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At the Bottom of a Well: The Ketamine Chronicles (Part 33)

I forgot to put on a scopolamine patch the evening before this ketamine infusion, but other than that, this one was packed with stuff intended on making the ketamine more effective. Cimetidine, magnesium, petocin, some anti-nausea drugs, to be honest, it’s all a blur. It was “the kitchen sink.” Getting infusions of IV ketamine for treatment-resistant depression is kind of a balancing act. It works best as an individualized recipe, and it seems that mine is always changing.

I don’t usually start out my ketamine infusions with chit chat, but this time, I spoke to Sarah for a couple of minutes before closing my eyes. What we talked about, I no longer remember, but it was casual and light. When I did close my eyes, I had the sense that this infusion might be a gentle experience at the surface between lucid and zonked. I was very wrong. I think that focusing on my conversation with Sarah diverted some of the weird sensations of ketamine from overcoming me, but they hit me later.

Sand and some lessons about depression

I remember a lot of sand. I was in a desert near some ancient stone ruins, and the sand was shifting like a river in the sunlight. I was on the ground, watching a snake struggle to squeeze between a crack in the stone building before the sand could drag it down. The snake succeeded, turning into a blooming flower as it rose up from the river of sand.

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Photo by @wolfgang_hasselmann on Unsplash

At some point, I was looking down a long tunnel into the ground – like a well – at some people on the other side. But as I strained to see who they were, I realized that I wasn’t looking down, I was looking up from the bottom. The people far above me leaned over the edge to gaze down, and the walls of the well crumbled into sand and buried me in darkness. It was quiet. It was something of a relief.

These experiences of being buried or of drowning are never frightening, but they do evoke a certain hopelessness. I used to have whole infusions dominated by water and the feeling of sinking, but lately, that theme has been absent. This theme of sand is different, but it feels much the same. I wonder if it has to do with the state of my depression at the time. In thinking back to the last few times I had a water-based internal experience, I do remember feeling similarly to how I feel now. I’m treading water, still moving a little in the direction of my goals, but I’m decidedly denser than my surroundings. Sinking would be so much easier than pulling myself upwards.

When I’m drowning or being buried in my ketamine infusions, it feels completely out of my control. The forces of water, sand, or perhaps depression, in this metaphor, are simply overwhelming. I think that my perception of depression is manifesting itself as unbeatable natural forces in my ketamine infusions. Most of the time, it doesn’t seem hopeless to that extreme in my real life, so it’s interesting that that’s how it comes out in my ketamine appointments. But, maybe that’s the only way my mind can conceptualize it in that setting.

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. But in reality, it’s neither of those things. It’s an illness that, like others, can be treated. Reality is clouded by depression, and it’s easy to forget how turned around I can become in my own mind.

Is the ketamine infusion over? Should I get up now?

At the very beginning of this ketamine infusion, my doctor pointed at the photo on the wall across from me and said, “We’ll just see if this starts moving.”

“I’m not supposed to have my eyes open,” I replied, referring to our frequent conflict in which I open my eyes and stare at various entrancing objects while he patiently reminds me over and over again that I’m supposed to have them closed.

“That was a test. You passed.” He laughed.

And then at some point in the infusion, I proceeded to leave my eyes open for what felt like a really long time.

In my defense, I was confused. I opened my eyes because I thought the infusion was over and that everyone was waiting for me to get it together. Let me tell you, trying to fight ketamine while it’s still infusing into your bloodstream is pretty impossible. I kept thinking that I needed to get up and walk to the car, and that seemed utterly beyond my capabilities.

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Photo by Michael Dziedzic @lazycreekimages

I vacillated between anxiously willing myself into wakefulness and resigning myself to living the rest of my life in that very chair. Words can’t describe how disoriented I was. Every time I blinked (which wasn’t often and was probably more like a short time with my eyes closed), the room seemed to change somehow. It was wider than I remembered, then it was taller, then the picture was farther away, and everything was tilting to the side. I couldn’t understand why it was taking me so much longer than usual to regain my faculties.

I distinctly remember thinking, “I wish someone would just tell me what I’m supposed to be doing.” That thought gave me some satisfaction because after all, how could anyone get frustrated with me for being slow when they didn’t even tell me that I was supposed to be speeding up? “That’s *their* problem,” I thought. Having convinced myself that transportation to the parking garage was not my concern, I stared at the wall with the photo of the wolf and the goat and found that there actually were three frogs hidden in there, too. I occasionally thought things like, “What time is it?” or, “When did we start?” or, “Which way is up?” only to realize that the answer would mean nothing to me and there was no point in mustering up the energy to ask.

After some amount of time that may have been five minutes or five hours, I was told to close my eyes and that there were eight minutes left. Oh my God, what a relief. “How long did I just spend thinking I needed to get up? No matter, now.” Somewhere in my mind, I found some wry humor in my ability to carry my anxiety about inconveniencing people into Ketamine Land. I guess it follows me everywhere.

After that, I spent some time thinking about oobleck, which is a non-Newtonian fluid often made in middle school science class composed of corn starch and water. It moves like a fluid at rest, but solidifies when you exert sudden force upon it. I felt like I was surrounded by oobleck. Or maybe that I was made of oobleck. Things were flowing like a lazy river when I let go and rested, but when I tried to move, I found myself glued in place.

The eight minutes that were left when I closed my eyes instantly shrunk down to about twenty seconds, and then before I knew it, I was back to searching the inside of my brain for control of my limbs. I got my coat on, missed my face a couple of times trying to put my glasses on, wobbled out the door, and successfully made it to the car.

IV ketamine for depression is different every time

The rest of the day passed uneventfully. I was interested to see if the reintroduction of magnesium into my infusion would result in the wild limb jerking that happened the last time we used it, but thankfully, it didn’t. The bizarre afternoon I had that time has continued to be an isolated event. This time, I slept for most of the day, got up for dinner, then went back to bed. I think. To be honest, I don’t remember the details, but I know that it was fairly mundane.

Every infusion I’ve had has been different, which is why I find it so interesting to write about them. Even my experience once I get home tends to change, and I can’t always pinpoint why. Sometimes, I go about my day – working, writing, walking the dog – and sometimes, I just crash.

It doesn’t even seem like a wackier or more mundane experience correlates with any particular result. At least, as far as I can tell. Maybe there are just too many factors for a clear pattern to emerge.

For the time being, I’m planning some more changes to my medication regime, trying not to nap too much, and carrying on with tiny clams.

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My Unofficial Therapy Dog

I’ve started bringing my dog to therapy. Does she sit with me and look patiently into my eyes while I cry? No, definitely not. She spends 10 minutes wandering around, smelling the smells of the week with great vigor. She pokes the diffuser with her nose, sticks her whole head in the trash can, and squeeeezes behind my therapist’s chair to not-so-sneakily smell her belongings. Then, she goes back and forth between the window and relaxing on the rug, ears perked up, listening for outside sounds. She comes over to me for pets and cookies every once in a while, but mostly, she’s just nice to have around as my unofficial therapy dog. She’s completely oblivious to my human problems. Looking at her blissful ignorance during therapy is like a brain palate cleanser.

You can’t help but wonder what she thinks of this development. Here we are, in this room we come to sometimes for no discernible reason. Pretty comfy. New smells since last week. 8/10. Would be better if I got second dinner. All that matters to her is that I feed her, walk her, and let her sleep at the foot of my bed. She’s a simple creature – intensely curious and frustratingly smart – but simple in that she really doesn’t need a lot to be happy.

She shares some of that innocent joy with me. She makes me smile every single day. It doesn’t matter how depressed I am – she does something goofy or sweet and has no clue that I find her antics ridiculous. Like how she leads with her face when encountering snowdrifts, or her exasperation at me taking constant photos of her, or the many, many hilarious faces of Sleeping Stella.

Sometimes, when I try to change something in my treatment(s), my depression says, “No, thank you.” Changing my medications has not gone well for me in the past, but I continue to clutch my personal dream of reducing the number of things I pick up from the pharmacy. I recently added a drug which required me to get off of something else, which overall, does not seem to have gone well. The options now are complicated and I don’t particularly like any of them, but I still have Stella! The routine, obligatory outdoor time, and turbo-boosted zoomies have done me immeasurable good. She demands my attention and action, and there’s really no telling her to just go entertain herself. Our walks are sacrosanct to her. No replacements. And no skimping on length, either!

This was part of my goal in adopting her, and it worked in more ways than just the responsibility of it. I thought that it would be healthy for me to be forced to get out of bed and do things, but that the emotional reward of that would come during my good times. I wasn’t expecting my unofficial therapy dog to be able to careen through the fog of my depression and make me smile every single day. A smile or laugh every day certainly doesn’t fix everything, but it’s something to be thankful for.

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“We’re snuggling! This’ll be cute.”

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Depression in Men: Why is it Different?

Four times more men die by suicide than women, and yet half as many men are diagnosed with depression as are women (1). In researching this topic, I was encouraged by the shift our society is making towards understanding depression in men and the factors that push them to such lengths. However, there is clearly still a long way to go. A book I skimmed early on in my search, aptly titled Men and Depression, by Sam Cochrin and Frederic Rabinowitz, mentions in the introduction that “A book that examines distress and depression in men may be seen by some as politically provocative.” In 2000, when that book was published, many researchers and clinicians were working to move public perception of mental disorders in men inch by inch. They recognized that the disparity between the number of men diagnosed with depression and the number of men who kill themselves indicates a hidden population of men who battle their depression in secret. 21 years later, the number of articles under a “depression in men” search in Google Scholar numbers over 3.5 million.

As a woman who suffers from depression, I feel relatively safe in disclosing my diagnosis. People are generally sympathetic and understanding when I discuss my symptoms. But how do men feel about the way their depression is received? A man I know has been dealing with depression for a long time, so I asked him exactly that question. Thankfully, he told me that his social circles have been largely supportive, which I think is an encouraging sign for our culture’s direction. But what factors make the rates of suicide between men and women so different? If we’ve come from “politically provocative” to millions of research articles in two decades, why are many men still suffering in silence? I want to dig into this issue to understand the historical trends, what sometimes makes depression in men different, and what we can do to keep the conversation going.

Historical Epidemiology of Suicide

In a really deep dive, we could go way back to Hippocrates and Galen to explore the perceived gender divide on mental disorders, which would be interesting. But in this context, we’ll stick to the 20th and 21st centuries. Let’s take a look at this set of data from the CDC’s Data Finder (12). It’s compiled mostly by decade between 1950 and 2015. This graph of the data, which I made with my rusty skills in Excel, illustrates the suicide trends by rate among men in various age groups.

Although the rate of suicide among all ages has remained relatively stable, trends within age groups are concerning. Suicides among 15-24 year-olds have increased dramatically, as have those among 25-44 year-olds. Despite a somewhat steady decline in the suicide rate of men aged 65 and older, they remain the group with the highest rate. By 2019, the rate of suicide in men had increased from 21.1 deaths per 100,000 to 23 deaths per 100,000 (13). For every 100,000 men, 23 deaths doesn’t immediately sound shocking. But to illustrate the numbers in a different way, consider that in 2019, a horrifying total of 37,256 men killed themselves in the U.S.

It introduces another layer of complexity to compare the data on men to the data on women. The suicide rate among women of all ages has increased since the 50’s more than it has among men, but it still sits markedly lower. In 2019, the overall suicide rate among women was 6.2 deaths per 100,000 people (13). Compared to 37,256 male suicides, the country saw 10,255 female suicides. Both of those numbers are unimaginable to me, but it’s worth investigating; why is the rate for men so much higher than it is for women?

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Photo by Mykyta Martynenko on Unsplash

Diagnostic Factors

The wildly higher rate of suicides among men than in women, combined with the average 2:1 ratio of depression diagnoses in women versus men, convincingly suggests that depression in men is going undiagnosed. An increasingly accepted hypothesis regarding this conclusion is that depression in men and women can be experienced in different ways (10). The current diagnostic tools don’t capture all of the symptoms of depression that men commonly face. The gender differences in symptomatology have led some to argue for the recognition of separate depression diagnoses for men and women. Magovcevic and Addis conceptualized the differences as constituting typical depression plus a subtype, masculine depression (6). Subsequent research shows that some men who don’t fully fit the diagnostic criteria on traditional depression questionnaires may be diagnosed when masculine depression symptoms are considered.

Masculine Depression Symptoms

“Masculine depression” (also called male depression and a variety of other terms), is characterized by more symptoms of anger, aggression, risk taking, and substance abuse than tend to occur in women. These symptoms are examples of “externalizing features.” They serve to express a person’s emotions in an outward, active way. “Internalizing features” of depression are identified by retreating into one’s self, such as by ruminating, engaging in negative self-talk, and isolating from others.

New Self-Report Scales

To investigate the efficacy of adjusted self-report scales at identifying depression in men, researchers created the Gender Inclusive Depression Scale (GIDS) using two other male depression scales validated with small cohorts. When symptoms of masculine depression – the externalizing features – are included in a traditional diagnostic survey, the rates of depression diagnoses among men and women are not significantly different (7). In other words, the gender differences disappear. Another scale, the Male Depression Risk Scale (8), measures emotion suppression, drug use, alcohol use, anger and aggression, somatic symptoms, and risk-taking. The sensitivity of the MDRS is similar to that of the PHQ-9 in recent suicide attempt identification (9).

Why is Depression in Men Sometimes Different?

To be clear, it’s a continuum; many men are diagnosed with depression using traditional questionnaires. But for the ones who aren’t, the answer is probably based in gender norms. Men who have depression and who identify with traditional ideals of masculinity are more likely to experience masculine depression symptoms (4). In a society that has traditionally viewed men who express sadness as “weak” or “feminine,” it makes sense that sometimes, depression in men is displayed as anger or in attempts to cope with it through substances. Sadly, it’s more socially acceptable for men to express anger than sadness, self-doubt, or anxiety.

Photo by Jordan McQueen on Unsplash

Why is the Suicide Rate Among Men so Much Higher?

If newer diagnostic scales indicate that the rates of depression in men and women are actually more alike than previously thought, what is going on with the suicide rates? Why would men die by suicide four times more often than women? It’s hard to know how many suicides could have been prevented by mental health intervention, but it’s logical to think that men who aren’t seeking counseling or who are dismissed without a diagnosis would be more likely to turn to suicide as the answer. Additionally, we know that although men complete suicide more often than women, women attempt it more often (11). Men tend to use more lethal methods, and for some men, the act of suicide represents an affirmation of strength and independence (2). It is crucial that we improve identification and treatment of depression in men (5).

A Note on “Masculine” and “Feminine”

With all of this discussion about a “masculine” depression facet, I have a small fear that readers of this post will leave feeling as though their diagnosis of depression must have been of the feminine kind. It’s not. It’s just depression – men, women, nonbinary people – it doesn’t impose judgement on your identity, it simply is. Just as men may experience more anger and impulsivity as part of their depression, women may be more likely to suffer body image issues and self-harm behaviors. But it’s a bell curve; just because men are more likely than women to exhibit anger as a sign of depression doesn’t mean that women can’t as well. Statistically, neither gender is more closely associated than the other is with the typical symptoms (8). The only gendered difference exists in the subset of “masculine” symptoms. The core set of symptoms that are covered in typical scales like the PHQ-9 remain the main diagnostic components of what we know depression to be. Expanding the criteria by creating a subset of symptoms more associated with men is just a way of widening the net in order to keep people from falling through the cracks.

For more reading on how men can view depression, suicide, and masculinity, check out this article. The author provides evidence for a variety of views that men hold about how mental health and suicide relate to masculinity.

Identifying Depression in Men Going Forward

For a long time, our definition of depression was too narrow. The research on gender differences in depression, which I have only barely scratched the surface of, is vast and still growing. Although the standard depression questionnaires remain focused on internalizing features to the exclusion of the externalizing ones, authorities on the matter have acknowledged the issue in other ways. The American Psychiatric Association has a webpage from 2005 that describes the early research and what to watch out for in men who may have depression. They now have a number of web pages, magazine articles, fact sheets, and books about men and depression. Someday, I hope that standard depression questionnaires will include measures for symptoms that men exhibit, but until then, we can continue to reduce stigma and spread the word about how depression in men can manifest.

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Photo by Marco Bianchetti on Unsplash

You can pass online resources on to the men you know. You can talk about it with your doctor. You can listen to your friends, fathers, brothers, and sons. Assure them that having feelings doesn’t make them less of a man, it just makes them human.

Resources

  • National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255)
  • Advice on looking out for friends: beyondblue.org
  • Potential symptoms and tips for self-care: texashealth.org
  • Information, resources, and community: headsupguys.org

Citations

  1. “By the Numbers: Men and Depression,” December 2015. https://www.apa.org/monitor/2015/12/numbers.
  2. Canetto, Sylvia Sara, and Anne Cleary. “Men, Masculinities and Suicidal Behaviour.” Social Science & Medicine 74, no. 4 (February 2012): 461–65.
  3. Cochran, Sam, V, and Frederic Rabinowitz E. Men and Depression: Clinical and Empirical Perspectives. Academic Press, 2000.
  4. Genuchi, Matthew. “Anger and Hostility as Primary Externalizing Features of Depression in College Men.” Psychological Sciences Faculty Publications and Presentations, August 1, 2015. https://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1223&context=psych_facpubs.
  5. Keohane, Aisling, and Noel Richardson. “Negotiating Gender Norms to Support Men in Psychological Distress.” American Journal of Men’s Health, October 11, 2017. https://pubmed.ncbi.nlm.nih.gov/29019282/.
  6. Magovcevic, Mariola, and Michael Addis. “The Masculine Depression Scale: Development and Psychometric Evaluation.” APA PsycNet, 2008. https://psycnet.apa.org/record/2008-09203-001.
  7. Martin, Lisa, A, Harold Neighbors W, and Derek Griffith M. “The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication.” JAMA Psychiatry, October 2013. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1733742.
  8. Rice, Simon, M, and Anne-Maria Moller-Leimkuhler. “Development and Preliminary Validation of the Male Depression Risk Scale: Furthering the Assessment of Depression in Men” 151, no. 3 (December 2013): 950–58.
  9. Rice, Simon, M, John Ogrodniczuk S, David Kealy, and Zac Seidler E. “Validity of the Male Depression Risk Scale in a Representative Canadian Sample: Sensitivity and Specificity in Identifying Men with Recent Suicide Attempt.” Journal of Mental Health, November 2017, 132–40.
  10. Rutz, Wolfgang, Jan Walinder, and Lars Von Knorring. “Prevention of Depression and Suicide by Education and Medication: Impact on Male Suicidality.” International Journal of Psychiatry in Clinical Practice, January 8, 1997. https://www.tandfonline.com/doi/abs/10.3109/13651509709069204.
  11. Schumacher, Helene. “Why More Men than Women Die by Suicide.” BBC Future (blog), March 17, 2019. https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women.
  12. “Table 30. Death Rates for Suicide, by Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950-2015.” CDC, 2017. https://www.cdc.gov/nchs/data/hus/2017/030.pdf.
  13. “Underlying Cause of Death, 1999-2019 Request.” Data Table. CDC WONDER. Accessed January 17, 2021. https://wonder.cdc.gov/controller/datarequest/D76.
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Having Good Days with Depression

Every time I have a sudden improvement in my depression, I’m blown away by how much easier life is. When you live with something every day, you get used to it. It no longer catches your attention when your symptoms don’t stand out from the daily noise.

Yesterday, I had a good day. I called a friend, went for a run, attended a virtual writing group, and only napped for one hour! This is a dramatic improvement from recent weeks. I can’t believe that such a mundane day could feel so novel and exciting. Today, I woke up and thought, “What am I going to do today?” Not in my usual “I’m tired, every day is the same, and I’d rather stay in bed but I have to do something.” way. More of a “I could accomplish something today” way. I actually feel slightly enthusiastic about it. I’m looking forward to the near future but nothing in particular, which is a foreign feeling to me. It’s a kind of vague “the day is full of possibilities” feeling that is a dramatic change for me. I attribute this shift to a second ketamine infusion I had just a few days after my regularly scheduled infusion. The goal was to sort of trampoline-double-bounce me, and hooray – it worked!

I had a conversation somewhat recently about how easy it is to doubt yourself when you have a chronic, “invisible” condition. You might start to forget what “normal” feels like, which makes it hard to tell if you’re there or not. For instance, I often find myself questioning whether I’m being sluggish because of depression or because I’m not putting in enough effort. When you check in with yourself often (“Am I feeling better yet? Is _____ working yet?”) it’s easy to get bogged down in minute details and lost. But a sudden shift in my mood shows me that I can easily tell when I feel better. It’s a change that I notice right away. It’s somewhat validating, actually.

I also try not to dwell on the anxiety that this improvement could be short-lived. I’m accustomed to the very slow seesaw of my moods, which makes a worsening of my depression at some point in the future seem likely. It’s an exercise in mindfulness to focus on the day as it happens. Right now is pleasant and noticeably easier than just a few days ago. The future will unfold as it will, so I may as well appreciate the present.

Here are some things I appreciate: As I’m writing this, my dog is asleep with her head on my legs. I can feel her twitching as she dreams of canine life. I’m astonished at how much she helps me – how important she is to my mental health. I’m grateful beyond words for her. It’s almost noon and I am still awake, having made it several hours past my usual nap. I’m getting tired, but that’s ok. I’m going to enjoy the improvements and be kind about the symptoms that remain. I appreciate comfortable clothing, raspberry tea, and the flexibility my job provides. I recently learned that clams have internal organs but mussels do not, and I’m thankful for Wikipedia. I appreciate my curiosity, both for random facts and for how far I can go with this newly lightened mood.

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Kaleidoscope: The Ketamine Chronicles (Part 29)

Right away, I could hear my heartbeat in my ears and head, and my face seemed to be pulsating with the rhythm. My ears became surprisingly hot, but all of that faded away after a few minutes. Usually when I close my eyes, I see bizarre images, but they’re mostly distinct and recognizable. This time, there were points when I felt like I was traveling through a three-dimensional kaleidoscope – just shapes and colors that morphed together as they moved. The real world was also especially distorted this time, and once, when I opened my eyes, the wall across from me appeared to be covered in pale yellow cobwebs. There were two tiny silhouetted figures standing among the cobwebs, engaged in what looked like a silent argument. After a minute or so, one of the figures sprouted wings and fluttered away like a moth. I don’t think I’ve ever had my ketamine dreams intrude upon the real world when my eyes are open before. It was really trippy.

I don’t remember much of the internal experience, but I know that there were a ton of lines – straight lines, wavy lines, crosshatched lines, diagonal lines, lines moving away from me, and lines coming closer. Sometimes, I was looking for something among the lines, but it was always hidden out of sight. If you’ve ever seen those “deep dream” images created by Google’s neural net API, you know roughly what my experience was like this time. Here’s one I just made out of a picture of a sloth.

I had always assumed that trippy pictures like that were just weird approximations of what it would be like to be high. But no, it really looked a lot like that. Just take that image and imagine it moving, and that’s pretty much it.

There were rarely any distinguishable objects in my inner view this time, though. It was mostly just a sea of odd, moving blobs and spirals. When the lines and colors and moving kaleidoscope patterns got to be too much, I’d open my eyes briefly. I’m technically not supposed to do that, but it did serve as an effective break from my brain’s wild mishmash of subconscious vomit.

At some point, I switched my crossed ankles and was immediately struck by the sensation that my legs were melting. My bones seemed rather rubbery, and the weight of my feet extending past the footrest made me feel as though my shins were bending in the middle. I remember thinking that I felt just like a Salvador Dali clock, melting over the edge of the footrest. My whole body threatened to melt, at which point I’d slip off the chair into a puddle on the floor. It occurred to me that it would be difficult to get back to the car that way.

During my moments of open-eyed room viewing, I noticed that the door looked unusually soft. It appeared to be made entirely of clay or putty. The color was the same, but it looked temptingly squishy, like if I went over there and pressed my hand on the edge, it would just mush in on itself. Perception is so interesting. Just 20 minutes earlier, I had interpreted the same visual signals in a completely different way.

Ever since I wrote that post about water in my ketamine dreams, I haven’t had any further peaceful drowning experiences. Maybe it’s a coincidence, but I do think it’s interesting that after contemplating potential meanings of that recurring image, I no longer find myself experiencing it. What does still happen is the spreading darkness. This time, I was trying to look through a bright skylight while inky blackness approached from all around. It closed in until all that was left was a pinprick of light. Whenever that happens, my mind just switches gears and I begin a new dream-like vision.

My next appointment is three weeks from now. I think I already feel lighter, although still a little spacey. My memory of yesterday is kind of foggy, and conversations I had feel choppy and surreal. I got home mid-afternoon and promptly fell asleep. At 11pm, I awoke suddenly, wondering where I was. I had fallen asleep on top of my blankets, oriented the wrong way with my feet on my pillow. I sometimes nap this way in order to differentiate naptime sleeping from nighttime sleeping, but it was still incredibly disorienting. I managed to do all the usual things I do before bed and then crawled under the covers the right way.

I hope this ketamine infusion works; I’m feeling discouraged again. I’m tired of being tired and unmotivated. The pandemic set me back a good deal, and I find myself forgetting that I had made some good progress last winter. It just feels like I’ve felt this way forever.

If you liked this post, consider starting from the beginning of The Ketamine Chronicles, or visit the archives for month-by-month posts.

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Depression is a Sinkhole: The Ketamine Chronicles (Part 4)

When I was looking for information about ketamine infusions for treatment-resistant depression, I didn’t find a lot of descriptions of what the infusion actually feels like. My internet forays left me with the impression that it would be like what I experienced in my second infusion– that feeling of being so relaxed that you’re near sleep and aren’t aware of your physical body. What I read online certainly didn’t prepare me for my first infusion, which was extremely bizarre and hallucinogenic, nor did it reassure me that the right dose of ketamine for me would produce an entirely different experience than the previous infusions.

My third infusion happened last week. I had persistent nausea after the first one, so we lowered my dose for the second infusion. Not seeing any improvement, this time we increased the dose of ketamine and doubled up on some nausea medications. I was given five milligrams more than my initial dose, so my doctor assured me that if it was too intense, it would be okay to tell him and he’d either slow it down or give me a gentle sedative to make it less overwhelming. Writing about this today, only four days later, I’m already struggling to remember what it felt like. It was absolutely less intense than the first infusion, but it was more intense than the second one. Where the second infusion was pretty boring from a descriptive standpoint, the third had slightly more of a visual component. I remember watching organic shapes fill my mind, colored in blues, browns, and oranges. Lots of small circles packed into varying levels and areas. Then, thin lines with colors in between resembled layers of sediment, flowing out of sight.

One common experiential thread between all of the infusions I’ve had is the altered sense of time. I get sucked into my brain and completely lose connection with anything identifying time, then am shocked (as shocked as a partially-anesthetized person can be) when I’m told that much more time has passed than I think. Or, the opposite happens and it seems that time moves incredibly slowly. It’s oddly freeing to accept that for roughly 45 Earth minutes, I have no choice but to abandon all concern for time. I’ve checked out of humanity’s need to measure minutes; talk to me when I return to my bipedal meat suit.

Coming out of it is also a similar feeling each time, which is unfortunate because it’s not super pleasant. It’s not terrible, either, but it does leave me feeling vaguely unbalanced and zonked out pretty much until I get the chance to sleep it off. This was difficult for my third infusion because I was traveling later that day. I shuffled through security with the rest of my bleary-eyed fellow travelers, then felt eternal gratitude when, after the flight, my mom led us to the car pick-up area and even engaged our talkative Uber driver in conversation at almost midnight. I was ready to curl up in the fetal position on the vacated shoeshine stand and give in to blissful sleep.

I returned home and yesterday, I had my fourth ketamine infusion. I tolerated the last dose and feel, possibly, a tiny bit better. It’s unclear. In any case, we decided to increase it again in the hopes that we just haven’t hit the right number yet. Like always, I twiddled my thumbs a little before I started to feel it. I vaguely remember asking the nurse if this ever gets boring for her, as she sits quietly next to me and makes notes on her clipboard. She said something like “No, everyone reacts differently. I don’t get bored” to which I replied “Oh, good, I’m gl a d  i’m n o t bor i ng  y o o o u u” and promptly left this dimension.

As I described it to my doctor at the end, this infusion felt like a combination of the first and second infusions– both somewhat visually engaging and also relaxing. The very first sensation after leaving my nurse sitting next to me was of sinking into inky blackness. Normally, that would sound terrifying, but this was very soothing. At first, all I saw was black behind my eyelids. I began to think that I should think of something to think about. This was more difficult than I expected, because every time I had an idea, it floated away. My mind seemed to have its own plan for yesterday’s infusion. Much like with time, I’m learning that trying to control anything during a ketamine infusion is futile.

Despite trying to think about my dog, I saw landscapes. Many moving landscapes empty of people, buildings, or animals. I saw a desert with packed, cracked sand. I saw a beach with gravel and sand underwater with volcanic stones bobbing and rolling. I saw a forest, and when I began to think about depression, I saw a great sinkhole open up. It swallowed pine trees and boulders, sucking everything closer. It was like pulling on a tablecloth, everything dragged inexorably towards the central force.

The landscapes were beautiful, and unlike looking at photos of nature, these felt real, like they were part of me. I felt connected to them, and I was glad, then, that time was moving slowly (it had only been ten minutes- I thought it had been 30). Occasionally, something would tug at my awareness, and I’d come back to my body.

humanoid statue with large hands and head
Photo via The Brain Geek

The blood pressure cuff would suddenly tighten, reminding me that I did indeed have an arm. I was reminded of the cortical homunculus concept (a humanoid figure with body parts proportional to the density of nerves dedicated to sensing and moving those parts), as my hands felt very large and very close to my face, although I knew they were resting in my lap.

The position of my body in space, which I generally have trouble detecting because of Sensory Processing Disorder, was also a strange experience. I could have sworn I was upsidedown, but somewhere in my mind, I knew that was absurd. Several times, I was captivated by the feeling that my eyes were open, even though they were definitely closed. I remember thinking that maybe this is what people mean when they describe a third eye; my body’s eyes were closed firmly, and yet it felt for all the world like I was looking around.

The whole experience of my fourth ketamine infusion felt rather profound, although I couldn’t tell you why. Maybe that’s a good sign? I’m doing my best not to feel discouraged, and to continue on with detached curiosity and a tiny bit of optimism.

Until next time,

lumpdates

woman wearing floral dress blocking sun with hand while walking on sand dune in desert

Mental Health and Resilience

Is it ever ok to give up? Cultures around the world are inundated with myths, lore, and tales of a protagonist overcoming seemingly insurmountable obstacles and emerging triumphant. They’re admirable, they’re heroic, and we strive to be like them. How do they do it? It’s not that they’re unaffected by tragedy and hardship. Their secret is resilience.

The concept of resilience can be difficult to pinpoint, but I think this quote by Janna Cachola encapsulates what I think of as the essence of resilience.

“Resilience is not about being able to bounce back like nothing has happened. Resilience is your consistent resistance to give up.”

Resilience does not mean that you’re the same after your ordeal as you were before; we’re constantly changing. It means that even in the darkest of times, we either wait for it to pass, or we work to change our reality. These are both demonstrations of resilience- sometimes you just have to hunker down and hold on. But no matter what, we refuse to give up.

TW: This section discusses suicide

September 10th is International Suicide Awareness Day. In the last few days, I’ve been reflecting on what it means to be resilient in the context of mental health.  Cultivating resilience is one way to help us resist hopelessness and feelings of helplessness. It puts the power back in our hands. It says “I can get through this, no matter what.” This line of thinking is in no way a judgment on those who have died by suicide. It’s simply an attempt to continue a conversation started by researchers, therapists, and people fighting mental illnesses every day.

I’m no stranger to the importance of resilience in mental health. I’ve thought about suicide in such detail and for so long, sometimes it seems like an acceptable option. At the same time, the part of me that values hard work and persistence is appalled that I would consider giving up. It’s a dangerous balance that I need to monitor carefully in order to remain safe. Resilience doesn’t mean that you have to do it on your own. Rely on the people who care about you and all of your other resources. Ask for help, and accept it when it’s offered. As the saying goes, you’ve survived every single bad day so far- that’s a damn good track record.

– Love, your brain

 

“i was not born with roses
in my chest
to be afraid of thorns.i was born to
bloom
in spite of them.”
― Vinati Bhola, Udaari

green-vine-climbing-white-wall

How I Learned to Advocate for Myself

I’ve been enjoying all of the content online for Mental Health Awareness Month, and I thought I’d contribute my own story. Here’s my own experience of why advocating for yourself is important.

I have severe psoriasis, an autoimmune skin condition that makes itchy, flaky plaques where my skin cells regenerate too quickly. During my recent hospitalization (for severe depression), I let my doctors know about this in a brief, it’s-not-that-relevant-but-you-asked kind of way. When the psychiatrist asked if I had any physical conditions, I informed him of my psoriasis.

A few days later, I was meeting with my social worker to discuss my treatment plan. Under “diagnoses”, Major Depressive Disorder and psychosis were listed. Before I even said anything, my social worker quickly brushed it off and said “don’t worry too much about the psychosis- it might just be that you were confused when you came in”.

Now, I’m the kind of person who will eat the wrong food at a restaurant rather than speak up and point out a mistake. I’m the kind of person who willingly takes the middle seat on an airplane because my neighbor explains that she has to pee a lot. Seriously. I am not assertive.

However, diagnoses are a whole ‘nother bucket of fish. When I saw that on my treatment plan and heard my social worker minimize it, I made it clear that I was confused by it and wrote my concern in the questions portion of the form. The next time I saw the psychiatrist, I steeled myself in preparation to ask about the mysterious psychosis that I definitely didn’t have. Before I could bring it up, he sat down, sighed, and said “it turns out that they couldn’t read my handwriting and thought I wrote ‘psychosis’ when really, I wrote ‘psoriasis’. It’s all fixed, now.”

I laughed about it at visiting hour that night and for many nights after. Really, we’re still laughing about it. We’re getting some serious mileage out of that one.

The important thing is that I spoke up for myself and that it got remedied. I almost had an incorrect diagnosis which could have caused more confusion down the line. So, speak up! If something doesn’t look right or feel right, let your doctor know. They’re people too, and sometimes mistakes happen.

Also, handwriting is more important than you might think.