A body of water with four white pelicans on an overcast day

Insomnia and Seeing Spiders

I have not been sleeping well lately. TMS seems to have worsened my insomnia such that I’ve slept five hours a night, give or take an hour, for the last few weeks. It’s not so little that I was dramatically impacted right away, but the cumulative effects are becoming apparent.

For one thing, if I stray below 5 hours of sleep at this point, everything looks like spiders. Little clumps of dirt, loose threads on a napkin, you name it – if it’s small, dark, and in my vicinity, I think it’s a spider. It startles me, I flinch away from it, and then I feel stupid when I realize it’s just a particularly grainy spot on my wooden desk or some other innocuous thing.

Anything in my peripheral vision that seems at all unusual catches my attention. I was sitting at my desk on Friday, trying to work when I got this feeling that someone was standing in the hallway to my left. I looked – nothing there. It happened again, so I looked again – nothing there. I think I was seeing the hinge on my glasses against the empty hallway. The dark spot somehow got turned into a vaguely person-shaped image in my mind, and it unsettled me. Information coming in through my senses feels chaotic, and I find myself being jumpy and on edge.

Trazodone helps me fall asleep, but I continue to wake up after 4 or 5, sometimes 6, hours of sleep. Five hours is unpleasant, but the world looks mostly normal. Four is when things get wacky, and six seems to restore my sanity somewhat. I’ve definitely gone long periods of time on 6 hours a night before and been free of spiders and other illusions, so I guess five hours most nights with occasional dips below that is my limit.

I think it’s interesting that creepy crawly-related hallucinations/illusions/perceptual mixups are so common. Some of my ketamine infusions resulted in hallucinations of insects when I went home. (It is not supposed to do that.) One time, I was transfixed by some bug-inhabited cobwebs that weren’t real, and another time, I mysteriously hallucinated for three days. Small, black bugs scurried from one side of my visual field to the other and sometimes took up residence on tangible objects. I slept about two hours a night and found myself unreasonably motivated to complete tedious jobs like pruning our overgrown grapevines and reorganizing the hall closet.

That incident happened after I had been taking 12 mg of Emsam for a few weeks. My post-ketamine experiences started to become more and more bizarre and culminated in the three-day…whatever that was. I decreased the Emsam back to 9 mg, and my ketamine infusions went back to how they used to be.

Months later, I ran out of 9 mg patches and decided to use leftover 12 mg patches until I could get my prescription refilled. It was an informative experiment. I had horrible insomnia and felt similar to how I feel now. Inanimate objects started to sway back and forth in my peripheral vision, white noise sounded like music, and small, bug-like dots explored the world to my left and right until I looked at them directly. Then, they would disappear.

However, all of those incidents were different in that the insects were completely fabricated; my current spiders are actual things in the real world that my brain is transforming into momentary terrors. Thanks, brain.

I haven’t noticed any benefit from TMS yet, but we’re adding an off-label priming protocol to my regular treatments. Maybe I’ll just be a late responder. I’m trying not to feel discouraged, as I know it’s not a helpful state of mind. I’ve been feeling worse the last few days, which isn’t making it easier to be optimistic about TMS. I suppose I’ll just keep at it.

An outstretched hand holding an outline illustration of a brain against a grey background

What My Initial TMS Appointment Was Like

I recently started TMS for treatment-resistant depression. My first appointment was an interesting process. Regular visits are fairly straightforward, but there are a lot of steps to complete in a first TMS appointment that set you up for the rest of your treatment. Here’s how mine went.

I arrived at the clinic at my appointment time and went into a room containing a large machine with a digital readout connected to a tube with a peculiar-looking black attachment at the end. The room looks rather like what you’d expect if a therapist with a special interest in neurology suddenly switched fields and became a dentist. There’s a painting with uplifting words and two matching prints of the human brain on the walls, a mechanical reclining chair complete with a little paper bib over the pillow, and a desk with a computer and monitor. The walls are a relaxing shade of dark teal, and there’s a TV mounted at eye-level across from the chair.

TMS Mapping

The psychiatrist and two technicians were present, and they began by explaining what would happen. The first portion of the appointment would be dedicated to “mapping.” First, they would place a white cap on my head and take lots of measurements that would be used to mark the location of a couple parts of my brain. Then, I was to sit with my right forearm resting on a pillow on my lap while they held the magnetic coil (the black attachment at the end of the tube) up to the left side of my head and delivered pulses of varying intensity into my motor cortex.

Cortex sensorimoteur1.jpg: Pancratderivative work: Iamozy, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons

The purpose of this part of the process is to determine the lowest intensity that causes the patient’s thumb to twitch involuntarily. That intensity is known as the motor threshold. Mapping allows providers to tailor the patient’s treatment to specific parameters – the exact spot where the coil should be placed and the intensity of magnetic pulses that is most effective for that person.

What Does the Mapping Process Feel Like?

I found this part of my initial TMS appointment to be fascinating and a bit intimidating. As someone who hates being the center of attention, having three (very nice) people hovering over me, touching the cap, and stretching a tape measure over and around my head was uncomfortable. You only do it once, though, so that cap is now used for all of my treatments.

Determining my motor threshold was the fascinating part. I sat with my elbow bent and my forearm on my lap, oriented with my palm slightly up so that my thumb was visible and unhindered. The team placed sticky electrodes on and around my thumb and connected them to a machine next to me. I was asked to relax my arm as much as possible. The coil was held in contact with the cap. It produced a clicking sound and a small tap on the side of my head when pulses were administered. As they worked, the psychiatrist and technicians watched my thumb for movement and checked the readout on the machine for spikes in electrical activity.

Although it was bizarre to feel my hand moving without my conscious direction, nothing about the process was painful. It’s like when you develop a temporary eyelid twitch; it’s maybe a little disconcerting, but that’s about it. Subsequent pulses became less intense and had mixed results. A slightly different spot on my head would cause all of my fingers or even my wrist to move. Eventually, we landed on my motor threshold, and the electrodes were removed from my thumb.

The First TMS Treatment

At this point, I think I put earplugs in, but I might have done that earlier. Once I was tilted back in the chair, the pillow was adjusted, and someone held the sides of it up by my face. The air in the pillow was then vacuumed out, leaving a stiff, shell-like nest for my head to rest in. It feels a bit weird, but it helps keep your head still.

The coil was then attached to a mount connected to the chair. The mount is a mobile arm that allows the coil to be positioned on the patient’s head. Positioning the coil is a delicate business, so the techs did a lot of adjusting, locking it into place, and walking in front of me to look intently at my head from different angles before walking back and adjusting it some more.

There is a paucity of royalty-free TMS images online, and this is one of the only ones that show anything resembling the position of the coil. This image cracks me up. Is it the inexplicable lack of a shirt? Is it the arms held out to the sides? The coil descending from the heavens on a pole? I don’t know, but I love it.

(MistyHora at the English Wikipedia, CC BY-SA 3.0 http://creativecommons.org/licenses/by-sa/3.0/, via Wikimedia Commons)

What is “Intensity” in TMS Treatment?

We started at an intensity below that of my motor threshold. Intensity is measured in terms of relative percentages. When mapping, intensity is expressed as a percentage of the total output the particular brand of TMS machine you’re using is capable of producing. The motor threshold exists at some level of intensity, which means that it is also expressed as a percentage. For instance, mine is 32% of the TMS machine’s total power.

As the appointments progress, the intensity of the treatments increases. The easiest way to think of this part is to consider the treatment intensity as a percentage of the motor threshold. So, my motor threshold of 32 is the new 100%, and each treatment is set to an intensity that’s described in relation to my motor threshold. We started at 60% of my motor threshold (19 or so on the machine) and bumped it up a few times during that treatment, reaching about 70% by the time it was over.

What Does TMS Feel Like?

I knew that there would be a series of sounds and accompanying taps on my head, followed by a period of a few seconds of nothing, then more taps, and that would repeat. My insurance will cover the “10 Hz” protocol (10 Hz refers to the frequency of magnetic pulses), which follows a 75-repetition pattern of four seconds of pulses (known as trains) and 11 seconds between trains. A frequency of 10 Hz means that there are 10 pulses per second (and 40 pulses per train). 40 pulses times 75 repetitions equals 3,000 pulses per treatment. Each treatment under this protocol lasts 18 minutes and 26 seconds.

Initially, the “taps” didn’t feel much like taps at all. It was like drops of cold water were falling from a great height into a small hole in my head. The sensation would spread out from the center, although it remained restricted to a very small area. When each train ended, so did the sensations.

Every few minutes, someone would ask me if they could turn the intensity up a notch. As the intensity went up, the pulses felt more like tapping. I found it uncomfortable but not painful at that level.

A woodpecker makes for a good analogy when describing how it feels. At lower intensities, it’s like a small bird — maybe a downy woodpecker — that’s persistently curious about the acoustic properties of your skull. The higher intensities I’ve reached in subsequent appointments have replaced the little woodpecker with a much larger one, like a northern flicker.

Speaking as someone who has been licked on the forehead by a flicker and had one land on the top of their head (I worked at a wildlife rehab center), I can say that, like a TMS machine, they make a lot of noise and have incredible persistence. Thankfully, unlike flickers, TMS machines do not scream, and you can stop them whenever you want.

The machine is pretty loud — both the beeps it emits and the clicking pulses — but the earplugs help muffle the sound. The coil is heavy, and I was very aware of it resting on the side of my head. It did help me remember to stay still, though. Talking was a bit challenging, as I’m used to relying on nodding and shaking my head to supplement my conversational skills. I felt rather stunted without it, but we muddled through.

After that, my first TMS appointment was over. I had been a little apprehensive about it, but it turned out just fine. In fact, it was reassuring to know what it felt like and what I could expect going forward. Sometimes, the best way to handle uncertainty is just to jump in and get started.

a black and white illustration of a woman standing in front of a window in a dark room at night

Shifting My Depression Treatment from Ketamine to TMS

Unfortunately, ketamine is not helping me much anymore. The infusion before last gave me a small boost, and I remember feeling good for about five days following my appointment. Some of the other benefits I get from ketamine, including improved appetite, fewer thoughts about self-harm and suicide, and more energy, still seemed to extend for a week or so post-infusion. On the whole, though, I wasn’t feeling encouraged.

My most recent ketamine infusion came just a few days before I started transcranial magnetic stimulation (TMS) treatments. I have almost no memory of that infusion. The day after the infusion did seem better, and I had the sense that things around me seemed a bit brighter or more colorful. I hate to say it, but aside from that mild improvement on that particular day, I don’t think the infusion did much of anything for me.

So, I’ve decided to stop getting ketamine infusions for the foreseeable future. It’s unclear why they stopped helping me, so I’m not opposed to keeping the option of restarting them in my back pocket. Right now, though, I don’t think that continuing them is providing much, if any, benefit to me.

Lithium and My Poor Kidneys

I’m disappointed that I’ve come to this conclusion about ketamine, but I’m also in a slightly delicate spot, and something needs to change.

Image by chenspec on Pixabay

I increased my lithium dose in March because my mental health was deteriorating. Lithium is probably the medication that I have the most conflicted relationship with. Taking such a high dose is effective at reducing my suicidal thoughts, but it’s not ideal for my poor kidneys. And when my kidneys can’t keep up, my lithium levels begin to inch toward toxic.

My lithium level as of a few weeks ago was slightly above the upper limit of “therapeutic.” It’s back in range now because I’ve been working on doing that human thing where you drink water, but I’d still rather not take this dose of lithium for very long.

Deciding to Try TMS

It’s the combination of ketamine’s waning efficacy and lithium’s waxing toxicity that led me to TMS. I’m not in a good place, and I need a different solution. TMS is mostly covered by my insurance, there’s a clinic I like close to where I live, and the downsides of trying it are very few.

Initially, I considered continuing ketamine while doing TMS, as one could receive both treatments concurrently. I’ve opted to do TMS alone because ketamine is not offering me relief and no longer seems worth the expense. However, it’s possible that ketamine is helping me more than I realize, and stopping infusions might worsen my depression. I’ll just have to see how it goes.

I also considered ECT because of how severe my depression was before I increased my lithium dose, but I think it makes sense to try TMS first.

I’ve done a few TMS treatments so far, and they were strange and interesting experiences, but I think I’ll save my descriptions for another post.

Setting Ketamine Infusions Aside

It makes me rather sad to think that this part of my life is over. I’ll miss the wonderful people at my ketamine clinic, and I’ll miss writing about my experiences there. I’m glad I documented my ketamine dreams, which I will remember with equal measures bemusement and fascination.

I’m also upset that I’ve “failed” yet another treatment. It’s a discouraging development that leads me down well-worn paths of self-criticism and frustration.

That said, I’m incredibly grateful for the improvements I gained from ketamine. There was a while there where it was really turning my life around. I started volunteering, I was happier, I felt excited about life, and then the pandemic hit, and a series of stressors undid all the positive progress I’d made. (My therapist would remind me that not all of my progress was lost. That’s just my brain lying to me again.)

Although I won’t be getting infusions, I would love to keep up with the research and continue sharing information about ketamine. I would especially like to see what data exists on the long-term efficacy of ketamine and whether my experience of it is represented in the literature. A quick search shows tons of studies published in 2021 and 2022, so there’s certainly new information out there. My brain power is lacking, though, so I’ll have to save that for another time as well.

Photo by Brad Christian on Unsplash (@y_barron)

I still believe that it’s important to raise awareness of ketamine treatment for depression and reduce the stigma associated with it. It may not be working for me right now, but it’s still a valuable option that people with treatment-resistant depression should be aware of.

So, I’ll leave the door open for further posts in The Ketamine Chronicles. I still want the series to be a resource for people who are considering IV ketamine infusions and find first-person accounts helpful or reassuring. I hope I’ve accomplished that to some degree in this phase of the series. If you’ve been reading for a while or just started, thank you for clicking and scrolling and reading about my bizarre, profound, and nonsensical ketamine dreams.

A network of raised ice patterns on concrete

Thoughts on Depression, Trauma, and Change

My depression has not been great lately, and I’ve let my blog go wild in my absence. The longer I go without posting, the harder it is to pick up again. I have to think back to where I left off and decide how to begin.

After the Disaster

Last I wrote, I was wrestling with the loss of our house and belongings after a grassfire destroyed them. Life has gone on, as it tends to do. I’ve been back to the house a few more times, but only to look at it – not to search for anything. Yesterday, I parked by the trails near my neighborhood (when do I start calling it “my old neighborhood?”) and got out to look at the mesa. Green grass was growing like stubble over the burned landscape. I don’t know why I was surprised to see it that way. I knew the mesa would recover quickly. I suppose it was just more painful than I expected to notice the passage of time after a disaster.

A flat landscape with mountains in the background and partially destroyed wooden fences in the foreground

It’s not prominent in national news anymore, displaced people have scattered and settled, and we’ve acquired all the things we need in our new place. The wider community is moving on, as is reasonable and expected. And yet, it still feels so immediate and all-encompassing to me.

The Day-to-Day Stress

Wind, for instance, makes me feel a horrible sense of dread. It reminds me of walking Stella by the houses across the street that morning, several hours before the fire. Snapshots of it come back to me: a woman in her pajamas, rushing to pick up trash from her capsized bin; a full recycling can skidding across the street at high velocity; picking up crumpled, Christmas-themed debris and hearing someone remind me that wrapping paper can’t be recycled.

Most viscerally, though, wind reminds me of stumbling to a fencepost on the mesa, my hair whipping around my face in the deafening howl of near hurricane-force wind. It reminds me of standing there in disbelief, watching the wall of smoke move closer.

I was driving during a high wind advisory the other day, and all I could think about was my dog, Stella, alone in the apartment. I wanted to get back there as soon as possible in case a fire broke out. I couldn’t help but imagine the terrible possibilities. What if the road to the gate was clogged with cars? Could I park on the sidewalk and climb the fence? How would I transport Stella and our things to the car? What would I take? I imagined myself climbing the fence and running to our apartment, only to realize that imaginary me had left the garage door opener in the car, and I would need it to get inside. Should I break a window or run back to the car?

Suddenly, my GPS told me to get off at the next exit, so I took a deep breath and reminded myself that it was windy. That was it. No emergency.

The slightest thing will make me think of the fire. A wooden bowl in a craft store brought me to tears the other day. The realization that it’s spring and I don’t have any warm-weather clothes is disheartening. Then again, I don’t think about it all the time, and in some ways, I’m settling into our new place and getting used to my new routine. When I try to notice when things don’t suck, I can identify things about the apartment that I like. It’s sunny, conveniently located, and it has walking paths nearby. I like my room, which feels bigger than my old one. My new plants are doing well. It’s a nice place to live, and we’re fortunate to have it.

Depression is Stubborn

Despite the positive developments, my mental health has been declining for a while. Well, it’s on a low plateau, like one of those deep-sea shelves. Even before the fire, things were trending downward, so all the upheaval hasn’t helped my depression.

I’m having a hard time pulling myself out of the hopelessness. Whenever my depression worsens, I struggle to see things positively, and not just about the fire. The future is hard to imagine. Depression seems to stretch on infinitely. I can go out and do things and even enjoy them on some level, but underneath the top layers, any kind of meaningful goal or long-term ambition feels like too much effort and utterly out of reach.

Depending on when I finish working for the day, I either take a nap or go for a walk with Stella. My afternoon walks feel long and exhausting, but Stella doesn’t mind if I walk slowly and stop a lot. I let her point us down a new street the other day, and I ended up getting completely turned around. I had to use Google Maps to get back. Small hiccups like that make me irritable when my mental health is poor, so I put Stella on a short leash for the rest of the walk. She eats goose poop, rolls on damp dirt, and forgets she’s on a leash when she takes off in pursuit of squirrels. It’s better if she walks right next to me.

A black dog with pointy ears sitting on dirt while looking up at camera and panting

I know that I’m very isolated. It’s somehow overwhelming to talk to friends or even make a blog post. I worry that if I go do something social, I’ll run out of energy and won’t be able to muster up any enthusiasm. Usually, it’s fine, but the thought of it is so exhausting that I’d rather be alone. I’m more comfortable alone, but I know it’s not good for me.

I don’t like abandoning my blog for long periods of time. Depressed me struggles to create an entire post that follows a cohesive story or structure. When I do write something, I usually convince myself that it needs more work before I can post it. I let it languish in my drafts folder until I eventually return to it, read it, and wonder why I thought it was so bad. This post, for instance, is a conglomeration of several drafts I wrote over the last few weeks.

The combination of depression and perfectionism is a strange mix. When it comes to things like showering and eating, I’m apathetic. But, when I’m writing a blog post, an email, or even a text, I have to edit obsessively. That is, until depression fills me up with apathy like sand in an hourglass, and I decide to set aside my writing.

Let’s see how long it takes me to write the next one. I’m setting that clam for one week. Maybe two.

Long exposure blue lights in the shape of sound waves against darkness

Sound Sensitivity: The Ketamine Chronicles (Part 36)

I have found that my most vivid experiences with ketamine treatments for depression happen when I’m listening to classical music. At my appointment this week, I popped both earbuds into my ears and started listening to a classical playlist while the infusion pump started to whir. The piano in the first song was soothing, and I settled back, holding my phone in my left hand and a worry stone in my right.

Music During Ketamine Infusions for Depression

The next song was heavy on the cello, and while I love cello music, this song gave me a decidedly creepy feeling. It brought to mind lots of puffy, white items in creamy white rooms that made me feel suffocated. It reminded me of a funeral home. I thought about changing the song, but that would have required control over more muscles than just my fingers, so I just waited it out, circling my thumb around the stone in my right hand.

The Worry Stone and a Mild K-Hole

The worry stone has proven to be a useful addition to my IV ketamine treatments. Even though it’s just my thumb that I can feel, that one little point of contact helps anchor me to the real world when I start to dissolve into nothingness.

During my previous ketamine infusion, in which I did not have my stone, I had found myself unable to move. I was probably experiencing what people call a “K-hole.” At times, I was aware enough to know that I only had one earbud in and wanted to grab the other one from my lap. I just could not force my arm and hand to move toward it. I’d try for some undetermined amount of time before giving up and being whisked away from my body once again, only to repeat the whole thing a little while later.

It wasn’t scary so much as it was frustrating. There was something I wanted, and not only could I not do it myself, but I was incapable of communicating my request in any way. We lowered the dose a little for this infusion, and I think that combined with the itty bitty scrap of control I maintained through the worry stone made for a much more comfortable ketamine infusion.

Controlling My Thoughts During a Ketamine Infusion

When the next song came on, I decided that I did not like all of the white imagery I was seeing, so I changed it to a more tan color and was immediately more comfortable. I don’t think that I’ve ever been able to just decide to change something about my experience of IV ketamine, so this was an interesting development.

I’ve contemplated the connection that happens between my recent experiences and IV ketamine that occurs in the form of bizarre, distorted versions of real-life items or events. I often start to see things during a ketamine infusion that I remember having a passing thought about a couple hours earlier. For instance, the oceans of corn I witnessed after briefly thinking about movie theater popcorn before one of my early ketamine infusions.

I’ve been mostly unsuccessful in doing this on purpose by seeding my mind with ideas. I had thought that my brain simply has its own agenda, but if I can change details like color while the infusion is happening, maybe I could learn to guide myself more reliably over time.

Machinery Noises

The infusion pump next to me whirred and chugged away, and although sometimes it faded into the background, at other times, it was extremely loud and menacing. It started to sound like a deep growl, and I felt as though I were trapped in a small space with a sinister beast and a red glow all around me. This occurred for only a few seconds, as I quickly tried to ground myself using the worry stone in my right hand. I remember thinking to myself, “This isn’t real. You’re sitting upright. You can feel the stone in your hand. This isn’t real.”

Abstract red painting with black shadows and gold splatters
Photo by JR Korpa on Unsplash

Forcing myself back to the room felt like dragging myself up, up, up through a dark corridor to the surface. I turned up my music to drown out the sound of the pump and found myself floating into another feeling entirely.

What Am I?

At times during this ketamine infusion, I felt like I was a thin layer of ice spreading across a pane of glass. I watched the methodical movement of tiny ice crystals marching across the pane, like an army moving to claim new territory.

Closeup of ice crystals covering one half of a pane of glass with a view of trees outside
Photo by Sydney Rae on Unsplash

I watched it and I felt like I was it. It’s difficult to explain how disconnected I feel from my own body during a ketamine infusion. In fact, it’s difficult for me to fully comprehend after the fact, despite having experienced it many times. I still feel like myself, I’m just lacking a physical body. I’m free to move around as what feels like my pure essence, observing and sometimes participating in events that sound nonsensical to my rational mind. Although I seem not to have much control over what I see or become, it’s a somewhat pleasant experience to not feel constrained by my human identity.

Real-World Distortions

I rebelliously opened my eyes once to see the room coated in a gently moving, gauzy film. The walls seemed to shift as the film moved, creating odd, geometric patterns over everything. The photo on the wall suddenly had an ornate frame that stood out to me as being different than the understated one that had existed before.

My mom sat in the corner, typing quietly on her laptop. I tried to focus my eyes on her, but ketamine messes with my depth perception and I couldn’t even manage to keep my gaze on her face without my eyes jumping around the room and then back again. Finding the effort of this to be tiring, I closed my eyes again.

As usual, I was underwater for a time, but I don’t remember any specifics. I don’t know if it was the ocean, a lake, a river, or a stream. All I remember is that it felt somewhat healing.

Going Home After IV Ketamine for Depression

I have vague memories of getting home from my ketamine appointment and walking Stella through the park. I must have hung up my laundry at some point. I definitely remember lamenting my poor timing before leaving them to sit in the washing machine during my ketamine infusion, but now they’re on the drying rack. I may also have filled up the dishwasher, but again – it’s a blur. Maybe I should save some truly unpleasant task for post-ketamine productivity time. That way, I wouldn’t have to remember actually doing it!

I napped from 5:30 to 7:00 PM, then ate dinner and promptly went back to bed. I woke up later on at 11:00 PM and had a snack before getting back into bed. My face felt strange – like there was something weighty resting on my cheekbone and the right side of my scalp.

My tremor was bad the next day, and I struggled for minutes on end just trying to clasp a necklace around my neck. I felt spacey for two days following my infusion, and time had an odd quality to it. I tend to sleep poorly for a few days after a ketamine treatment, but mostly because I have a burst of energy that leaves me wanting to accomplish things instead of going to bed. Forcing myself to get in bed before I’m really ready results in extreme restlessness – it’s difficult to stop moving and I have to constantly remind myself that there is no reason whatsoever why I should be tensing every muscle in my body. Besides, I spend so much time sleeping when I’m depressed that finding myself actually wanting to do things is a refreshing change.

The side effects of ketamine typically go away very quickly after an infusion, but I have the added factors of multiple anti-nausea medicines and the MAOI antidepressant I take, Emsam. In my experience, the combination of all this makes for a more intense experience of IV ketamine and slower recovery from its acute effects.

My previous ketamine infusion felt more effective than recent ones felt. I didn’t start napping again until a few days before this infusion, I’ve been fairly motivated, and my general level of hopelessness hasn’t been too bad. Hopefully, this one will have the same effect on my depression.

If you’d like to read more about my experience with ketamine for depression, start from the beginning of The Ketamine Chronicles or visit the archives. Click here for mobile-optimized archives of The Ketamine Chronicles.

A metallic green hummingbird perched on a red plastic flower ring being worn by a hand held in the air with fingers bent.

Enjoying Good Days with Treatment-Resistant Depression

When I have good days with depression, it feels like coming out of a long, dark winter to find that the Earth is still spinning. In all of its complexities, the rhythms of life kept going on around me. Maybe I feel lighter, I laugh more, or I once again find enjoyment in my interests. Then, because I tend towards perfectionism and outrageous expectations, I throw myself into working on various tasks that have gotten out of hand in my mental absence.

Frantic Feelings of “Wasted” Time

Take, for instance, laundry. I tend to do absolutely none of it when I’m struggling with depression, which leaves me wearing dirty clothes or reaching into the recesses of my closet for that neglected, ill-fitting shirt I should just get rid of. Then, a good day comes along. And I have to do ALL of the laundry. In ONE day. Don’t get me wrong – I do enjoy the sense of satisfaction when this happens. It’s nice to finally have the motivation to do something and be rewarded with the feeling of a job well done. But I can’t help but notice the faintly frantic sensation I find in the background.

From experience, I know that my depression is very stubborn. If it lets up for a day or two or even a few weeks, it could be back soon. I’m like a squirrel hiding nuts for winter, except I’m vacuuming my floor and doing all my laundry because my treatment-resistant depression could come back at any moment. It’s best to be prepared for whatever is ahead.

A backlit mountain with dark pine trees in the foreground.

Being Mindful of the Good – Despite Depression

I’m always working on noticing when things don’t suck. When a good day with depression comes along, it’s nice to get things done, yes. But it’s also nice to just appreciate the little gems of each day. Dappled light on November’s yellow leaves, watching Stella roll over for belly rubs from the kids down the street, the aroma of coffee brewing in the early hours of the morning – these small moments that slip by me when I’m depressed are important because they demonstrate that there is good in the world to be appreciated.

The silhouette of a hummingbird in flight near a green tree and a red hummingbird feeder

About a month ago, I started sitting outside in the mornings with a hummingbird ring feeder. I’d just sit very still, sipping my coffee and listening to the hummingbirds zip around in the neighborhood. One day, a brave little bird came by to check out the nectar in my fake flower ring. It hovered nearby for a second before moving in and landing its tiny feet on the edge of the flower. I could feel the gusts of wind from its wings on the back of my hand. It stayed for about 30 seconds, drinking the nectar and alternately taking off and landing again before moving off into the early-morning air. It was legitimately one of the coolest things that’s ever happened in my vicinity.

The hummingbirds have migrated south by now, but that experience has stayed with me and reminded me of the value of being still. Depressed or not, taking time to observe the world around me almost always gives me a positive feeling. It’s good to stop and smell the roses, as they say. Or maybe they should say, “It’s good to stop and let a tiny bird drink sugar water out of a gaudy piece of jewelry on your finger.”

Depression Recovery isn’t Perfect

Instead of preparing every item of clothing I own for the possible approaching depression, I’d like to store away moments of gratitude. I’m trying to let go of the fear that my good days with depression will inevitably end. I’ll have to loosen my grip on perfectionism – do a little of what needs to be done, but save space for noticing the delightful morsels of a good day. I know that I rarely remember them in the same light when I’m depressed, but perhaps having an entire hollow tree filled to the brim with pleasant moments will convince me that if past me thought they were worth storing away for winter, future me will, too.

Red maple leaves growing on tall branches against a white background

How Psoriasis Affects My Mental Health

I recently took my first dose of Stelara, an injectable medication known as a “biologic” that treats, among other things, psoriasis. I’m so excited, I could pop.

What is Psoriasis?

Psoriasis is an extremely visible autoimmune condition which results in red, inflamed skin with scaly white flakes. My immune system is attacking my skin, causing the affected skin cells to turn over at a dramatically accelerated rate (7-10 times faster than healthy skin!) The severity of my psoriasis can be seen not only from the outside, but from the inside as well. My bloodwork shows evidence of systemic inflammation, which puts me at risk of developing other illnesses, including psoriatic arthritis.

Treatment with Topicals

For the past 15 years, I’ve tried to make topical creams, ointments, solutions, and for a while, UV light treatments, work for me. Using topical treatments properly requires that you follow a schedule of twice-a-day application for two weeks on, two weeks off in various combinations of steroids, vitamin D derivatives, and whatever other prescriptions you’ve been given. It takes me about 30-40 minutes each time.

After about a week, I see definite improvement, which used to be incredibly exciting but is now a pointless exercise in bitter disappointment. As soon as I begin the recommended two-week steroid-free period or simply run out of motivation, my skin begins the infuriating cycle all over again, often worse than the last time. I have never had a period of complete remission.

A brown cardboard sign with white letters in cursive that say "feeling flaky?"
Yes, yes I am. (Spotted in a Safeway. Puff pastry, I think.)

Treatment with Biologics

I reached a tipping point. I don’t know what exactly pushed me over the edge, but I know that I can’t take it anymore. My psoriasis is “severe,” meaning at least 50% of my body’s surface area is affected. Topical treatments aren’t enough, so my dermatologist and I decided that Stelara is the best option for me.

Biologics like Stelara function by suppressing the immune system, which puts you at risk of infections and certain cancers, but the newer biologics are more targeted than older ones. They attempt to treat only the parts of the immune pathways that are going wrong, which reduces the impact on other immune system functions.

Take That, Psoriasis

It makes me anxious to include photos of myself in this post, but I’m tired of trying to navigate the steps I take to hide my skin. Do I dare wear something with an open back? Should I stick to shirts that go up to my neck? Better avoid dark colors so the flakes aren’t obvious.

Psoriasis has been squashing the self-confidence out of me since I was 10 years old. Knowing that I’ll likely deal with psoriasis in one way or another for the rest of my life, I’ve worked to derive my confidence from who I am rather than how I look, but it’s an internal conflict that I’ve never completely solved. I desperately want Stelara to work for me. It’s exhausting to be, on some level, constantly self-conscious. I can’t fully imagine how much of a relief it would be to put that behind me, but I also don’t want to forever be embarrassed about these years of my life. I don’t want psoriasis to win.

This is what I look like, and if you look like this too, know that you don’t have to fit societal standards to be confident in the skin you have.

A person's torso with large psoriasis plaques.

Living with Psoriasis and Self-Criticism


[In this post, I describe my feelings about life with severe psoriasis. I do not want readers who have skin conditions or any physical differences to be hurt by my self-judgments and insecurities. My words are about my experience only.]


It’s taken me so long to come around to the idea of taking a biologic because I blamed myself for not being more consistent with topical treatments. I thought that if I could just be more diligent, my psoriasis wouldn’t be so bad.

It was like boiling a frog; maybe I could have kept it at bay in the beginning, but it just got worse and worse. Eventually, I was so accustomed to it and so convinced that its severity was my fault that I chose to stay in the scalding water rather than get a lift out on a ladle. I also do this with my mental health; I must not be trying hard enough. If I just keep at it, I won’t need to accept more help. If that sounds completely unreasonable, it is – but it’s hard to change thought patterns like that.

Bottle it Up (don’t, though)

I’m 25 now, and my psoriasis is so severe and I’m so disillusioned when it comes to making a dent with topicals that I only use them “as needed” (in my view of “need”). When just twisting at the waist splits the plaques down to raw, bleeding skin and I can’t stand the torture of having unreachable itches in my ear canals, my motivation is briefly renewed. When it inevitably worsens again and I can’t manage it, I’m hard on myself for letting it happen then and all the times that came before. So in order to deal with despair over what I came to see as a failure to fix myself, I became an expert at avoiding the emotions of it. If I let myself fall apart every time I thought about it, I’d never move. It’s far more comfortable to disconnect.

The reality of living every day in this burning, itching skin is too horrible to acknowledge all the time. Instead, I bottle it up until it explodes. I can go long stretches of time feeling like I genuinely don’t care – as long as I cover it with my curated wardrobe of acceptable garments and don’t have too much psoriasis on my face, I’m really quite good at pushing it out of my mind.

But eventually, it’s like I catch a glimpse of it from a stranger’s perspective and am knocked over by the pure shock of it. It hits me suddenly and I break down into tears and fury and grief over how it holds me back and the hopelessness that it could be forever. I’m suddenly overwhelmed by how disgusting and ugly I feel – judgements that I try to keep beneath the surface, but which sometimes bubble up painfully. Then, I gather myself up, shove it all back down, and tell myself that self-pity is pointless. I basically close the Faulty Logic Door on the Emotional Vault until the next time it explodes. Super healthy.

Prioritizing Experience over Appearance

Despite the harsh messages I send to myself about my appearance, I still want to move through the world unhindered by social stigma. Lately, I’ve been pushing myself to wear clothes that make me a tad anxious and, with the exception of swimming, I never let it stop me from participating in things. I’m always worried that people will be rude or hurtful, but that’s rare and stems from ignorance, not malice. Some people stare at me and I occasionally get well-meaning but unsolicited and questionable advice from strangers, but I’ve found that the vast majority of people don’t even bat an eye.

Facial Psoriasis

By virtue of being literally on the face I present to the world, facial psoriasis is particularly hard to deal with. Everyone sees it and has thoughts about it that I’m not privy to. My fears that those thoughts might be judgmental and mean are hard to set aside.

I decided a long time ago that wearing makeup to cover my psoriasis was not worth it. Besides the issues of time, money, and probable skin irritation of heavy-duty foundation and concealer, my desire to fit in and feel confident bumps up against my belief that it shouldn’t matter. It seems like a step too far for me, but for others, it makes a huge difference in their confidence, so, to each their own.

Mild topical steroids and other prescription creams do improve my facial psoriasis considerably, but only for as long as I’m using them, which is sparingly. The skin on your face is delicate, and the decade and a half that I’ve spent using topicals makes me reluctant to risk the side effects of overuse or – God forbid – getting them in my eyes. That’s tricky for me, because I have psoriasis on my eyelids.

On the left is how I wake up during a period of average/low inflammation. With very gentle soap, some careful flake removal, and unscented moisturizer, I can sometimes go from that to the righthand photo without using a prescription cream, which I save for really terrible days. I tend to have wonky, uneven eyelashes because, during bad flares, psoriasis spreads along my lash line and causes sections of eyelashes to fall out.

A psoriasis plaque that looks like a smiley face
A different kind of “facial” psoriasis

Interference and Feedback Between Psoriasis and Mental Health

Stress is a common trigger of psoriasis, which is hard to fix because having psoriasis is pretty stressful. As my mental health waxes and wanes, my psoriasis follows suit in an awful feedback loop. The stress of depression makes my psoriasis flare, and the hit to my self-esteem certainly doesn’t do good things for my depression.

My mental health definitely gets in my way when it comes to skincare. Even if I didn’t have depression, I probably wouldn’t be able to keep up with the treatment routine, but when depression makes getting out of bed and changing my clothes difficult, you can bet that I’m not spending an hour and 20 minutes per day applying goop to the skin I hate looking at.

Overwhelm and Support

Depression and psoriasis are both chronic and painful, and they both take a lot of work to manage. Metaphorically, the overwhelmingly hopeless experience of depression feels like trying to beat back a chronic rash that covers your whole body using nothing but a little tube of ointment. Each is a monumental effort that seems to never end. I’ve learned that tackling difficult, stigmatized issues gets a little easier if you don’t do it alone.

Balancing Impacts

Lithium, which treats my depression and suicidal thoughts, has the unfortunate side effect of causing or worsening psoriasis. (Is that a cruel joke, or what?) I’m not sure how much of an impact it’s had, but I suspect it’s contributed somewhat to the progression of my psoriasis.

[Left: After a dedicated effort to clear my skin in time for a wedding in 2018. It was brief but wonderful. Right: A terrible flare in the cursed year that was 2020.]

Starting Stelara

Any time I spent bullying myself about my skin and my willpower was too long. This change is not a failure, but a success in finally allowing myself to accept help.

Stelara is a momentous step for me; I’ll admit it’s filled with a fair amount of bitterness about how many years I’ve spent suffering, but also acceptance, excitement, and hope.

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