Reward Myself

Today's the day we head to Assateague Island National Seashore.  It's also the final day of my half-year, which included a goal of three trips to Maryland Attractions.   I've admired the art at the Walters Art Museum after shabbos morning at Beth Tfiloh and strolled the boutiques of Chesapeake City.  I almost included a short time at the National Harbor during a trip to DC, but we really only had supper there, with more dedicated site seeing pre-empted by the closeness to dusk and the difficulty of parking.  So we just ate our supper, not itself an easy or entirely pleasurable outing, and moved back to our hotel.  I did not credit myself for a Maryland tourism visit.  Ocean City became the next destination, postponed at least once, but about to be fulfilled.  Always gratifying to complete these initiatives outlined six months in advance.

The trip, and some of the pleasures that go with petty travel, also qualifies as a reward.  I submitted an entry to the NEJM Fiction Contest.  Not a level of writing that has a chance of publication there, but a challenge to myself to see if I can move from journalism or op-ed writing, or from describing elements of my life, to fiction with universal themes.  I could, though with a lot of abandonments and restarts.  That gets a reward.  So does persevering on my exercise program, though at a reduced intensity, despite some right leg problems.  As my BP rose, I increased amlodipine.  BP down last evening and no apparent side effects.   My doctor helped with the decision of what to do, but I selected from the reasonable options.

Our curtains got hung.  Our living room approaches full entertainment capacity.  I'm off my SSRI reasonably successfully.  In the last six months I've read more than my quota of books, submitted articles for publication, have some semblance of herb and vegetable gardens.  Been a good six-month cycle.  Worthy of a reward.

Unfocused

My ability to focus and express has become inconsistent.  I do not know the cause.  Perhaps an effect of letting my SSRI use lapse, but consider other causes.  And it may not even be accurate since I have written decent responses to things others have presented.  But I feel restless.  I don't feel annoyed, though, even when I have reason to.  Responses still are thoughtful and articulate.  What I generate spontaneously has not been.

Semi-annual planning, a major project for this month, has helped.  So have my several timers which force limited attention, though more to tidying my home than expressing or even generating mental ideas.  As much as I look forward to some brief getaways, I do not feel in genuine need of an escape.  Since stopping my SSRI I have needed less sleep, even feel more alert.  

I currently have a few defined mental projects, some with deadlines, so plod away and keep score.

Post SSRI

Things go better when they have a purpose, one defined, unambiguous, and pursued with some flexibility.  I put myself on SSRIs while still in solo practice, using office samples, with the approval and guidance of my doctor.  Its purpose was to get me more focused so I could stay on task.  Mixed results.  It's beneficial side effect, almost a theme of Peter Kramer's Listening to Prozac, was that it resulted in my being more congenial. A less favorable side effect was that my mind often felt dulled, in exchange for focus and productivity.  

Several drug holiday's have had similar results.  Sharper thinking, more impatience.  And more dissatisfaction with wherever I found myself.  Chemically driven contentment.  As I get more irritable and become less cordial, I note it and resume the pills.  Yet that was not the purpose of medicating myself, indeed it was a useful side effect.

Now it's time to get off without the intent of a limited respite.  Been off a few weeks, don't miss them.  I'm abrasive but maybe if my synagogue experience irritates me I should be abrasive.  My mind seems more incisive.  I read more carefully, immerse myself in the difficult, take pleasure from being interactive.  My telos may not be to be personable but to express candor, which I do.  Consequences positive and negative, but I'm more in control without the added serotonin floating through the synapses.  

The original prescription was for a purpose that need not be maintained.  I'll deal with social abrasiveness and its unfavorable consequences.

Emerging from Withdrawal

Mar Cheshvan=Me Cheshvan started out with great optimism, time to pursue things put off.  But it got hijacked by an email hack with substantial loss and deterioration of my dear Honda.  I had been off my SSRI, got mostly impatient, often rather cross, enough to resume medication.  My muscles ached.  I felt lonely much of the time, often isolated, with a major respite when I got together with an old friend in Annapolis.  Car replaced.  Computer capacity restored.  Can't say I missed synagogue or anything particularly Jewish,  OLLI a bit of a disappointment this semester but a new course in the second session begins.  Housework and writing that had been my intended focus did not materialize.  And I'm struggling with this month's Medscape article.

However, I am starting to feel physically better for sure, emotionally better probably, less beaten down, less despondent, actually more optimistic.  The things to do short term seem reasonably well defined:  get acclimated to new car, submit Medscape article, treadmill schedule consistency, full contingent of prescribed medicines.  At least that much, maybe as much more as I can.

More Animated

Maybe the SSRI, suspended a few weeks, has kicked in.  Maybe I've just emerged from an emotional trough.  I start today feeling better.  Achiness has abated enough to go for a low intensity walk on the treadmill. My mind has focused a little better, perhaps enough to resume some of the writing I've neglected.  My transition from previous to new vehicle does not seem to affect this, nor does the approach of shabbos.  I'm just feeling less inwardly battered.

Rather Irritible

Been off my SSRI for a few weeks, compulsivity and irritability symptoms did not take long to return, though I think my mind is a little sharper off the treatment.  An article from the NEJM recently looked at SSRI withdrawals in stable patients using the medicine for depression.  https://www.nejm.org/doi/full/10.1056/NEJMoa2106356 Symptoms were more likely to return off the medicine, though some staying on the medicine still had breakthrough symptoms while others sustained remission from their depression.  You pay your quarter, or your shilling since this study came from England, and take your best shot.  I prefer to stay off and control how I respond to the various triggers as they come my way.

My car AC started failing intermittently, so that gets added to the list.  Ordinarily I take the car to the dealer but they underperformed on AC repair last time, my interaction with the technician did not endear him to me, and at 213K miles, the extended warranty has long expired, so I'll try someplace else of good reputation if it can be done before next week's expected day trip.

Had a few adverse events in my own bedroom with what should be minor maintenance.  Clutter prevented getting into my closet to repair a shoe rack or even change the closet light bulb.  I could not make the bed properly because I could not get to my wife's side of the bed.  When the laundry baskets were removed, they had clean but crumpled clothing unattended for weeks at a time, which I folded.  I checked Angie's List for housekeeper options, as by now it's clear that my wife has no interest in making the housework gradient less lopsided. We meet with our financial advisor soon.  I simply lack the ability to do the needed interior upkeep, so I will either have to get help or we will have to downsize, as many of my contemporaries have already done.  Better to do this voluntarily than abruptly as a byproduct of nursing home placement.  But it certainly adds to my diminishing personal fuse.

And some chronic musculoskeletal discomfort hasn't helped.  Since the pain concentrated in two locations anatomically, I started applying topical Voltaren to the one I can reach.  It's helped the discomfort, no effect on mood.

And a vacation might help. Or there's always that chemical inducement to tone me down.

SSRI Holiday

My daily pill container once had seven tablets.  Multivit not renewed after finally completing the contents of a one year supply of horse pills that took a lot more than a year to finish.  I've just never seen beriberi, scurvy or night blindness in all the years I took care of patients.  Some probably took a vitamin.  The majority did not.  The popularity of these escapes me, but also drew me in at one time.  Not expensive but not efficacious either.  Aspirin can be had at the Dollar Tree for $1 for a package of 60 tablets which is $6 a year, even less than the multivit.  The efficacy of this for people my age who do not have heart disease, which would be me if my stress test is accurate, does not seem to be there when studied in the manner of mainstream medical studies.  I've not had any adverse effects but people in the study groups have.  Just finished my weekly supply one week ago and never went back to reloading it into the weekly container on Sundays.  My need for an NSAID varies.  There are weeks when lumbago of some type makes this a scheduled medicine.  It has been my good fortune to go into remission, making this a prn medicine.  I keep a bottle between the front seats of my car but no longer put a daily dose in my case. And it delays my platelet donations which might be among the more useful things I do for people.  I could say the same about that prostate stuff the doctor prescribed a few years ago.  It alleviated symptoms which then stayed in remission after I stopped taking the medicine.  Usage has been minimal.  It is not a prn medicine so when I need it again, it will reappear in the weekly case, but hasn't for a while.  My PPI is still there.  The intent of these drugs is a two week course unsupervised medically for GERD.  And I have stopped it for brief periods only to have GERD symptoms come right back.  An EGD showed no Barrett's or other serious disorder, so the SSRI is for symptoms which have demonstrated themselves as either persistent or recurrent.  That one stays.  There is a statin.  My cholesterol level is well beyond dietary modification, as was my father's who developed symptomatic angina at an age slightly less than mine and a CABG at an age somewhat older than mine.   The medicine has been efficacious, at least by lab numbers if not by patent coronaries, when I am faithful about taking it.  The cost is not burdensome.  I had transient minor myalgia when my current high grade treatment was introduced but in recent years no adverse effects have been noted.  That one stays.  So does the ACE inhibitor.  My BP has been consistently above optimal when I have let it lapse.  There have been no side effects.  So my pill case in recent weeks has been depleted to three:  PPI, ACE, statin.

There remains one more variable, the SSRI.  I might have ADHD by childhood restlessness and inattention but I've never been treated or even tried a stimulant.  As a 60-something, I've succeeded pretty well and rarely if ever speculate to what loftier heights I might have soared had my attention span exceeded that of a Brussels sprout.  Or maybe I wouldn't have does as well.  What I seem to have, though, is compulsivity and hyperawareness.  I can be maniacal to detail, abrasive and impatient, particularly with people less astute than me.  INTJ's like me tend to be that way so it's not necessarily pathological but often not helpful either.  Maybe a dozen years ago I asked my doctor a therapeutic trial of an SSRI might improve this, remembering Peter Kramer's Listening to Prozac published a few years after the medicine became available but listened by me on audiobook quite a few years later.  While these drugs are antidepressants primarily, the have a role in tempering compulsivity.  Dr. Kramer described a patient whose personality, focus, and productivity soared on the drug with a setback on withdrawal and return of favorable results on retreatment.  That's a pretty fair prototype for me.  The pills had declared themselves safe, if not annoying at times. 

Starting with office samples of Prozac 10mg I avoided side effects.  It made me sleepy which is better than making me wired.  Paxil samples were easy to come by.  I lasted about three days.  It made me feel like I took something.  Then 20 mg Prozac by prescription for a while.  Eventually Celexa came out, better tolerated by office samples, then continued indefinitely by prescription with lapses.

This month, I thought it time to hit the reset button.  Avoided my shul on shabbos, withheld Facebook, withheld Celexa (citalopram), bringing the pill case to its current three.  Facebook hiatus a very good thing to do with return next month in a highly scheduled way, much like I did for Sermo six months back.   My shul in its current circumstances still annoys me but I will return in a scheduled way and maybe return to tossing blogbarbs at the Rabbi and Executive Committee.  Not having the SSRI, though, took a real toll and has been resumed.

I found myself mentally a little sharper without it, sometimes hyperaware, sometimes hyperfocused.  I also found myself unusually impatient, overreacting to minor glitches like losing something which may also hint that I didn't pay attention to detail as well, too eager to move on to the next activity.  I was not as nice a person, much as Dr. Kramer described his patient in his book when on and off Prozac.  I exercised less but tolerated the effort the same.  My appetite seemed unchanged but weight might be up about a pound.  Insomnia unaffected.

Before/After assessment shows that I like myself better when toned down a little, so the pill case for the evening doses has returned to four.

Artifical Contentment

I ingested my last Celexa tablet a few weeks ago, part of a drug holiday I gave myself after muffing a scheduled platelet donation last month by mindlessly taking an 81mg enteric coated aspirin tablet that I neglected to omit from my weekly pill case. So until the next platelet donation last weekend, I treated myself to a drug holiday. No aspirin as the blood bank program requires but also no statin, PPI, multivit or SSRI. Other than some wicked heartburn tided over by antacids, while disabling initially but just slightly annoying at present, no medicines. Yesterday, I restored the pill case with all but the SSRI. Aspirin and statin have evidence of life prolongation and other than some achiness early on as the Crestor dose was increased, there have been no adverse effects, though I always wondered if I really would need the PPI if I deep sixed the aspirin. I accept the endoscopist's finding that there really is some reflux but no Barretts, so both the aspirin and omeprazole returned to the pill case. I have a whole jar of OTC house brand men's formula multivitamin, so that went back to the pill case too. My citalopram tablets, even though of ample supply, stayed in the amber tube that I got from the Super G pharmacy a couple of months ago for $10.

Other than some annoying reflux, I clearly feel better without the medicine. It has been a tenuous course with the SSRI, starting many years ago with Prozac samples from the office, then Paxil samples which made me feel drugged and finally Celexa samples which became the generic citalopram. It is not my first withdrawal but unless a lot of people start complaining about me I do not plan to return to this medication.

Peter Kramer in his Listening to Prozac best seller of twenty years back described using the medicine for Obsessive-Compulsive Disorder, which at the time was an experimental use, and for which I worked out with my doctor my first trial of it in the 1990's. Dr. Kramer described Tess who became charming and sociable. I did not become charming, or at least nobody gave me feedback. What I became instead was dulled, almost emotionally neutral, without placing a value judgment on it. Irritants no longer irritated me. My patience improved and I could read or watch TV for longer periods of time with greater safety than if I had tried to achieve the same result with ADHD agents. In exchange for some form of artificial inner peace and perhaps a slightly better attention span, my mind wasn't as sharp. I had no particular inclination to look up medical information I did not already know. My abiltiy to write in an incisive way and to follow thoughts in sequence declined dramatically. Moreover, I felt tired, this being the symptom that prompted each of the previous withdrawals and return of irritibility guiding each restart.

So now I again find myself able to think clearly with very little inhibition to my natural candor. I am less tolerant of myself for not accomplishing at the end of the day and less tolerant of others who now irritate me.

Another book on the subject, Artificial Happiness, comes from Ronald Dworkin a few years ago. While the writing and analysis seem almost primitive next to Dr. Kramer's more elegant prose, he makes an important point that sometimes life's goals are best persued while irritated. If AKSE leaves me unsatisfied and treats me like a picador with multiple little sharp provocations, then using a pill as a surrogate to disaffiliating when I should diminishes my Jewish future. While patients may also irritate me more, I owe them the full measure of my skill which should not be set aside for my own inner peace. As I compile my intentions for the next six months I really want to work on conducting myself in a more gracious, less abrasive fashion than has been my history. But I need to give myself a genuine chance to do this without the phony pharmaceutical restraint.