:10. Looking in the mirror was an unsettling experience, but I expected that, so it wasn’t too disturbing.

By 4:22, I felt like I was completely past the effects of the ketamine. So, all told, the entire process took about an hour and a half from the time I first noticed the ketamine affecting me.

I haven’t noticed any improvement from the ketamine, but I have two more to do before the end of my two weeks. In the meantime, I’ve decided to get back on lithium. It seems obvious that stopping it was a bad idea and that I’ve clung to the hope that I could make it work without it for too long. I’m trying to keep the perspective that my experiment was informative, and it’s good that lithium helps me. But to be honest, I just feel defeated. The better I feel, the easier I am on myself for needing medication, so hopefully, this ultra-critical side of myself will quiet down when the lithium starts working.

Testing My Mental Health Baseline Is Not Going Well

When some questions about my diagnosis arose a couple months ago, I realized that my medications made it difficult to determine which symptoms were side effects and which were stemming from me. I’ve wanted to get off my meds for a long time, partly because I have an unhealthy tendency to blame myself for my illness and expect myself to fix it through willpower. But that’s a whole separate issue. Don’t do as I do in that regard.

I decided to get off Emsam first, as I suspected that was the main culprit when it came to the occasional hallucinations and sudden mood shifts I was experiencing. Decreasing my dose was difficult, but when I stopped taking it completely, I felt better. Not by a lot, but it was noticeable.

The next step was to decrease my lithium dose. That process has progressed in the reverse of how Emsam went. Lowering it was mostly fine until I got to 300 mg. I started to feel worse, but I hoped that if I stayed at that dose for a while, my mood would even out. I started napping again. If I have nothing scheduled in the afternoon, I spend it sleeping. Walking Stella was one of the only activities I was enjoying before I started changing my meds, and now I don’t even want to do that. I still take her on at least one long walk a day because she needs it, but I find myself getting irritated and impatient the farther we get from home. Sometimes we go to the dog park so I can stand in one place and throw a ball for ten minutes before we leave. It’s a good thing she likes fetch.

A black dog tossing a tennis ball in the air

I stopped taking lithium over a month ago, and I’m still on the fence about it. I’ve definitely crossed into not-okay territory, but I’m stubbornly refusing to reverse my plan. Part of me thinks this is a bad idea and I should go back on lithium, but part of me wants so badly for it to work out that I’m willing to give it more time.

My determination to get off my medication, even though it has a slightly positive influence, seems confusing on the surface, and I struggle to articulate my reasoning for it. I always think that I’m not doing enough to help myself, and I have a long history of feeling ashamed of my reliance on medication. I think the most succinct way I can describe it is that I’d rather believe I’m failing at doing something possible than accept that it’s impossible. Truly accepting that I need medication in order to function would require me to admit that I don’t have full control over myself, and that’s a frustrating and scary thought for a perfectionist.

I’ve mentioned this in previous posts, but to be clear: I don’t feel this way about anyone else. It’s a bizarre thought distortion that makes me feel as though everyone else is perfectly justified in taking medication, but I am not. The more depressed I get, the harder it is to see the irrationality of that.

I’m trying to push myself to do things and go places because I want to support my mental health as much as possible while I make these medication changes. It’s hard, though. The holiday season is upon us, and the twinkling lights and pine-bough wreaths on nearby homes are making me sad. I automatically think about all of our holiday decorations burning up in the fire five days after Christmas last year. I felt like I was moving on during the summer, but the cold weather has caused a resurgence of painful memories. It’s probably not the best time for me to be messing with my brain chemistry, but here we are.

I’m just so frustrated with medications. The possibility that I have bipolar disorder offers a nice, neat explanation for why I’ve had such sporadic and limited success with antidepressants. Getting off everything so that I can tell where my baseline is (and whether I eventually cycle back into hypomania without the influence of mood stabilizers) might make a difference in my plan going forward. The diagnosis is arguably not as important as figuring out what helps me, but since I tend to spiral into believing I’m not actually ill but rather just low in the willpower department, having a name for what I’m experiencing would be helpful. I’m just not sure if it’s worth the difficulty of achieving confidence in one diagnosis over the other, and it’s obviously not going great so far.

In fact, my mood has sunk so low that I agreed to retry ketamine – but in a different format this time. My psychiatrist prescribed ketamine troches, which dissolve under your tongue. This formulation of ketamine can be taken at home, which would be new for me. I’m nervous about it – for one thing, it’s much less controlled, in the sense that an IV ketamine infusion can be stopped suddenly; once I take the troche, I’ll just have to wait out the whole dose. I started to really dislike the feeling of ketamine toward the end of my time getting infusions, and although I don’t think troches will feel as intense, the uncertainty is making me anxious.

I am, however, passively suicidal and having trouble keeping up with self-care. I frequently sleep in my clothes and re-wear them the next day, and my hair keeps developing hidden matted sections because I can’t bring myself to brush it. So, perhaps something like a short burst of at-home ketamine would help me get myself into a better routine.

My depression brain is yelling about how I got myself into this mess by stopping my meds, so I don’t deserve help getting out of it. But that’s not healthy at all, so I’m going to try to resist it. I’d like to do some research on ketamine troches tonight so that I know more about what to expect, and then I’ll try to pick them up from the compounding pharmacy tomorrow. Ketamine seemed to stop working for me after a while, so I’m interested to see whether taking a break has impacted its efficacy.

Writing has always been helpful for me, but I’m finding the motivation to do it hard to come by. When I was more actively questioning my diagnosis, having a written record of my symptoms and how different treatments have affected me was incredibly useful in trying to piece together a timeline, so I’m going to renew my efforts to keep up with my blog. It might come in handy later.

Was I Misdiagnosed? Unipolar vs. Bipolar Depression

In late summer of last year, I increased my antidepressant, Emsam, from 9 to 12 mg. I was staying in a hotel at the time, and something odd began to happen. I started to hear music when the AC was running.

It is normal for people to hear tunes in the mechanical background noise of fans. It is not a psychotic illness – merely an odd perceptual idiosyncrasy. However, what I experienced was much more complex than any small, lilting buzz I’ve ever heard in a fan before.

The Musical Phenomenon and A Shift in My Mood

I was hearing soundtracks. Vocalists, instruments, the whole nine yards. I couldn’t decipher any lyrics, but there were distinct genres that ranged from pop to broadway to country. It sounded as if the music were coming from a different room, and for a while, I believed it was. But eventually, I began to get suspicious.

I walked around the hotel room, putting my ear to the walls, listening for a change in volume. I opened the door and poked my head into the hallway. I stood on the bed and listened to the ceiling. It was always the same volume. When the AC shut off, so did the song. A different song would start up after a few minutes of the AC running again. Sometimes, a sudden shift in my attention would cause the music to stop, even when the AC continued to run. It became clear to me that what I was hearing was not real, and it disturbed me.

A Mountain Escape

I was about to go to a new location – a trip with my mom to a small, mountain town for some wilderness relaxation. We planned to hike up to a lodge at 11,000 ft above sea level and stay for a few days. The hike up was arduous; it was the hardest hike I’ve ever completed, despite being shorter and with less elevation gain than other hikes I’ve done.

I remember that I wasn’t sleeping well, and my body just refused to cooperate as I forced myself up the trail. I had to stop frequently and lean on my pole, taking gasping breaths. At the lodge that night, I heard phantom hummingbirds zipping all around me as I lay in bed. In the morning, the sound was gone. I was unsettled, but I tried to put the experience out of my mind.

I was testy on that trip. My head was not in a good place, and my mind was filled with overwhelming irritation. I cried a lot. Neither my mom nor I were having a good time, so we left early and headed down the mountain to get a hotel room.

Upon reaching the hotel, a minuscule setback occurred, and it sent me over the edge. In a second, I went from chill to overwhelming, roiling anger. It was like calm seas to tsunami in the blink of an eye. I contained most of this energy, but some escaped in the form of expletives, fist clenching, and undignified, hurried marching on my way to our hotel room.

I am typically a very levelheaded, patient person. I strongly dislike being angry, and when I am, I make every effort not to show it. (Is that unhealthy? Yes.) In that moment at the hotel, I felt completely unhinged.

My dog had never seen me in such a state, so she hid under the table. The sight of her filled me with guilt and self-loathing. I immediately dissolved into dramatic, uncontrollable sobbing, which only frightened my dog even more. I was convinced that she would be afraid of me forever, a consequence for which I wholeheartedly believed I would never forgive myself.

Luckily, dogs are good creatures, and Stella came around once I had composed myself. Composure took a while to reach, but a hot shower helped.

Looking back, I feel like I was not myself from the very start of that trip. The rest of it passed fairly uneventfully, but I continued to hear sounds and music that were not real until a few days after returning home.

She forgave me quickly ❤

I’ve gone back and forth between 9 and 12 mg of Emsam since then, and the musical illusions occur sometimes when I take 12 mg. Sometimes it’s music, an incessant buzzing, or the murmuring sound of a group of people talking far away. Sometimes I can identify the background noise that accompanies it, and other times, it seems to happen on its own.

The Ketamine Incident

A couple weeks after returning from our mountain trip, I had a ketamine infusion that resulted in a bizarre, seemingly manic few days. I wrote a post shortly afterward that described my experience. I slept a couple hours each night but was compelled to keep moving. I worked on various projects for hours at a time, periodically bothered by the sight of small, insect-like dots scurrying across my visual field. I felt restless, productive, and somehow rather pressurized from the inside. I was also unsettled by dissociative spells in which I’d suddenly feel as though I were wearing my body, but it wasn’t really mine. Or, I’d walk by a mirror and be disturbed by my own face, which seemed unfamiliar.

When the strange symptoms ended, I plummeted back into depression.

I decreased my Emsam dose and my ketamine dose and had much more typical ketamine experiences, although I still found myself unbearably restless after infusions. The incident was strange, but since it didn’t happen again to the same degree, we carried on with treatment for a few more months.

Do I Have Bipolar Disorder?

I explained some of these experiences to a psychiatrist recently. I was being evaluated for ECT, although I’m not yet sure whether I want to do it.

The doctor interviewed me thoughtfully and asked a lot of questions about my symptoms. When we reached the end of the evaluation part of the appointment, he said that I might have been misdiagnosed with major depressive disorder, when really my depression is of the bipolar type.

It’s just a theory, but this would explain why antidepressants haven’t worked very well for me, or at least not for very long. The antidepressants actually seem to trigger these odd experiences.

A blue seven-day pill organizer filled with medication near a glass of water on a coaster

There have been other times when my mood suspiciously shifted, like the first time I took Wellbutrin. A day or two after starting it, I felt dramatically better. I was motivated, energetic, and utterly thrilled with how well it was working. Of course, then I developed a rash and had to stop taking it, at which point, I spiraled in the other direction.

The second time I tried Wellbutrin (the brand-name instead of generic), I wrote a post titled “Depression on Fast-Forward.” Wellbutrin didn’t make me happier that time, but it did make me anxious, jittery, and restless. I wrote about feeling “an almost constant low level of adrenaline” and feeling mismatched, like I wanted to sleep but was unable to. Was this just a side effect, or something more? Was taking lithium what made the second trial less happiness-inducing than the first?

The Antidepressant/Bipolar Controversy

These and the other incidents I can identify always happen in response to something, usually a medication change. The question of whether antidepressant-associated hypomania (AAH), also called treatment-emergent affective switch, or TEAS, indicates an underlying bipolar disorder is a controversial one.

Some people think that you can have unipolar depression and be reversibly pushed into hypomania by antidepressants, while others believe that switch indicates the existence of an underlying bipolar disorder or a shift from unipolar to bipolar illness. It has also been suggested that AAH should form the basis of a new diagnostic label, “bipolar III.”

I have experienced multiple incidents in the last few years that felt like a dramatic change, complete with insomnia, high productivity, perceptual disturbances, and euphoria or irritability. And yet, I find it difficult to verbally describe these events in a way that emphasizes the aspects I think are important. I habitually understate the severity of my symptoms, which doesn’t serve me when I really need help but can’t communicate accurately.

I’ve sought a few opinions from professionals on this matter, and I’m having trouble just reaching a consensus on whether my experiences count as AAH or were simply improvements in my depression with some side effects sprinkled in.

Even when I make a concerted effort to be more emphatic, the theory sometimes gets dismissed because the episodes I describe are too short by DSM standards to be mania, and I didn’t have racing thoughts, go out and spend all my money, take unreasonable risks, or have grandiose plans. These are all excellent points, so I’m really not sure what to think.

The DSM has strict criteria defining bipolar I and II, but that’s not the only way people conceptualize the condition. Some experts believe bipolarity exists on a spectrum, and that viewing antidepressant-associated hypomania as part of unipolar depression contributes to an overdiagnosis of MDD and an underdiagnosis of bipolar II.

On the other hand, some authors argue that bipolar disorder is overdiagnosed due to inflation of the diagnostic criteria, making the concept of bipolar disorder too vague.

Stopping My Antidepressant

Given the number of conflicting theories out there, it seems unlikely that I’ll get a solid answer about my own experiences at this point. One way to clarify the picture is to gradually get off my antidepressant and see what happens.

EMSAM-patch-packaging-with-label

I thought for sure I’d go back to the excessive sleeping I was doing before I started taking it, but so far, that hasn’t happened. I’ve been off Emsam for a couple of days, and the insomnia continues to plague me.

It’s troubling to look back at the last few years and imagine that there may have been a process occurring outside of my awareness. At the same time, I’m ever so slightly encouraged to have a different direction to go in. It could offer an explanation for some mysterious things and provide me with more effective treatments. Then again, maybe I have major depressive disorder, and I’m looking into a problem that doesn’t exist for me. Regardless of how it turns out diagnostically, I’m relieved to be connecting some dots.

Black tiles with white letters spelling therapy on a blank background

Why Anxiety About Therapy Isn’t a Bad Sign

Having anxiety about therapy doesn’t mean that therapy isn’t “for” you or that you can’t benefit from it. Instead, it might be a fear you can change by adjusting the way you approach your sessions.

We often focus on the role of the therapist and how well we connect with them when talking about how to feel comfortable opening up in therapy, but we don’t often examine our expectations of ourselves. Self-criticism and high expectations had me feeling anxious about therapy until I changed the way I thought about myself as a client.

When I decided to start going to therapy in college, I was apprehensive about having to do the classic back-and-forth discussion with my chosen therapist. In fact, I’m still not always keen on it. But the expectation that I held for myself – that I would sit down and spill my guts and cry and reach some kind of catharsis every week – did not pan out. The more accurate picture was (and sometimes still is) one of me sitting down, saying I’m okay, shrugging a lot, and forcing my therapist to sit in silence with me while I wrestle with my thoughts.

I thought for a long time that I was bad at therapy. I was very critical of myself for inadvertently shutting down. Sometimes, I still feel guilty because I perceive my excruciating quietness as a waste of my therapist’s time.

Shifting My Perspective on Myself in Therapy

The longer I’ve stuck with it, the more I can see that this perspective of myself as something like a student who is expected to achieve success is preventing me from recognizing the progress I’ve made. As a perfectionist, I’m prone to thinking that no amount of improvement is good enough, and if I’m not meeting my own expectations, I must be failing. Perhaps even more importantly, my anxiety about therapy gets in the way of me focusing on what I can get out of the process despite and because of my difficulty with certain topics.

Image by Stefan Schweihofer from Pixabay

I have been trying to shift my perspective on my role in therapy to be more like that of an explorer or some kind of self-ethnographer. I go to therapy, I do my best to talk, and I observe whatever happens. I’m there to be curious, and if talking about something is suddenly challenging, that in itself is interesting information.

Why Go to Therapy if It’s So Uncomfortable?

I learned early on in my experience with therapy that although talking about myself is deeply uncomfortable, it feels worthwhile. I have always been quiet and reserved, and I tell myself that it’s a preference. But, finding myself unable to answer personal questions in therapy taught me that I have less control over it than I wanted to believe.

To Challenge Myself

When pushed to discuss something I’m uncomfortable talking about, I simply clam up. It frustrates me because it does not feel like a voluntary reaction. Obviously, I go to therapy to talk about myself – why can’t I override my tendency to shut down? It’s like a drawbridge lifts in front of me, and I can no longer get my words across the gulf between myself and my therapist.

To Practice Being Vulnerable

Ultimately, therapy led me to the realization that while staying quiet is comfortable for me, it is also lonely. I don’t intend to change my natural tendency to be reserved, but I do hope that by practicing being open about difficult things, I can allow my reservation to be a choice, not a barrier.  

Photo by Shane on Unsplash

Everyone has secrets, and it’s perfectly okay to keep them private. But there are times when it’s good to share personal information, especially if it’s going to help you overcome a challenge in your life. Holding secrets out of an inability to put them down can be a deeply isolating experience.

Finding Ways Around My Anxiety About Therapy

I’ve gotten better at talking about myself in therapy, but it’s still hard. I still have sessions where I can’t seem to find the lever to lower the drawbridge and let the words out, and that’s okay. My therapist knows that I stay quiet not out of disinterest in the process but because it’s hard for me to engage in it.

On days when I don’t say much, I go home and write her an email with all of the words I couldn’t set free. It gives us somewhere to start the next time and lets me communicate in a way that’s easier for me. I still challenge myself to talk, but I know that I have a backup line of communication if I need it.

Whether I choose to discuss something or not is up to me, of course. My therapist is there to guide me, even push me a little, but ultimately, I decide what to talk about or not. If I want to set aside a more difficult subject in favor of discussing something easier but still meaningful, I can do that.

Considering the Therapeutic Relationship

I have found that for me, viewing a therapist’s role as that of a knowledgeable partner rather than an authority figure helps me stay intrinsically motivated and makes me more willing to push myself. We’re exploring my brain together, and I know that if I don’t accomplish something I set out to do, I won’t be “in trouble” with my therapist the way I would think I were if our relationship were less equal.

Photo by Jess Bailey Designs: https://www.pexels.com/photo/pen-and-notebook-1119792/

It’s a strange relationship to navigate — one that is inherently unequal in more than one way. You go to a therapist for help because they have knowledge and a perspective you don’t. You pay them, and you probably defer to their expertise. They are in a position to set expectations and try to interpret the implications of what you say or don’t say. It’s easy to start seeing your therapist as someone to impress, especially if, like me, you’re a chronic people-pleaser.

At the same time, clients have the option to stop going, the freedom to ask for adjustments in their treatment, and the potential to view themselves as indispensable experts on their own experiences. It can be motivating to think of therapy as something you get to take part in with your therapist rather than something you have to go to. Ultimately, I think the dynamic of a partnership makes me less likely to fear that my therapist might disapprove of or be disappointed in me for not achieving something or even for not talking enough.

I’m still trying to let go of my self-imposed pressure to be a wonderfully verbose client. I go to therapy to work on my depression and anxiety, and part of that involves being less critical of myself. I used to think I was a bad client because of my anxiety about therapy. Now, I think I struggle to talk about myself, and that’s part of why I’m in therapy.

A view of green trees and shrubs on a mountainside

TMS, Seroquel, and Sudden Relief

Initially, my extended TMS course didn’t seem to have much of an effect on me, except perhaps to kick my insomnia into a higher gear. After much thought and discussion, I decided to stop TMS suddenly rather than taper my appointments.

Getting TMS treatments every day had begun to feel pointless. We’d tried several adjustments and protocols, remeasured my motor threshold, and extended my treatments beyond the planned schedule, but none of it made me feel any different.

At this point, I’ve tried what feels like an exhaustive list of medications. Combine that with my lengthy treatment with ketamine infusions, years of therapy, and now TMS, and I can’t help but see a hopeless picture. I know I’m not out of options, but the pattern leads me to conclude that any further effort to get better will result in the same outcome: more depression.

However, I know that’s a logical fallacy. Just because many treatments didn’t work does not mean that the next one won’t work. It’s hard to grasp that when you’re deep in depression, though. I left the TMS clinic feeling hopeless. It’s indescribably discouraging to try treatment after treatment, clinging to a tiny scrap of hope that just gets smaller and smaller as you go.

I sometimes feel as though I’m trapped inside myself, carried along by my depressed body like a prisoner. I’m in here — I’m just unable to break through the impenetrable walls around me no matter how hard I try. At other times, I feel as though depression has eroded my mind, letting the essence of me wash away. The “me” I am when I am not depressed seems to be gone. The movement stops, the lights go out, and I wait in internal darkness for some motivation to stir in my mind. The little scrap of hope flutters somewhere out of reach.

The second version is how I felt when I stopped TMS.

Ending TMS meant that I needed to consider my next steps. ECT is one option, and I’m interested in doing a consultation, but the thought of actually starting that process is daunting. I had increased my dose of Emsam, the MAOI I take, and figured I would wait a little while before doing anything. In the meantime, I wanted to get a handle on my insomnia.

Sleep Meds

I did not sleep more than five or six hours a night in the last two months, so that’s been a barrier to my mental health, too.

Temazepam

Increasing my usual sleep medication helped but then plateaued, so eventually, I decided to try Temazepam. I was a little nervous about taking it because I don’t like feeling impaired, especially if I’m uncertain of how it will feel. But alas, I was tired. I read the medication info sheet front to back because that’s the kind of person I am, took the pill, and prepared for a blissful night of uninterrupted sleep.

Yeah, right. It was one of the most unpleasant nights I’ve ever had. I was unbelievably restless – not just my legs but my whole self. I didn’t stop moving for hours. I was too hot, so I moved downstairs to the couch, but then I could feel my heart beating, and the sound of my breathing was grating in my ears. Sometime around 4 AM, I fell asleep, only for the sun to come up two hours later.

Some people (but not many) have paradoxical reactions to benzodiazepines. I now know that Temazepam is not for me. It was a learning experience.

Seroquel

One category of medications that I had not tried before now is the atypical antipsychotic class. Seroquel is a drug in this category. It’s used as an off-label treatment for depression, and it is also sometimes prescribed for insomnia due to its sedating effects.

I decided to switch from Trazodone to Seroquel, and overall, it’s been a positive change. I started with too high of a dose and had an unpleasant day afterward, but I quickly adjusted. As long as I give myself enough time to sleep it off, I no longer feel sluggish and half-asleep when I start my day.

I’ve managed to increase my sleep to six or seven hours a night. Although it’s not an enormous difference in terms of hours, I feel like the quality of my sleep is better. I no longer wake up during the night, and I feel slightly more rested overall.

It probably helps that I reduced my lithium dose a little and don’t wake up feeling like a dried-out sponge several times a night. I keep my ridiculous 64-oz. water bottle by my bed for easy middle-of-the-night hydration. My psychiatric np finally told me so many times to drink more water that I stepped up my efforts and bought it. It’s so big that it’s basically an insulated bucket with a lid, and I love it. I don’t have to deal with the extra step of refilling a glass or smaller bottle frequently. It’s a silly reason to not drink water, but when I don’t care about myself enough to keep up with hygiene or eating, refilling a glass of water is surprisingly challenging.

Restarting TMS

But, I digress. After a few days of no TMS, I found myself feeling – impossibly – worse than before. Whether that was because TMS was helping in small ways or I was simply despondent after giving up on another treatment, I still don’t know. I decided to pick up with TMS where I left off.

The timing makes it difficult to determine which factor caused what result, but after restarting TMS, sticking with the increased Emsam dose, and adding Seroquel, I suddenly felt dramatically better for a few days. I found myself walking Stella with a decidedly peppy step instead of my usual brick-like feet. I suddenly wanted to go places and do things, which is the complete opposite of how I felt before. I actually felt like I could feel the dopamine I had missed so much. I felt happy about nothing in particular.

A closeup of a black dog with pointy ears panting while sitting in the forest.

I always marvel at how impossible it is for me to imagine how it feels to be less depressed. I know it sounds odd, but every time I get some relief from my symptoms, I find that the sun feels warmer, the breeze feels more refreshing, and colors seem more vibrant. I feel like I’ve been released from a state of deadened perception and pushed into a shockingly bright, intense world.

Despite experiencing such improvement before, I’m always taken aback to realize that I could not grasp how distant I felt while depressed. The memory of what improvement feels like disappears when depression returns, and the only way to understand it again is to experience it.

A closeup of the center of a yellow flower outside

The Current State of Affairs

I don’t currently feel as amazing as I did for that brief time, but I do think that I’ve maintained some improvement. I still feel considerably more energetic, and although my mood has embarked on a journey of hills and valleys, it’s nice that there are still hills.

I’m not sure where this will leave me. I’m planning to do three more TMS treatments and then stop. I don’t feel nearly as desperate as I did when I stopped TMS the first time, but I am concerned that some symptoms seem to have worsened slightly since my sudden improvement.

Part of me thinks that now would be a good time to look into eventually making more treatment changes, whether that’s ECT or something else, since I’m still relatively motivated. The other part of me thinks that I should just focus on adding habits and activities to my life that could help me hold on to the improvement, and see where that takes me. I guess I have some decisions to make.

A pink rose growing in a beige pot with another plant in the background

Saving the Roses and Losing the Trees

This might be my last Marshall fire-related post, at least for a while. The remnants of our house have been cleared away, and it seems like a natural opportunity to reflect. While painful, I hope that this step in the process can offer us some closure.

My other wildfire posts can be found here:

My House Burned Down in the Marshall Fire in Colorado

Letting Go of Items Found in the Ashes After the Marshall Fire

Thoughts on Depression, Trauma, and Change

Saying Goodbye to the House

Part of me struggled with the idea of the lot being cleared because, although it was all ash, rusty metal, and shards of glass, much of it was still there, just in a different form. When the crews demolished the foundation and cleared it all away, our belongings truly disappeared. The property as it was had become a sad monument in my mind, marking the events of December 30, 2021. Now there is almost no evidence on the property of our home ever having existed.

On the other hand, I think it will be a relief to move forward without the wreckage occupying space in my mind. It felt strange to go about my daily life while a violent reminder of something terrible existed nearby. It was always draining a small amount of my attention.

I have to resist the muscle memory of taking that exit on the highway, and it still feels weird to call my current residence “home,” even six months later. When I close my eyes in the shower, the smell of my shampoo transports me to my old bathroom, with the sun streaming in through the frosted glass window. Sometimes, when I’m somewhere between asleep and awake, I feel disoriented; I can’t picture the room I’m in. Not home. Not here. Where am I?

I visited the house on some Thursdays on my way back from therapy. Sometimes, I got out and stood on the front step, looking down at the piles of ash. Sometimes, I just sat in the car. Every time I went, I wondered if it was the last chance I had to say goodbye to it.

The Roses

On one such visit a while back, I saw some greenery sprouting out from the dry, brittle remnants of a rose bush. The above-ground vegetation was burned or singed, but the rose’s root system was still alive. It sent up brand-new stalks when spring beckoned.

burned rose stalks with new stalks growing next to a red brick wall
Rose #1

Actually, two of our four roses survived the fire. Seeing as how they were running out of time before the crews arrived to clear and level the property, we bought two large plant pots and got to work digging the roses up.

It was arduous; when soil burns, it can become somewhat hydrophobic, so although it had snowed and melted before we started, the soil was still incredibly hard. We brought water with us, but pouring it on the ground was only effective at wetting the top 1/8th of an inch of soil. It simply ran off, leaving the packed dust underneath it untouched.

Once we got down to the lower layers, the water helped more, but we still could only make progress by chipping away clumps of hard dirt and clay with our newly purchased gardening tools.

Rose #2

After about 20 minutes of digging, I came across a pill bug scurrying on its tiny legs across the disturbed earth. It struck me that I hadn’t seen any invertebrates before then. In our eight hours of digging across two days, we saw three or four worms, a couple more pill bugs, and one ant. The soil was barren.

In some ways, digging up the roses was familiar. We’d planted, pruned, weeded, and watered that garden bed countless times over the years. The sun was out, birds were calling to one another, and I knelt on the walkway as I worked, just like I did before.

Parts of it felt familiar, and feeling around for roots and gradually excavating them was mesmerizing. We lost track of time.

And yet, in the background, I was always aware of the space the house no longer occupied. It sat off to my right and tugged on my attention. There were no insects or spiders in the dirt, no kids running down the block, and no noises in the air. Without lawnmowers, dogs barking, and sprinklers chugging nearby, the neighborhood was eerily quiet.

We wanted to get as much of the root systems as possible, but we had to start cutting them somewhere. We also had to get rid of the top three to six inches of soil because it was contaminated with toxic ash. It pained us to sever so many roots and expose the fragile sprouts to the sun, but we figured the roses had nothing to lose. They would be destroyed if we didn’t save them.

The Trees

Unlike the roses, the trees were not saveable. There was an ash tree in our front yard that had new growth, but an arborist assessed it and delivered the sad news: it was too damaged to survive long term. The sap on the inside of a tree burns more effectively than the outer layers of wood. Essentially, trees can burn from the inside out. The outer layers of the trunk might have survived enough to grow new branches, but the tree’s ability to transport water was so reduced that it would not be able to sustain itself.

A mostly bare ash tree with small leaves growing from large branches

We arrived at the lot just as the crews were beginning to remove the trees. They started with the pine to the left of the driveway, then moved on to the ash tree in the front yard. They had cut it down at the base beforehand, so the backhoe operator got to work breaking the tree apart. We listened to the terrible sounds of dead wood being snapped under pressure, chunks of main branches flying into the air.

Slowly, the tree was reduced to where its main trunk split into three branches. The operator picked it up from the top to break it down again, and it dangled in the air for a moment. It was surreal – like I was watching a child use a toy backhoe to play with sticks on a playground. Except, it was such a familiar tree that seeing it lift off the ground and hang there did not sit right with me. The deconstruction of something so solid and unchanging was difficult to accept, even as I saw it happen.

When I was in middle school, I used to climb up to the best branch of that tree and read books, swinging my legs and listening to the rustle of the leaves in the breeze. I used to sit under it with my childhood dog, and later, with my current dog. I patted the bark and said goodbye to it when I went to college, and then I said hello when I moved back home.

This week, I stood on the other side of the street and watched my favorite tree get snapped into pieces by a backhoe and carted off in the back of a truck.

We left after that, trusting that the rest of the process would be even more disturbing to us. It’s necessary, and I’m relieved to finally be at this point, but it is distressing to see your already-obliterated home be torn apart even further.

Growth and Looking Ahead

Overall, I feel like I’m making progress, but I also feel like I’ve been changed by my experience, and no amount of moving on will restore the sense of safety I used to have.

I find myself organizing my important belongings so that they would be easy to grab in an emergency. I sometimes have nightmares in which something is on fire and I can’t find enough fire extinguishers to put it out or even hold it back.

There are some things I feel better traveling with than leaving at home because you never know what could happen while you’re away.

Some of my anxiety about fires feels useful to me, like it could help me respond more effectively in the future. At the same time, it seems to be in conflict with the sense of urgency I have about taking back control of my reactions to fire.

If the last few years have taught us anything, by late summer, Colorado will be so dry it will practically burst into flames of its own accord.

There will be more fires this year, and I don’t want to be thrown into a panic every time one crops up in the mountains or a few towns over. I don’t want it to impact my love of my home state or my desire to live here. I’d much rather adapt.

Rose #2