Delan Azabani

Triple fault

I sought treatment for depression and anxiety just over three months ago, while trying in futility to continue living my life with minimal disruption. My counsellor and my friends convinced me to trudge onwards through the final year of my university course, and in fairness, it was worth a shot. I had an excellent career with Atlassian lined up, with no less than a signed contract, and all I needed to do was simply graduate. As difficult as it was to commit to this decision, I need to devote the rest of this year to my health, during when I can reset my mind without external pressure.

Aberration

I may need to quit my internship with Diamond Cyber. This doesn’t just hurt because they’re such a skilled and diverse team to work with, and I’d lose the opportunity to train myself in the real infosec industry so early. This hurts because it mirrors the story of my internship last year, where I quit after less than two months, then due to anxiety, now due to depression. The symmetry between these repeated failures is terribly frustrating.

I won’t be attending either of my exams, and while this may be tinted by my cognitive biases, I don’t think that attempting them this semester is worth the effort. Given my current state, I’m adamant that I would not pass Artificial and Machine Intelligence, and the only way I could pass Fundamental Concepts of Cryptography is if I managed to capture an elusive day of lucidity — a species so mythical that I’d be generous to have seen five of them in the last three months — between now and its exam.

While it has no exam component, the Software Engineering Project is also a lost cause for me. Students are expected to invest 10–20 hours into their projects weekly, but I’ve only yielded about ten hours of productivity for my team overall, and that’s with rounding to the nearest ten hours too. My team members are both incredibly capable students, and they did very well without my help, but I feel awful knowing that were I healthy, I could’ve brought a similarly capable mind to our proverbial table. Instead I occupied a third spot in our team that could’ve gone to someone that was actually useful.

I’m applying for a Withdrawal Under Special Circumstances for all of the units in which I’m enrolled, and a Leave of Absence for the next semester. The latter is fairly easy to obtain approval for, while the former generally requires a professional letter of recommendation as supporting evidence. The letter would essentially need to assert that I had a chance of passing the units before the Census Date, and this only changed after said date. I’m reasonably confident that my counsellor will support my application when I see her fourteen days from now, but I have no idea what I’ll do if she refuses. Relying on a personal statement, general medical certificate, or course coordinator’s statement seems far less likely to allow me to substitute withdrawn grades for failure grades.

I know little else with complete certainty than two consequences. I won’t be able to graduate until at least the end of the second semester next year, and I won’t be able to join seven of my current Curtin peers at Atlassian next year. Don’t get me wrong, this is a huge blow, which is why a handful of my friends persuaded me to persevere, but at this point I think it would be both unrealistic and irresponsible to do anything other than clear my mind and work on my health. “Slow and steady wins the race” feels appropriate here.

Debilitation

I haven’t qualified “health” as “mental health” thus far, because mental illness doesn’t operate in an isolated system. I can’t think, but I also can’t sleep, and these form a vicious cycle. I have no energy, but I also can’t eat, and these form another. I grow lonely, but my fear that the people I care about will grow bored of my antics only pulls me further away from these people when I need them the most, and so on.

It now seems nearly impossible to remember what it was like to “feel normal” and see myself as a healthy person with a heterogeneous and lucid mind. I’m seeing someone who’s brilliant on so many levels, and whose affection is orders of magnitude more efficacious than any medication I’ve been prescribed, and yet my online dating profile remains live, because its fields serve as a handy reference guide that prevents me from forgetting who I’m supposed to be and what I’m supposed to be interested in doing with my life.

I’m ultimately losing my ability to even function as a human of reasonable physical health, but a solid physical foundation is exactly the environment that I need to effectively climb out of depression, and the last seventeen months of my life that I’ve more or less wasted.

I’ve broken down several times, and I’ve wept for the first time in several years. While crying was cathartic, and regaining my ability to do so was positive, these episodes take a toll of their own. I’m depleted, lonely, and universally apathetic.

Medication

One of the two major components of the modern consensus on the treatment of depression and anxiety is medication. I’ve hopped between medications a handful of times, but sadly I expect to undergo more changes before I find a combination that works well for me. I’ve tried to keep track of my benefical and adverse experiences in a spreadsheet, without which I would quickly lose track of the nuances of each drug.

For nearly six weeks from the start of March, I took 10 mg of escitalopram oxalate daily, a reasonable choice given that it’s at least as effective as, and frequently better than many other contemporary monoamine reuptake inhibitors in regard to efficacy and acceptability (Cipriani et al., 2009). Even across drug classes, it’s among the most affordable (Wessling & Ramsberg, 2008) and safe (White et al., 2008) antidepressants. My symptoms of depression improved marginally, while anxiety has diminished to an impressive degree. Aside from significant sexual dysfunction, narcolepsy, and insomnia, the only adverse effects that persisted were whimsical, such as a restlessness of my limbs.

As the weeks passed, I developed what I’d describe as both insomnia and narcolepsy, where my sleep cycle alternated between either being completely unpredictable or halved in frequency, staying awake for 30 hours, and sleeping for 18 hours at a time. When I was awake, I would intermittently and inevitably fall asleep several times a day. I wasn’t surprised to see no improvements when introducing caffeine, as I’ve never noticed any eugeroic or stimulant effects from it. The symptoms of narcolepsy were resolved with modafinil, and later armodafinil, an enantiopure derivative with a more favourable plasma concentration curve, but I’m still struggling with an unreliable ability to sleep.

Not satisfied, I switched to 30 mg of duloxetine hydrochloride daily. As an SNRI, there was early evidence (Thase et al., 2001) to suggest that it may be superior to an SSRI via studies comparing venlafaxine against fluvoxamine and sertraline. Some later studies compared duloxetine favourably against escitalopram, although most of those that I found (Nierenberg et al., 2007; Pigott et al., 2007) were sponsored by Eli Lilly. Khan et al. (2007) found that “escitalopram has better tolerability and comparable efficacy relative to duloxetine”, but I take most studies about antidepressants with a flagfall grain of salt anyway, especially when they tend to span very short durations.

The first time I switched to duloxetine, I did so abruptly on the advice of my doctor, even though I raised concerns that switching from an SSRI to an SNRI would indicate a tapering period. That week was a genuinely awful experience that included my first serious breakdown, so I switched back to escitalopram until I contracted food poisoning in late May, where I was incapacitated for just over a week. Having taken neither during that period, I’m giving duloxetine another shot to see if it will work for me.

I’m not self-medicating though, as I have appointments with another doctor and my counsellor scheduled in the next fortnight. I’ve been told that I may need to start seeing a psychiatrist, which was quite startling, as my thoughts upon hearing that made me reflect upon how I’ve gradually let depression encroach upon and define my identity, but also how there are still stigmata attached to mental illness that even I need to unlearn.

Other medications which may be promising from my cursory research include bupropion, which Serretti and Chiesa (2009) found to be particularly favourable in regard to sexual adverse side effects, mirtazapine, clomipramine, and moclobemide, a reversible MAOI. Nevertheless, I’m still early into what will be a long journey. These other drugs could also bring with them a decreased tolerability due to their less selective nature.

Reflection

I apologise most genuinely to anyone around me who I’ve bored by discussing my mental health so frequently and openly. Even I somewhat resent how what I’m going through has made me appear seemingly one-dimensional, but I suppose it’s more healthy than vigilantly keeping it all to myself. Whether or not an apology is requisite is debatable, but I long more than anyone for a time when I can simply feel normal and healthy.

One of the phenomena I wanted to write about the most is how I’ve felt guilty when finding a rare day of lucidity, particularly when I’ve spent it doing something against which I have “better things to do” by the standards of others, whatever that means. It’s a train of thought that I need to avoid, particularly as I take the second half of this year off university in an effort to make my life normal once again.

Since I’ve started writing about my mental health a few months ago, I’ve spoken to multiple friends who are currently going through depression too, and it goes without saying that the shared prism of experience has helped bring us closer to one another. While I thought that I’d be able to provide unique and pertinent answers to help them with what they’re going through, I’m actually nearly as helpless. I’m in the same ostensibly helpless boat as they are, and that is what disheartens me the most.

I’m alive every day, but I’m not living every day. I’m here because I’m so apathetic about everything at this point that even the idea of committing suicide does not provide me with any appeal. More positively, I still have a small amount of hope that life will improve. Whatever ends up happening though, I’ve still got a long road ahead.

Attribution

Cipriani, A., Furukawa, T. A., Salanti, G., Geddes, J. R., Higgins, J. P., Churchill, R., Watanabe, N., Nakagawa, A., Omori, I. M., McGuire, H., Tansella, M., & Barbui, C. (2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. The Lancet, 373(9665), 746–758. doi:10.1016/S0140-6736(09)60046-5

Khan, A., Bose, A., Alexopoulos, G. S., Gommoll, C., Li, D., & Gandhi, C. (2007). Double-Blind Comparison of Escitalopram and Duloxetine in the Acute Treatment of Major Depressive Disorder. Clinical Drug Investigation, 27(7), 481–492. doi:10.2165/00044011-200727070-00005

Nierenberg, A. A., Greist, J. H., Mallinckrodt, C. H., Prakash, A., Sambunaris, A., Tollefson, G. D., & Wohlreich, M. M. (2007). Duloxetine versus escitalopram and placebo in the treatment of patients with major depressive disorder: onset of antidepressant action, a noninferiority study. Current Medical Research and Opinion, 23(2), 401–416. doi:10.1185/030079906X167453

Pigott, T. A., Prakash, A., Arnold, L. M., Aaronson, S. T., Mallinckrodt, C. H., & Wohlreich, M. M. (2007). Duloxetine versus escitalopram and placebo: an 8-month, double-blind trial in patients with major depressive disorder. Current Medical Research and Opinion, 23(6), 1303–1318. doi:10.1185/030079907X188107

Serretti, A., & Chiesa, A. (2009). Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. Journal of Clinical Psychopharmacology, 29(3), 259–266. doi:10.1097/JCP.0b013e3181a5233f

Thase, M. E., Entsuah, A. R., & Rudolph, R. L. (2001). Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. The British Journal of Psychiatry, 178(3), 234–241. doi:10.1192/bjp.178.3.234

Wessling, A., & Ramsberg, J. (2008). The review of antidepressants. Retrieved from http://www.tlv.se/upload/genomgangen/review-antidepressants.pdf

White, N. C., Litovitz, T., & Clancy, C. (2008). Suicidal antidepressant overdoses: A comparative analysis by antidepressant type. Journal of Medical Toxicology, 4(4), 238–250. doi:10.1007/BF03161207