Psych meds and mutant genes

A little while back, I mentioned that I was having a pharmacogenomic test done, i.e., a genetic test to suss out how my body might respond to different medications.  In my case, the test was looking at antidepressants and other psych meds.  The results are in; they’re nothing dramatic, but they’ve validated my experiences with certain medications.

For example, I had been taking aripiprazole (Abilify) as a sort of helper drug to complement my primary antidepressant.  I started out taking the very lowest available dose, and when that seemed to be going well, my psychiatrist recommended increasing it.  I tried that for three weeks, went “NOPE, not OK,” and dropped back to the lower dose.  Even though my psychiatrist had given me permission to do this, she seemed disappointed and continued suggesting the higher dose.

Well, guess what?  It turns out that I have genetic markers for processing aripiprazole very efficiently; the test results note that I should “use with caution” and “lower doses may be required.”

I was right.  I was right that the higher dose was wrong for my body, even though it’s a “normal” dose for other people.

The test also looked at a gene called MTHFR, which produces the gloriously long-named enzyme methylenetetrahydrofolate reductase.  It converts folic acid to a form called L-methylfolate, which is the form used by the body and brain.  (Moms, remember how important it was to take folic acid while you were pregnant?  It’s because L-methylfolate is super important for brain and nervous system development.)

Long story short, it turns out one of my MTHFR genes is a mutant version, meaning my body might not be processing folic acid as well as it ought.  There’s some preliminary research that this is associated with depression and maybe with low energy levels.  [Cautionary note: If you’re curious about this for yourself and decide to start Googling about MTHFR, put your critical thinking hat on tight.  Those search results are going to pull up a lot of BS.  Real medical research about MTHFR seems to be fairly scarce.]

In an odd sort of way, it’s exciting to finally have a test actually find something wrong with me.  I’m depressed and I’m anxious and I’m tired, and yet all the normal tests (iron levels, thyroid hormones, etc.) are always, well, normal.  I now have a new and different thing to try: taking L-methylfolate supplements.  I’m not incredibly optimistic that they’ll make much of a difference, but one can dream.

Referring PhD students to counseling is treating the symptoms, not the disease

I went off on a bit of rant on Twitter yesterday, starting with the sentence above.  Around about the 7th or 8th tweet, I realized that I needed to work this up into a full-fledged blog post.  So here we go.

Two things set off this rant.  The first was reading the latest in a long line of articles about the mental health problem in grad school.  Don’t get me wrong, it’s a fine article, and the more people talk about this, the better.  However, like many of its predecessors, it focuses on access to counseling and other mental health care as the solution.  That’s absolutely important, and so is emphasizing the message that it’s OK to seek treatment.

But offering counseling and antidepressants is just treating the symptoms.  If my toddler woke up with a dangerously high fever, I would give him Tylenol to bring it down, but I’d also take him to the doctor, where the cause of his fever would be evaluated and treated.  If all the kids at his daycare came down with the same serious illness, the staff would give us all information about how to get them treatment, but they’d also clean the heck out of everything and assess whether their hygiene policies needed changing.

Along those same lines, we need to talk about why anxiety and depression are so prevalent among PhD students.  As the links above describe, graduate school causes mental health issues in many students, and exacerbates existing issues in others.  We need to make sure that those students who are suffering feel comfortable asking for help, but we also need to fix the system that’s causing this psychological epidemic in the first place.

I’m sure there are people out there who think that this is just how a PhD has to be, and sure, pushing yourself to your intellectual limits is always going to be hard.  But don’t you think people would do better—be more productive, produce better work—if the system didn’t function in a way that made them miserable?

The second trigger to my rant was a discussion that took place at a gathering of female postdocs and PhD students in my department.  It was a meeting to chat with last week’s (female) colloquium speaker.  Based on who organized this particular meeting, I suspected that any advice might tend toward the useless kind, but I went anyway.  (There were donuts, what can I say?)

The organizer and the guest of honor were both the kind of postdoc that the department likes to bring in to tell all us PhD students “how to succeed:” people who’ve won an especially prestigious postdoctoral fellowship, the kind that will get their resumes placed at the top of the pile in faculty searches.  These people tend to be extroverted, assertive, even cocky; in grad school, they did “groundbreaking research” and somehow managed to publish a half-dozen first-author papers.  Be like these people, goes the message, and you too can be successful and awesome.

This is the mold.  This is the person the system says you have to be.  There’s an underlying assumption that it’s possible, if you just work hard enough, for everyone to become this person—and that if you don’t, it’s because you didn’t try hard enough.

Which brings me back to why I’m not OK with “make counseling more available and less stigmatized” being presented as the full solution for poor mental health among PhD students.  It relieves the system of the burden of change and puts it on the individual students.  There is something wrong with you, says the system.  Go get that taken care of, and when you’re all fixed up, come back and fit yourself into our mold.  

Let me end with a personal example, in hopes of further clarifying my point.  One of the pieces of advice we always get is to talk to lots of faculty who aren’t your research advisor.  Make yourself seem more awesome.  Cultivate people who can write letters of reference for you in the future.

The problem with this advice isn’t its content.  Networking is an important skill that will serve you well in just about any occupation, and fundamentally, people won’t learn about your research unless you tell them about it.  No, the problem with this advice is that it’s universally delivered from the perspective of a confident, gregarious extrovert: “Just go talk to professors!”

I’m a shy introvert with major social anxiety—it’s incredibly difficult for me to “just go talk” to anyone, much less someone who’s presented as an evaluator and an important part of my career.  Talking to someone—taking up their time—makes me feel like I’m being a huge imposition.  These are my issues to overcome, and they do require real mental health care.

But you know what else would really help?  A system that acknowledges that this is hard for me.  A system that is just the tiniest little bit more encouraging of these kinds of interactions.  That reassured me that I’m not doing something dramatically wrong and weird and awkward when I knock on a professor’s door and ask to chat.  That doesn’t treat every discussion about research as an evaluation of me, designed to make the questioner look good.  And above all, a system that doesn’t assume that I’m a bad researcher just because I don’t fit the mold.

My antidepressant made me dizzy

The sticker was the first clue.

It’s bright yellow, with a picture of a droopy eye and the words “MAY CAUSE DIZZINESS.”  It’s one of three yellow stickers containing terrifyingly generic warnings that adorn my bottle of the antidepressant escitalopram (generic for Lexapro).  These pills are what I was prescribed to help combat my postpartum depression and anxiety, accompanied by the hope that they would not put me to sleep the way sertraline (Zoloft) did when I was in college.

I can’t remember exactly when I started noticing the dizzy spells, but I want to say that it was very shortly after Little Boy was born.  Maybe before I started taking Lexapro?  Leaning over to lock his car seat into its base, I’d suddenly feel like the car was moving around me.  I figured it would go away with time.  However, as my body healed from birth, these episodes got worse rather than better, and I became annoyed and suspicious.

Prompted by the sticker, I’ve typed numerous variations of “Lexapro dizzy” into Google.  The results were always situations that didn’t seem like they applied.  Dizziness and vertigo are supposed to be initial, temporary side effects that wear off within the first month.  They’re also frequently reported as a withdrawal symptom.

When my pharmacy was closed for inventory and I had to stretch my prescription over a few extra days before getting a refill,* the dizziness got much worse.  At times, just turning my head made me queasy.

Putting logic to work, then:

– The dizziness is a withdrawal symptom.

– My dizziness had a predictable element: it was usually worst in the mid-to-late afternoon.

– I take my pills at night, right before bed.

Conclusion: The level of Lexapro in my system was lowest in the afternoon and evening, and this was causing my dizzy episodes.

Prediction: If I started taking my pills in the morning instead,** the Lexapro would be at its lowest level in the middle of the night, when I presumably would not notice anything because I would already be lying down and asleep.

Result: It worked!  I’m still tired as all get-out, but the vertigo has all but disappeared.  [Bonus(?) side effect that does not appear to be coincidental: very elaborate dreams.]

*Not recommended.  Stay on top of your prescription refills.

**In general, don’t modify your medication routine without talking to your doctor.

Mental health care access is a joke

We’ve been trying to find my husband a psychiatrist.  It hasn’t been going very well.

The first place we tried was a local community health center with several psychiatric nurse practitioners.  A referral and some phone calls later, he was told to come in at 8 a.m. on a specific day for a walk-in appointment.  It turns out “walk-in appointment” is an oxymoron, because, when he arrived, he was told that the earliest available time slot that day was 10 a.m., and that wasn’t with any of the people he’d been told he would see.  For one of them, he’d have to wait until at least 3 p.m.

Well, my husband is a man with a job and a tight schedule, so he left.  Further calls revealed that the center has no non-walk-in options for the initial evaluation appointment.  That wasn’t going to work.

So we tried a different place.  The friendly assistant on the phone informed us that yes, Dr. M. was taking new patients, but the earliest available appointment was in January 2016.  What?!

Health care in the U.S. always tends to be a maze of referrals and insurance verifications, but mental health care seems to be the worst of all.  You see, to see a psychiatrist (or a psychologist, or a therapist or counselor), you have to do go through the following steps:

1.  Find a practitioner who sounds like a good fit for you.

You would think that you could just get a recommendation from your regular doctor.  You would think.  That’s how other specialties seem to work.  When I was referred to a physical therapist for some long-term hip problems, the referring doctor sent me to a specific person.  Someone they thought might be appropriate.

Mental health?  Nope.  When I talked to my OB-GYN about postpartum depression, I got some vague hand-waving about how they couldn’t recommend anyone in particular because they didn’t know who took my insurance.  When I walked into my university’s student counseling center – the people who handle all student insurance referrals for mental health – and asked to be referred to a therapist for postpartum depression, they had no idea to whom they should send me.  After a long while of awkward searching, I asked if they could just give me a blank referral and let me find someone.  They did.

2.  Check that the practitioner in question accepts your health insurance and is taking new patients.

The health insurance question seems to be particularly problematic with therapists, who often practice alone and may only contract with a handful of insurance companies.  And the only way to get a solid answer is to call the practitioner’s office and ask.  I’ve yet to encounter a health-insurance-created online “provider search” that is user-friendly in any way.

3.  Get the official, insurance-approved referral from your primary care physician.  [May be optional depending on how your health insurance works.]

That’s right, you have to make a completely separate appointment with your primary care physician, just to get the piece of paper / electronic signature saying that your mental health care is medically necessary.  Or in my case, you have to go through triage at the student health center again and re-answer a bunch of irrelevant questions about your drinking habits.

4.  Call to make an appointment.

Theoretically straightforward.  Often frustratingly not.  Sometimes, like The Mort Mommy, you face a bureaucracy so unorganized that you never get through.

5.  Wait for the appointment.

Maybe the soonest they could get you in was a few weeks from now.  Maybe it was eight months away.  It’s not like mental health issues are ever urgent, right?

6.  Attend appointment.  Decide if you feel comfortable enough to make another.  If not, rinse and repeat the entire cycle.

Comfort level is important with any medical professional, but especially when it comes to mental health.  If you don’t mesh with your therapist, it’s not going to work very well.  My latest attempt at therapy ended after just five sessions because it became clear that he didn’t have a frame of reference for my issues and so we were going over and over and over the same things with no forward progress.

This whole process is hard enough when you’re sane and have your life together.  It gets exponentially harder when you’re depressed.  When it feels like every little task takes an overwhelming amount of energy and it all seems hopeless anyway.  Or when you’re so anxious that every phone call to a stranger leaves you panicking that you’ve said something wrong.

It’s ridiculous.  My husband and I have decent health insurance.  We can afford the $25-a-visit co-pays.  We live in a moderately-sized city, and we have the job flexibility to make appointments during the work day.  Even at our worst, we have each other for support and the presence of mind to say to a doctor, “I am depressed and need help.”  And we still struggle to access mental health care.  Imagine how much harder it must be for those who don’t have the same level of support and privilege.