March 2022 – Barrelhaven

Frustrated keyboard-pounding noises

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A couple of things I don’t think I’ve mentioned here have cropped up again today. Among the reasons I took the job I currently have was the medical benefits kicked in on my hire date. None of this “the first of the month after your first full month of employment” nonsense, sign to accept the job; get benefits. At least that’s what I was told and, to be fair, that was probably the intention of my employer. Unfortunately it didn’t exactly work out that way.

I’ll spare the reader the blow-by-blow details of what happened but the short version is, for reasons that no one can adequately explain, Shannon did not get added to my medical and dental coverage. It took three weeks of fighting with the benefits people and me turning in my resignation for it to get fixed. I did withdraw my resignation after being promised the insurance would be fixed (by sheer coincidence this promise came almost immediately after me submitting my resignation). Anyway, as of yesterday it was supposed to be all fixed.

Imagine my surprise, then, when we got a message from our pharmacy saying there was a problem with the insurance, which is exactly what they said when we found out about the problem in the first place. Fortunately it turned out to be a relatively common and easily corrected SNAFU with the pharmacy’s records but the situation still put me very much on edge again, which is what I really came to talk about.

I have previously talked a fair amount of shit about trigger warnings. It isn’t that I object to their use, nor do I have any doubt that trauma-related disorders can result in certain otherwise normal everyday events and topics to be distressing for people. What I object to is the use they have commonly been put to in discussion forums and the like, which is to put responsibility for one person’s mental health on to someone else – “OMG I am so triggered right now! How dare you not put trigger warnings on your completely ordinary and generally uncontroversial content? Now my triggers have been triggered and its your fault for triggering me because you didn’t use trigger warnings which has resulted in me being very triggered by the triggers you failed to warn me about“.

So this is the difficulty I’m running into. It is hard to talk about the things that escalate my stress and anxiety, “triggers” if you will, without sounding like a complete choad. This gets right back to my baseline difficulty with mental health in general; the overwhelming majority of my professional experience with mental health has been with people ostentatiously using a, usually self-diagnosed, mental health condition as an excuse to behave like a raging asshole. This is a particularly sensitive topic for me right now because my own mental health condition has resulted in me behaving kind of like a raging asshole over the past few weeks.

I don’t know what the solution to this is. My worst fear… among my worst fears is becoming one of those people who may as well have their diagnosis tattooed on their forehead and who use it as a central piece of their personality and all their social interactions. Meeting someone for the first time? Better make sure you work the fact that you’re neurodivergent into the conversation in the first few sentences, no matter how tangential it may be to the topic at hand, to make sure everyone knows you’re different and interesting. On the other hand, if simple things are going to elevate my stress and anxiety it might be a good idea to let people know.

It’s a conundrum.

My very own To Err is Human

In 2000 the Institute of Medicine published To Err is Human: Building a Safer Health System, a landmark work that shone the light, really for the first time, on the incidence and severity of medical errors. Why do I mention this? Because I’m pretty sure I had one.

As seen in the previous post, for the last few weeks I’ve still been having panic attacks and was quite symptomatic with depression and anxiety which prompted Dr. Primary Care to start me on sertraline. While I was seeing Dr. Primary Care I also got a refill on my bupropion since I was nearly out. I started the newly refilled prescription yesterday and noticed something kind of odd.

I want to take a moment here to mention I am aware of the difficulties and pitfalls of identifying pills by sight. Pills from different manufacturers will look different even if they are the same drug and the same dose. That said, I’ve seen quite a few pills in my day and I can generally spot things that are different because of manufacturer and things that are genuinely off.

So I started my newly refilled prescription and noticed that the new pills were markedly larger than the ones I had previously been taking, in spite of appearing to be from the same manufacturer. By chance I have access to examples of 150 mg XL tablets in addition to the 300 mg XL tablets that I am supposed to be taking and I am as certain as I can be without any physical evidence that the pharmacy filled my last prescription for 300 mg XL with 150 mg XL.

Two additional pieces of evidence that could add weight to the theory; once I started taking my new 300 mg XL tablets I immediately started feeling better. My mind has not been this calm in weeks and my overall mood has improved a great deal. Also when I started taking my new 300 mg XL tablets, I was struck with a serious case of insomnia which is a common side effect of bupropion. It hasn’t really been a problem for me¹ except for a couple of days after a dose increase.

There are potentially confounding factors to consider however. As mentioned above, I don’t have any physical evidence. All I have is an empty bottle that says 300 mg XL, and a comparison of my mental image of the pills I was taking to known samples of 150mg and 300mg tablets that appear to be, but can’t be said for certain to have, come from the same manufacturer. There is also the addition of sertraline to my regimen. I’ve been on it for a week and, while usually SSRIs take a bit longer to really take full effect, the possibility that I’m just feeling the benefit of the sertraline cannot be ruled out. Finally, the insomnia could very easily have resulted from me working my first full week on night shift after being on a “sleep when you want, wake up when you want” schedule for a couple months.

Pretty sure but not certain.

The thought of the difficulties I’ve been having with my mood over the past few weeks being the result of a medication error is actually reassuring to me. I was feeling distraught because I thought I’d been making all this progress in therapy and introspection and self-analysis and all, but here I was feeling like shit most of the time again. Additionally, if this was a medication error, any doubt about the benefit of being on medication that I may have had is gone. Being on a half-dose was all kinds of no fun so I don’t even want to think what being off it entirely would be like at this point.

¹ I know, I know. But there is my baseline insomnia and then extra insomnia gets piled on top of it. Insomniaception. A couple of days after my last increase in dosage I was back to my baseline insomnia.

Back on the SSRI

Those sertraline girls really knock me out¹

As previously mentioned, I had a cast on my dominant hand for the last few weeks. This condition didn’t make typing or writing impossible but it did make both activities more frustrating than was tolerable for anything less than absolute necessity. Astute readers will doubtless have reached the conclusion that, since this post was typed out by me, and nothing I do here is even in the same neighborhood as anything even remotely necessary, I must be out of the cast now. This is, in fact, the case. Dr. Ortho-Hand was satisfied enough with how the fracture had healed that he didn’t even feel the need to put my in a removable splint. I have an entirely bare naked hand and, in spite of my wrist feeling like it tried to fuse solid and is now only grudgingly moving again, I could not be happier with the situation.

On the topic of not being happier², astute readers may also have reached the conclusion that, based on the title of this post, my prescribing provider and I have been messing around with the medications again. My PHQ-9 and GAD-7 scores³ have been getting uncomfortably high again and I have still been having panic attacks multiple times per week⁴. Fortunately my health insurance situation has stabilized and I was able to go back to the primary care provider I had been seeing for several years prior to starting my whirlwind tour of employers. Given the degree to which I have been symptomatic, Dr. Primary Care felt that adding a serotonergic antidepressant would be beneficial. I have been on sertraline twice previously and we’re at 50/50 in terms of it being effective. I did, however, tolerate it well as far as side effects go so that’s where Dr. Primary Care felt we should start⁵.

One of the complaints I have with antidepressants is they can take a ridiculously long time to really take effect, weeks in some cases, so it may be difficult to tell if any improvement is from the medication or from me just settling back into a work/school routine with a lower baseline stress level.

On the topic of work⁶, I have started my new, non-patient care job and I feel like it will be okay once my nervous system adjust to the idea of me going to work in a hospital but NOT going to work in an ICU filled with people dying from a pandemic respiratory virus. I’ll talk more about work later (probably) but for now I’m going to go eat some tylenol and rest my wrist.

¹ Apologies to Lennon/McCartney

²How’s that for a transition!

³ Patient Health Questionnaire and Generalized Anxiety Disorder scales for assessing depression and anxiety symptoms. These are a desperate attempt to put an objective measure on the extremely subjective experience of emotional distress. They’ve been validated in peer-reviewed studies and people more knowledgeable on the topic than myself rely on them, so ¯\_(ツ)_/¯

⁴ I don’t want to leave people with the impression that I’m getting worse. I still think I’m improving in general but “better” is not the same as “well” unfortunately.

⁵ For those keeping score at home, this brings the total number of prescription psych meds I’m taking to three.

⁶ I am just killing it with these transitions!