Despite progress in Mental health treatments in the past few decades, we still rely on a fair bit of trial and error to find the right treatments for each individual. Even when we know something does work, we don’t necessarily understand why or how. And symptoms, both in what causes them and what alleviates them, can vary widely from person to person.
Gone are the days when society would just shut people away in asylums (looking at you, Arkham), sedate the shit out of them, or force them to undergo painful, cruel procedures. Some of those procedures still exist, like Electroconvulsive Therapy (ECT), but are carefully considered, performed with informed consent (looking at you, One Flew Over the Cuckoo’s Nest), and conducted in a manner that is far more sensitive to patient needs.
We have developed a greatly expanded array of medications as we’ve improved our understanding of how our brains work and what physiological factors can be at play with challenges to mental health. Rather than just sedate the shit out of people, we can use medications targeting specific neurotransmitters, like serotonin, to help our brains use them more fully.
In this post, I will share my experiences with the medication game: the trial and error of finding the right treatments for my mental health challenges. I will discuss various medications I have taken for my mental health challenges, discuss gaps in our understanding of what works for some but not for others, and point to some exciting research that is aimed at taking guesswork out of the process for finding the right treatments for each person.
The Imitation Game (film)
The Imitation Game is a terrific film about Alan Turing and his team’s work during World War II to crack the cyphers that German Navy used for their communications. By easily changing settings on their Enigma machine, the Germans were able to create a new cypher scheme every day. Turing and team needed to start over every day. This work included a massive machine designed to churn through mathematical probabilities to quickly land on the most likely solution. The machine and the process behind it laid the early foundation for the computers we know and love and hate today.
Enigma machine
That daily reset necessary for Turing and his team parallels with the trial and error that is often a key component of finding the mental health treatments that will work well for any one person.
Note: The The Imitation Game – Wikipedia entry notes some historical inaccuracies between the film and what actually occurred, beyond some amount of dramatization that often accompanies films like this.
The Current Process: Fuck Around & Find Out
Despite how much we understand about our brains, there is still a tremendous amount we just don’t know. The human brain is massively complex and hard to study, particularly when it comes to disorders or injuries. We can’t just go around giving people tumors or concussions just to study what happens. It’s even worse for mental health challenges that can behave differently for each person, both in terms of symptoms and in the therapies that are likely to work for them.
The treatments for mental health rely heavily on the highly scientific process of Fuck Around & Find Out (FAFO):
- Fuck Around: Let’s try X.
- Find Out: Hm. OK. That didn’t work…
- Fuck Around: Let’s try more X.
- Find Out: Hm. OK. That didn’t work…
- Fuck Around: Let’s try Y.
- Find Out: Hm. OK. That helped some but the side effects were unmanageable…
- Fuck Around: How about X and Y together?
- Find Out: Shit. OK.
- Fuck Around: Z?
Not only is this a terrible experience for the patient, but it can take a long time. Some medications take four to six weeks before they reach their therapeutic efficacy. And then, it takes time to assess how it is working. As a result, the “Let’s try X” can last months, during which the patient can still be in a bad way.
Some interventions, like Transcranial Magnetic Stimulation (TMS) (see Transcranial Magnetic Stimulation (TMS) » Can’t Juggle) take place over several weeks and involve an investment of time (heading into the TMS clinic every weekday). Eye Movement Desensitization and Reprocessing (EMDR) (see Trauma, EMDR, and the Kobayashi Maru Test » Can’t Juggle), can take weeks and be absolutely grueling. EMDR kicked my ass so profoundly that each weekly session was followed by three to four days just to recover.
Even when we find a treatment that works pretty well, there is no guarantee that it will continue to work well over time. Sometimes a medication, for example, will be helpful for a few years and then stop being helpful for no apparent reason. This really sucks as it means starting the Fuck Around process over again (albeit with one less option since we now know something that is ineffective).
Some medications must be ramped down over time, rather than just stopped altogether, to avoid nasty effects, some of which can be just as awful as the symptoms they seek to alleviate. This can add even more to the process of changing medications.
To Thine Own Self Be True
One big factor in the challenge of managing mental health is that it relies heavily on the subjective reporting of symptoms by the patient. There is not an objective scan or test like there is for things like broken bones or strep throat. Progress requires that the patient both notice symptoms and communicate them effectively.
Even just noticing symptoms when they occur can be challenging, particularly when someone is in crisis and their processing centers of their brain are being circumvented. Stigma can also make it harder for someone to share symptoms due to feelings of embarrassment, shame, or fear of backlash.
Communicating symptoms clearly can also pose challenges. Sometimes we just can’t find the words to express ourselves. There have been times where my therapist has asked me questions about how I am feeling and there has just been a long pause followed by me saying, “I don’t know.” That’s not a good time. Nor does it actually help move forward.
My Own FAFO
I am going to focus on medications here. Over the years, I have been through several rounds of medication FAFO for my Depression and/or Anxiety. I will share some of them along with relevant experiences. It is really important to stress here that these are MY experiences. What worked or didn’t work for me does not provide a roadmap for someone else that is guaranteed to be effective or ineffective. Total shit-show, yeah?
Medications:
With medications, I work closely with my provider. This is an important partnership and is part of the challenge. If you and your provider are not able to work together well, then the results are likely to be poor. I have a great relationship with my provider, and it makes a huge difference.
Meds I no longer take and why:
- Sertraline (Zoloft)
- This provided me with no benefit.
- Bupropion (Welbutrin)
- This helped a little but gave me tremors in my hands something fierce as well as profound dizziness so we left it behind
- Aripiprazole (Abilify)
- This one made me way short of breath (I actually almost passed out just standing in my dining room) so we stopped it very quickly
- Venlafaxine (Effexor)
- This one took a bit of work to find the right dose but worked great once we got there
- A major downside of Venlafaxine is that it is VERY sensitive to missed doses. Most meds are OK if you miss a dose here and there. Not this one. Miss one day and the next day SUUUUUUCKS
- This one stopped working after a few years so we had to say goodbye to it
- Alprazolam (Xanax)
- This one was super helpful with my Anxiety and helped me profoundly with sleep
- It’s also a really powerful med so careful management is vital; It can be both habit-forming AND dangerous
- I did really well managing it… except this one time (see Almost There and Back Again: A Fat Man’s Tale » Can’t Juggle)
- Needless to say, I don’t have this one anymore
- I experienced very un-fun withdrawal symptoms after we removed it from my regimen
Meds I currently take:
I am currently on a mix of medications that took some FAFO to land on. I meet with my provider every few months (more often if we are Fucking Around on something new) so we sometimes make small adjustments here and there. It is not uncommon for folks to take more than one medication. For some, like me, there is no one medication that has all the right effects.
- Escitalopram (Lexapro)
- This one took a bit to find the right dose, but it works well for me so I still take it daily
- Lamotrigine (Lamictal)
- This one works well in concert with my Lexapro and I still take it every night
- Mirtazapine (Remeron)
- I take this one every night as it helps with my sleep
- Quetiapine (Seroquel)
- This one works well in concert with my other nighttime meds
A New Hope
The podcast Depresh Mode with John Moe | Maximum Fun is a wonderful part of my weekly listening. John Moe, author of The Hilarious World of Depression, interviewing a wide range of guests, from artists to comedians to musicians to actors to professionals working in the world of mental health.
Listening to John interview guests, many of whom have some of the same symptoms I have, makes me feel less alone. John does a wonderful job of guiding the experience with sensitivity, care, and humor. I highly recommend adding Depresh Mode with John Moe to you podcast feed.
The Depresh Mode episode from October 21, 2024, The Promising World of Precision Treatment for Depression | Maximum Fun, features a Stanford University researcher, Dr. Leanne Williams, who is working to develop a methodology using a Functional MRI (like a video instead of just a still shot) to help categorize how an individual’s brain is impacted by their symptoms. She then uses the results of this categorization to identify treatments that are likely to work well for that individual. The episode does a great job at describing the current FAFO process and why it is so challenging before diving deeper into the research.
Dr. Williams’s work has the potential to profoundly improve the treatment landscape for those, like me, who experience mental health challenges. Reducing the FAFO process and landing in a more direct manner to likely beneficial treatments sounds like a major step forward for us.
Wrapping Up
There is a lot of misunderstanding of medications for mental health. Some people see loved ones taking medication and expect it to make their loved one 100%; like the meds should “fix” everything. Others may see medications as weakness or failure on the part of the person who takes them. For many of us, our mental health challenges involve chemistry, our brains not properly using resources the rest of our body provides. Medications are a key part of helping us manage our symptoms.
I have said it before, and I will say it again: Medication doesn’t juggle for me, but it does allow me to use both hands.
