When we drink alcohol, or use other recreational drugs, there is usually a rapid effect. Scarcely has the glass been placed back down, than a feeling of well-being – or whatever your drug of choice promotes – radiates through the limbs and settles happily in the cranial control unit. Obviously, more may be taken, and the whole situation may progress to something less than pretty, but the point is that you take something, and feel immediately better (or at least different).
Before I became personally acquainted with psychiatric drugs, I suppose I thought that they would be the same – you would feel bad, take one and feel better. I wasn’t a psychiatrist at this point, so my ignorance may be excused. This can be true for some drugs, for example benzodiazepines, which are ideally not taken long-term, due to the potential for tolerance. It also fits nicely with the alcohol analogy, providing a quick-acting, pleasant (if possibly dependence-provoking) effect. And if all psychiatric drugs were like that, I’d have probably taken them quite happily – if not to excess.
My relationship with psychiatric drugs has, however, always been difficult – even writing this makes me anxious. I think I’ve mostly agreed to take them, but can come up with ever more inventive reasons not to continue them. Why is this? Do they have side effects? Are there long-term implications? Are they stigmatising? Do I not believe that I’m ill? Do I want to be ill? I’ve thought about this a lot, and I still don’t know. I’m pretty sure I don’t want to be ill, but any of the others may contribute.
At the moment I take lithium and fluoxetine. Now lithium is unique among drugs for me in that I have no side effects – although I think my weight is starting to creep up, and can’t help wondering… But lithium, unfortunately, has a whole load of other meanings for me. It implies serious mental illness, and it was also the one I was taking at the start of a pregnancy that ended very badly. No side effects – maybe it has no actual effects, either? My husband once told me I was boring on lithium, and although he seems resigned to this now, it makes me worry that my scintillating wit and conversation may be suboptimal. At the moment the pendulum is swinging slightly more towards taking it, but thoughts of damaged kidneys and being ruled by future toilet availability will probably change this.
Antidepressants can be very unpleasant. I don’t deny that they can make a difference to an illness that is even more unpleasant; but the late onset of any benefit makes it hard to connect the treatment with the cure. Fluoxetine is currently my go to drug of choice, and I now take a relatively low dose. I will swallow my embarrassment and come straight to the point – like many or most antidepressants, it has a most discouraging effect on libido. You may not think that’s very important while you’re depressed, and you’d be right, but try taking it for two years for relapse prevention. At times I also feel a bit guilty about taking fluoxetine – because I am fairly sure it elevates my mood slightly beyond the happy medium, and part of me enjoys this. It’s probably attenuated by lithium, but I can’t help hoping my levels of the latter are low enough to let in a little joy. The fluoxetine is currently on a downward trajectory (in my mind, anyway), but sometimes I paradoxically think a little wistfully about actually increasing it.
Fluoxetine is, for me, perhaps the best of a bad bunch. All the SSRIs make me quite shaky when I start to take them, but I will grudgingly admit that this tends to wear off. I’ve also always been able to stop them abruptly, which may not be entirely usual – I remember stopping venlafaxine, which is notorious for causing problems, without any reduction, and nothing bad happened. Clearly this is useful if I don’t want to take them, but it also makes me suspect that they are inefficacious, which is less so. I haven’t had tricyclics for a while, now, but the associated constipation, sedation and weight gain wasn’t attractive. Dry mouth, from various drugs, has definitely speeded my gum decline, and I just wish someone had suggested chewing gum a bit earlier.
As a doctor I do believe in antidepressants, and prescribe them – with caution, and I hope with enough information about side effects – whenever I think they may help. But I know that, for some of my patients, the delay in response creates a similar kind of cognitive disconnect. Has this tablet helped me? Would I have got better anyway? The difficulty is that some people would, but it’s impossible to know who. There’s a Russian roulette feel to it, albeit with a potentially positive outcome.
But continuing the pills after recovery can require even more of a leap of faith. The uncertainty around their efficacy persists, and is compounded by the fact that you’re taking something with unpleasant side effects and feeling otherwise perfectly fine. Even one’s own experience can be inconsistent, and it’s easier to remember the times it all went right.
When I was first ill, however, I had a couple of years of repeated short courses of ECT and antidepressants, kept stopping the latter, and kept relapsing. Then lithium was added, and, for whatever reasons, things went better. It was a terrible time – I think that had it continued I would have lost my baby, my husband, probably my life. I am now a psychiatrist, and many years have passed; and I think, looking back, that I was very foolish. But I still don’t know how I would explain this to my younger self – or why my older self still dreams of stopping medication. My belief in antidepressants will always be tempered with uncertainty, and the side effects can be intolerable. The difference is that I can advise others of the pros and cons – but when I take them myself, the final decision is down to me.