What's my next step in dealing with depression?
November 10, 2013 7:07 AM   Subscribe

I have rapid and extreme mood swings and am generally empty and anxious. I've got all the time in the world. What should I try, medication, self-help or therapy wise to get better and find happiness?

I’ve experienced depression for as long as I can remember. It’s gotten steadily more problematic as I’ve gotten older and had to take on more responsibilities. I finally realised I did have a problem during my second year of university when I pretty much stopped functioning and ended up having to retake my year. Since then I’ve been dealing with it in various ways, but I don’t feel like I’ve made an enormous amount of progress.

I graduated this year (24 now), worked at a startup for a while, then went to start my own. My partner decided he didn’t want to work with me anymore, and I realised I needed some time to focus on dealing with depression before doing anything else seriously. I loved what I was doing, but having massive mood swings while working full time was really unpleasant. I’m not working at the moment and I’m just doing bits and pieces to feed myself while I figure things out.

My mood is constantly up and down in huge fluctuations, though it’s generally a mix of various negative feelings. Here’s a sample of a few days:

* My baseline state is generally able to function, things seem ‘ok’ to me. I’m roughly able to work, socialise and keep my life afloat. I’m not very happy, feel awkward socially and I feel like I’m running at about 20% capacity, but it’s tolerable.
* At work I start chatting to people and get a good response, I start to feel very good about myself and want to talk to more and more people and lead the conversation. I feel excited and start imagining myself organising parties and changing the world. I’m desperate to be around people. I have a burst of physical energy. This lasts for a few hours before I realise this isn’t me and I drop into depression for a while then return to normal.
* Next morning: Feel fine, fairly relaxed and bright but with a profound sense of emptiness and distance
* Afternoon and evening: Suddenly feel incredibly black, lethargic, isolated and spend the evening watching films and eating.
* Next day: feel better again, back to before, bright and reasonably happy
* Evening: meet someone I have a difficult relationship with, fall into despair and speak as little as possible at a social gathering.
* Later that evening: watch a documentary about buses and feel absolutely buzzing and wonderful, crying with joy at people’s humanity
* Next day: feel a strong pain in my stomach, feel very frightened, find it difficult to talk to strangers, sad and lonely. Stop going out.
* Few days later: quite bright again, average feeling. Now I feel on edge, but not in a nervous way. I’m finding it hard to focus on anything, I can’t watch a film or read anything longer than 2 or 3 paragraphs. I’m eating excessively. Totally unproductive.

This is a slightly more extreme few days, but it’s a good approximation of how my mood changes and how quickly. Sometimes I feel good or bad for a few days, but never more than a week. There are many more lows than highs, and the lows are very unpleasant, while the highs are a minor annoyance.

What I've done so far
I’ve found CBT and REBT incredibly useful for explaining what’s going on. I can almost always identify a judgement about myself or the world that’s led to my emotion. Sometimes I use CBT to lift a bad mood, but I can’t always identify the specific situation. I’ve been analysing what leads to my emotions in a giant spreadsheet to help me work out causes that I can dispute with CBT, but I’m realising that my emotions are too transient to study effectively. I know what I judge myself for and I know the negative emotions I feel, but linking them and finding out what’s causing the problem now is nigh on impossible. Though my biggest problem here is procrastination, since it’s emotionally painful to think about these issues and I end up not doing it.

I’ve been to counselling, had CBT on the NHS (useless) and privately (reasonably useful). I feel like I understand what’s going on very well so I don’t need more analysis and self discovery, now I just want to change my core beliefs about myself.

My incredibly jealous and insecure stepmother had a big effect on me growing up. She used to shout, scream and berate me continually, chipping away at my self esteem. I never think about her in my life now, but the way I act think about myself is definitely influenced by those experiences.

Exercise, diet and sleep have absolutely no effect on my mood. I’ve not found any lifestyle factors useful. Running or cycling can provoke a high where I feel fantastic and have grandiose thoughts, but it comes with a corresponding crash when the adrenaline wears off.

I’ve been prescribed citalopram before, but I decided I didn’t need it after a week and stopped taking it. I was prescribed lamotrigine for several months, but at a dosage of 50mg/day, which from reading some other threads I understand isn’t enough to do anything.

I’m a little wary of drugs as there’s not much point in me dealing with the worst parts if I’m not also dealing with my ‘average’ state which I want to improve as well. My extreme moods come and go so quickly that I can just wait a while to be in a good enough state to do self help and therapy type stuff, which I understand is the reason why most people take medication.

I’d really appreciate any advice on how to start changing things, if anyone has had a similar experience and what they found helpful. Bipolar I & II don’t seem to apply given the speed with which my mood changes. Cycothymia/Bipolar III seems more appropriate, but I’ve struggled to find useful information about it. I’d definitely like to hear about useful kinds of therapy, and particular therapists in London.
posted by awesomathon to Health & Fitness (18 answers total) 6 users marked this as a favorite
"My extreme moods come and go so quickly that I can just wait a while to be in a good enough state to do self help and therapy type stuff, which I understand is the reason why most people take medication"

I can't give any practical suggestions for finding a therapist in London but I wanted to point out that what I've quoted above isn't true for a lot of people who take medication. For a lot of people the medication serves to flatten the range of moods you have and the lability of them so that your base mood is more stable and more a reflective of the situation you find yourself in (E.g. if you broke up with your long term boyfriend you'd be really sad, or if you won an award you'd be happy) The drugs make it possible to improve your average state because you no longer have to spend intense amounts of energy managing outlaying emotions that don't come from fixable/manageable events or sources.

Its really great that you've got insight into yourself and your moods but it sounds like you need to find a way to make managing your moods/emotions less work. It doesn't have to be an all consuming painful process. I think you should work on finding a psychiatrist and/or a therapist and maybe consider printing this question out and showing it to them.
posted by SpaceWarp13 at 7:37 AM on November 10, 2013 [4 favorites]

You need to see a psychiatrist (or two) to get an accurate diagnosis and treatment plan. A good psychiatrist will not simply prescribe medicine and send you back out; he or she will keep checking in on you and fiddle with the dosage until it fits you properly. The psychiatrist will also consider any therapy/counseling visits as a crucial part of your treatment plan, advising you on some possible options and (hopefully) working in tandem with your counselor, especially if they're in an affiliated practice.

Get that baseline diagnosis first. But don't let it define you: you're still the same person, just with a particular label and direction to take for more information.
posted by Madamina at 7:40 AM on November 10, 2013 [2 favorites]

Start with a medical doctor, a GP can be a great first stop, a psychiatrist is good. You say you stopped taking Citolapram after a week. Shit, it doesn't even begin working in that amount of time. I've been taking it for years and I view it as a God-send.

One symptom of mental disorders is the belief that one can simply DO something to make it better. If you think of depression, or other disorders as Diabetes, then you can see that the idea that one can "fix" the problem without drugs becomes rather far-fetched.

Unless you've been to medical school, chances are you just don't have the education to diagnose yourself, and to direct a therapeutic program.

Put yourself in the hands of professionals.

Bear in mind that your judgement in this matter is incredibly poor. Depression and mental illness will fucking LIE to you about what you think and feel, to keep you in the mentally disordered state.

Hie thee to a good doctor pronto and do EXACTLY what he or she tells you to do. Getting the drugs right is a process, but it is WELL worth it.

I am incredibly grateful not to be a knot of anxiety.
posted by Ruthless Bunny at 8:52 AM on November 10, 2013 [6 favorites]

Exercise, diet and sleep have absolutely no effect on my mood

That would make you pretty much unique, so it's prima facie implausible. Perhaps you could trial being a bit systematic about investigating connections between what's going on in your gut and what's going on with your mood, just to check out the possibility that depression and/or hypomania are lying to you about that as well?
posted by flabdablet at 9:28 AM on November 10, 2013 [3 favorites]

I’m a little wary of drugs as there’s not much point in me dealing with the worst parts if I’m not also dealing with my ‘average’ state which I want to improve as well.

You are not understanding the way properly prescribed drugs work. Citolapram will elevate the "average state" of your broken brain chemistry. Go back to whomever prescribed it and commit to taking it for 8 weeks.
posted by DarlingBri at 9:59 AM on November 10, 2013 [3 favorites]

Diagnostic categories are just a best effort to keep up with what's seen in real patients. The DSM-V (which isn't not the canonical reference in the UK) now includes Bipolar NED (not elsewhere defined, previously called NOS: not otherwise specified): "The diagnosis of bipolar NOS is indicated when there is a rapid change (days) between manic and depressive symptoms and can also include recurring episodes of hypomania."

You should see a psychiatrist. In explaining why you don't want to use drugs, you make waiting out your extreme episodes to get to an average place where you can work on yourself sound like an easy, straightforward thing. But everything else you wrote is about how that very thing is painful and hard.
posted by Zed at 10:03 AM on November 10, 2013

Drugs can be useful insofar as they can make you stable enough to work on whatever you need to work on mentally, emotionally or whatever. Please don't rule them out. Life can be much better without you having to gut it out.
posted by St. Alia of the Bunnies at 10:12 AM on November 10, 2013 [1 favorite]

Response by poster: Thanks for your input everyone. I have an appointment with the GP tomorrow and I will ask to be referred to a psychiatrist. I also have an appointment with another NHS service for psychotherapy.

I'm more open to drugs than my post suggests, I edited it for brevity and missed a bit out. I will certainly give them a go. But I thought that they were only good for severe moods and either not affect or come with too many side effects to make them useful for how I feel now: just a bit bleh. My concern is that I get stuck in a kind of limbo where I'm not severely depressed, but am unable to be truly happy either.

Re lifestyle factors, I used to eat very poorly and not exercise much. Now I eat very well and exercise daily - I lost 2 stone over the past few months, and I haven't seen any change in mood. I can't state absolutely since there are so many variables involved in my mood that change rapidly, but there was nothing obvious. I already sleep very well, so there's nothing to improve there. I've previously studied my mood in relation to where I am and who I'm with and found there to be no relationship whatsoever.
posted by awesomathon at 10:50 AM on November 10, 2013

thought that they were only good for severe moods and either not affect or come with too many side effects to make them useful for how I feel now: just a bit bleh.

"Drugs" are not a single category of things. Citolapram (Celexa in the US) is specifically an SSRI. For an SSRI, the side effects of Citolapram are generally mild and pass within a week, and there's a 50/50 chance it will work for you within six weeks and your depression will not return. If you want the dirt on a drug, do not consult Dr Google or Wikipedia; consult CrazyMeds.
posted by DarlingBri at 11:20 AM on November 10, 2013

My psychiatrist once told me: "Meds aren't the answer for everyone, but they can help you get to a place where you're able to do the work that will help you get better."

In my experience I found this to be the case. Medication helped me to be better able to participate in life (work, relationships, personal maintenance & mundane chores) such that I could then be able to benefit from therapy.

None of which is to say that therapy isn't worth doing unless you've had meds. In your case you certainly sound high-functioning and self-aware enough that you'd likely benefit from it quite soon.
posted by armoir from antproof case at 11:23 AM on November 10, 2013 [1 favorite]

Totally anecdotal but what armoir from antproof case said:
I was in an awful state of apathy and despair, letting myself grow fatter, sadder and more in debt than ever spending money to make me feel better—for 5 minutes.
I took a pill for a couple of months, and it made me start making changes: I became more active, more positive and in general it helped me get out of the bell jar. I stopped taking them and kept at the active lifestyle and am now much better. But for sure, one week of pills is not enough to get that little nudge.
posted by buck:fuller at 12:23 PM on November 10, 2013

In the US, I'd recommend a psychiatrist specializing in medications, and a good therapist. You may not be a good judge of what's working well, and should try prescription meds longer and with more help. Not sure who would be the meds specialist in the UK, but would not recommend a GP.
posted by theora55 at 1:43 PM on November 10, 2013

Not sure who would be the meds specialist in the UK, but would not recommend a GP.

It's a different system. It does not work the way people in the US expect it to.

GP's provide frontline meds in the UK, including psych meds. Unless someone proved med resistant or particularly problematic to prescribe for, there would not normally see a meds specialist. It is still standard to get baseline meds from your GP if you are waiting for a psychiatric referral, as the waits can be long.
posted by DarlingBri at 2:05 PM on November 10, 2013 [1 favorite]

When you talk to your doctor, do not downplay any of your symptoms. I glossed over important things (like paranoia) for years, out of embarrassment, or out of thinking it was no big deal. Only it was a big deal and I had trouble getting a proper diagnosis.
And don't try to figure out if you have Bipolar on the internet. Bipolar is like a jumble-sale of symptoms that are totally unique to every patient. You do sound like you're having mood regulation problems, so start there when you talk to the doctor. Don't worry if you fit the bog standard definition, that's what you pay the doctor for.
My experience with Bipolar was that lithium and risperadol got the mania sorted quickly. 3 weeks of partial day DBT got me thinking like a human again. 2 years on I'm still seeing my psychiatrist once a month to keep tabs on the depression, which still comes and goes. It's a chronic illness. It's not something you can hack.
Being at the mercy of your moods sucks. If you want to talk, Memail me.
posted by Biblio at 7:35 PM on November 10, 2013 [1 favorite]

Because you say you've gotten a lot out of CBT and REBT, may I recommend mindfulness-based cognitive therapy (MBCT), daily mindfulness meditation or a combination of both? Mindfulness practice has been the single most useful "packaged" remedy, if you like, for my mental state (I used to suffer from depression with intermittent rageyness). It is less about changing the content of your thoughts and feelings than about changing the way you relate to them. It has made a huge difference in my baseline rate of calm. My skeptical partner, who can also be a bit up-and-down although not to the extent you describe, has also begun a daily practice and grudgingly admits that the frequency of his morning black moods, along with the intensity and duration of our fights, has decreased by about 80% in the past few months.

If you're in London you may want to try an MBCT program near you (eight weeks of classes combined with work done at home). For a taste of what's involved (although a class is better than a book) you could also try the very popular Mindfulness, written by boffins from the Oxford Mindfulness Centre, which is written with minimal woo-woo and comes with a CD of guided meditations.

It's not a substitute for a visit to your GP or more in-depth personal therapy (the WPF does short-term psychodynamic therapy if you want to address how your family issues may be contributing to your mood without necessarily committing to a long or open-ended contract), but it is a way to be less at war with your mind and can only help with any additional therapy you decide to take on.

Memail me if you want to talk further.
posted by stuck on an island at 8:42 AM on November 11, 2013 [2 favorites]

Re lifestyle factors, I used to eat very poorly and not exercise much. Now I eat very well and exercise daily - I lost 2 stone over the past few months, and I haven't seen any change in mood.

"Eat very well" is fine, but some people's moods are quite strongly affected by sensitivity to certain foods (reactions to wheat and dairy are fairly common) and stimulants (most often caffeine) all of which are generally considered perfectly good parts of a healthy diet. If you haven't already tried systematic elimination of foods commonly associated with gut dysfunction, doing so will cost you nothing and might tell you something useful.
posted by flabdablet at 9:28 AM on November 11, 2013 [2 favorites]

lifestyle factors are also of pretty low importance for me, so it was good for me to read about someone who experiences something similar. I also improved my diet, and exercise regularly and whilst its definitely a positive thing to do, mood wise I don't feel any better

I would suggest thinking about this as long term as you can, it will take a while to find an approach that suits you and your ailments,

for instance for me it took a long time to realise that even if the meds work fine, ideologically they will never sit well with me, so I either need to change my view of the meds, or change my approach, and so i changed to an approach which suits me better and im very glad i did
posted by frequently at 10:31 AM on November 11, 2013

I know this is an old post and things may have changed, but I just found it and some things resonated with me, so I thought I'd comment.

You should be aware that there are a lot of American posters on metafilter. I get the impression that meds are more commonly used over there, so they may be more biased towards that kind of treatment. That's not to say it's right or wrong, but just that's how it is.

I too find that my mood is mostly unrelated to exercise levels or diet, or anything else. At least on anything more than a superficial level. So don't feel bad if those kinds of changes don't help.

I have also found CBT for depression on the NHS to be useless. In retrospect, I should have made a formal complaint about it as it actually made things worse for me. So don't feel bad about that either

I don't think you should necessarily give up on therapy. You say you've already done all the self discovery you need. That's great on an intellectual level, but have you felt all the feelings you need to feel?

Example: you say you never think about your step mum. That's clearly a bit of self delusion, as you mentioned her in your post! Whatever you're hiding from yourself there probably has a shitload of negative feelings attached to it.

If you're in London you could probably find a good therapist to help you with that. I have a little experience with therapists, but am limited by money and location (rural Cheshire). If I were to go to a therapist, I would look at any kind of body- psychotherapy; client centred therapy; or some kind of short term psychodynamic therapy. Many therapists seem to do a bit of training in several different things, then call themselves"eclectic", which can be a byword for "not very good at anything". I would look for someone who has a proven track record with people like myself as a lot of therapists aren't very good and don't seem to mind you just coming for years and continuing to pay them.

I'm also interested in hypnosis, but have no experience in that yet.

Regardless of my thoughts, I hope things have picked up for you.
posted by UncleCaveMan at 7:47 AM on February 9, 2014

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