Aug 12: Depression

My not posting for a while has been deliberate, but the sad news of Robin William's passing is the impetus.  Be warned:  this was a difficult post to write, and will probably be a difficult one to read.  Know from the start:  I'm venting, letting you know what's inside, not asking for answers or solutions, no matter how well meant they are.  That's not where I'm at right now. 

Depression.  It's a word that has different interpretations to different people.   It's a word that has changed and evolved over the years for me, which is what often happens as we live life.

My father was bi-polar, or manic depressive to use the older term.  He was born with the disease, as it is a chemical imbalance, although it wasn't diagnosed until he was almost 60 yo.  It lead to his alcoholism, his prescription drug addiction, it was worsened by a severe personality disorder that decades of psychotherapy couldn't dent.  The alcohol and 3 pack-a-day smoking took their toll on his body, and I believe affected his mind, since that was his weak spot. I haven't talked about it much in the blog, because it wasn't all that relative.  Honestly, I don't want to get into it much now, only in that it leads to other thoughts running around in my brain.

I chose psychology as my undergraduate degree, trying to figure things out, and recognized the manic depression diagnosis before his psychiatrists and psychologists did, because their exposure to him was much more narrow than mine--Bill only sought help when he was depressed, never when he was manic.  I made the decision then to not have children until being sure I didn't manifest.  By the time of PA school it was coming out that some women who were first degree relatives of bipolars were manifesting after pregnancy, with percentages up to 50%.  I didn't like those odds, and it was this reason I never wanted to get pregnant--ironically, this may have saved my life, as my undiagnosed heart condition might not have stood the additional strain of a pregnancy.

Everyone has ups and downs in their moods, but whenever I became depressed there was an additional terror: was I going to turn into my father?  It had always been my greatest nightmare.  In an instance of what I believe was Divine intervention the psychiatrist I was assigned to for my psych rotation as a PA student was the doctor who had finally diagnosed my father only a few years earlier; the same doctor at a different hospital, a different county.  He knew better than most the depth and depravity of Bill's bipolar disease, alcoholism and other issues.  At the end of the rotation, after the paperwork had been sent off and our scholastic association was ended, this doctor said to me 'Obviously, I've been watching you pretty closely over the last six weeks.  Let me reassure you: you are nothing like your father.  You have every reason in the world to be completely screwed up, but by some miracle that I don't understand, you aren't.'

It's difficult to say which sentence has meant more to me in my life: that one, or the one when Dr. Cohn told me I wasn't crazy for entirely different reasons.  Both of sentences were huge vindications.  (Dr. Cohn's was 'Congratulations! You have functionally critical severe mitral stenosis!'  He said afterwards that such a dire diagnosis had never been met with such elation.)

Depression is a well known, but little discussed, sequelae of open heart surgery. (Robin Williams had aortic valve replacement in 2009.)  What is the etiology?  There is a lot of debate.  Is it mechanical, from being on the heart bypass pump, affecting cells as they are put through the tubing and machine that does the work mechanically with the heart is stopped, and those damaged cells circulating through your brain lead to unseen damage to neurons?  Or is it from the horror of having your chest sawed open, your ribs spread with meat hooks and your heart--the center of your being--injected with potassium and adenosine, and then cut open to reveal the disease inside, which is then hacked out and manmade parts shoved in?

My depression began after the first heart surgery, although it wasn't for several months, when I was still so symptomatic and the surgeon and cardiologist refused to believe me.  I did start seeing a psychologist, who diagnosed me with PTSD, reflecting the horror that was the first surgery with all its complications.  I refused all medication, because I didn't want an anti-depressant listed, didn't want depression to be viewed as an excuse for my symptoms.  Medical professionals will deny it, but the reality is that if they see anxiety or depression listed they are less inclined to look for a physical cause, believing the patient is exaggerating due to their mental state.  Horrible, isn't it? 

So, what was the etiology of my depression then?  Being repeatedly incorrectly diagnosed? Being forced to work full time with a critical heart defect?  Dealing with personal morbidity and mortality at 41 years old?  Having my life changed forever?  Constant, unremitting pain?  A total change in every plan I'd had for the rest of my life?  Or from being on the bypass not once, not twice, but three separate times during the first ten hour surgery?  Who knows?

Whatever the depression was due to it certainly didn't improve with heart surgery #2, the horrid thoracotomy or heart surgery #3.  My total time on bypass is well into double digits from five heart repairs. Both those reasons: bypass machine and having my chest split open repeatedly were certainly going to add fuel to the fire.  And, again, increased unremitting pain, loss of function, financial hits, etc....

I tried to stop the antidepressants a couple times in the years since the third surgery, but felt much worse off them; I was angry and lashing out at people.   On them, I didn't think my mood was that bad.  Being exhausted all the time, being out of breath all the time, struggling to work and maintain a house, not being able to function enough to really live life, are all really solid reasons to be depressed.  But I didn't really feel all that badly.  (Or is it 'bad'--always screw that up.)

Until I stopped working in November.  Until I finally had to face that I couldn't go on anymore, working and suffering so much.  Until the recognition that every infection I caught was putting my life at risk, worsened by the medications for the autoimmune disorder, whether it be the chance of infection seeding on the valve or the cough that increased the risk of another life-threatening chest bleed.  Until I had to unequivocally accept that my livelihood, my career, my passion and my life of treating patients--touching them, examining them, fixing them, healing them, was over. 

I know--so  please don't tell me--that there are many other ways to help, even to heal people.  But I've been treating patients through physical contact since I was 16 years old and started on a volunteer ambulance, which amounts to almost 35 years.  It's what I know, what I'm good at, where my skills are. Any attempt to find something else, try to discover what I could still do with all my many restrictions, has been thwarted by the continuing, seemingly endless, litany of physical problems, making everything worse.  They all intertwine in unbelievable ways, each making something else worse.

The pulmonary HTN cardiologist is treating my right heart failure with more diuretics, which is making the Sjogren's much worse by further drying out all my mucus membranes.  My breathing is better with less fluid in my system, decreasing strain on my heart, but my mouth gets so painfully dry that I wake 4-5-6 times a night with the CPAP (for the sleep  hypopnea) adding insult to injury, despite a humidifier and nasal pillows instead of a face mask, so remain tired all the time.  I'm still following the difficult dietary restrictions in hopes of getting off the damn prednisone used for the autoimmune disease, which, among other side effects, gives you a dry mouth and in me retains fluid, which is probably in part what lead to needing more diuretics. 

Meanwhile, the plantar fasciitis continues, with my suspicion that it's being aggravated by the change in physiology from all the fractures in that foot, which will be made worse in the long term by the bones thinning even more with the prednisone.  The foot pain causes me to limp, which has now aggravated my degenerative disc disease, causing almost constant pain in my left hip and or back.  My chest pain seems to be worse, probably because my walking is so off kilter, with it being a toss up as to my limping being from the foot or the hip.   Maybe I'm just more aware of it with the additional pain.  The pain with walking has curtailed me going to pulmonary rehab, or any other exercise, so there is no way to tell if the decrease in heart failure has helped my symptoms.  It has also made it impossible to lose weight--I consider it a triumph that it's staying relatively stable. 

While the above list is certainly more than enough reason to be depressed, in my bad moments the little voice niggles at me:  what if you inherited the tendency from your father?  What if you didn't escape biology?  While there is an ironic reassurance that I'm not bipolar--certainly not getting any happy highs--it doesn't rule out a genetic predisposition as at least a contributing factor to the depression, which might be a unipolar depression.  Does it really matter?  It might not to most people, but it does to me, because I made a determined effort to be as different as I could be from my father.  His favorite threat to me, over and over  and over, was 'when you grow up you're going to be just like me', said with an evilness that would do credit to Satan himself.  (For the record I don't believe in Satan, but it's a useful allegory.)

In my dark moments suicide seems like a reasonable exit strategy from the constant pain, the continuing problems, the hopelessness that seems overwhelming and continual.   It gives me a different point of view on other's suicides, because I understand that without my deeply held beliefs it is entirely possible that it would have been my decision.  I'm not talking the suicides that are an 'easy out' to a single difficult situation, the sympathy is for those like Robin Williams who have spent years fighting against the darkness, pushing it back over and over until, just one time, it overwhelms them.  The recognition of the coping mechanisms that one develops to cover up  the darkness inside, not wanting others to see the depths that are there.  Humor is such a good defense, and the laughs are healing as well.  Smiling a lot, and judiciously applied makeup, create an illusion of health to many who see me.  There are probably only a handful who see through my façade.

But, be reassured, I'm not suicidal. I believe in reincarnation.  I believe that we have a part in the decision making that leads to the life we are placed in.  I believe that my higher self chose this difficult path, knowing it would lead to something for my soul to learn and grow from.  I believe in karma, in cycles, in things being part of the spiral of life, the spiral that repeats in so many things in nature and the Universe.  And because, in the darkest moments, I still feel the presence of something greater surrounding me, giving me courage and hope--against all logical odds.  My beliefs, held since conscious thought in childhood, keep a flame lit that even in the dark gives me a place to look towards, to focus on, to be centered by.   Suicide is not, for me, ever an option.  Just because I don't understand now doesn't mean that I won't at some point down the road.  Not being able to have a family seemed like a horrible fate, but looking back gives a lot of perspective.  What if I'd lived, but become bipolar to the same degree of horrible-ness suffered by my father, or passed on either the congenital heart defect or the bipolar with my father's wretched twist--or even both?  How much worse would that have been? 

Am I being too smug, too assured, too cocky?  My father heard voices all his life, something that he didn't reveal until late in his disease.  How can I be so positive that the wonderful, loving greater presence which currently carries me through the bad won't turn into something sinister and despairing?  What if I lose that light, that perspective?  After everything I've suffered through in my life--and there is more than has been laid out here--I believe that it would have already happened.  There have been many moments like the one with the psychiatrist which enforce my faith that there is something greater than us, whether you call it God, Goddess, Spirit or something else. 

This is why we can't judge someone else's pain.  Robin Williams might have had a voice that kept him going for the last 63 years, gave him strength through the worst of times, he believed in the Christian God.  But maybe that voice, or the light in his center, was suddenly gone.  Was it the drinking?  The drugs?  The heart surgery?  A chemical deficiency in his brain?  Something else we will never know about?  It's easy to be judgmental, to be so sure that we would never make the same mistakes.  But really, how can we ever truly be sure?  There is much wisdom in the Indian teaching to not judge a person unless you have walked in his shoes.   We all believe that we will be true to our morals and values, but until they are tested how can you know?  The reality is that you can't, not ever.  And that is the mystery, the scariness and the wonder we don't know in this world. 

The seasons.  The moon.  Life and death.  Everything in the universe, all life, is cycles. Perfect moments don't last, either do the bad ones--it just seems as if they are around for longer.  But I do know this time will pass.  Or maybe I'll just get used to it, develop more coping mechanisms.  Something that I may not have any clue about will manifest.  Or perhaps good seeds sown in the past will bear fruit in my future--that's the great part about karma.  There have been many blessings, even since my heart disease worsened, irrevocably changing my life ten years ago.

I still have so much more than many:  four limbs that work, a brain that functions (mostly!), use of all five senses, health insurance, a house, food, clothes, a car, a place to live that doesn't get bombed on a regular basis, electricity, indoor plumbing, a comfortable bed:  those things alone separate me from millions of others who are less fortunate.  And from that comes my practice of the gratitude beads, counting my blessings.  The more depressed I feel the more times I run my beads through my fingers, reminding myself of the positives in my life and my world. 

And besides, no one else could deal with Chester!  For all his many faults he has a special spark of life and intelligence in him, and if I wasn't around he would have to be put down.  So, Susan, you have to give him credit for giving me another reason to keep going! 

Warm fuzzies welcomed, and appreciated, but again--no 'helpful' suggestions.  I can guarantee you can't come up with anything that I haven't thought of, or that there is a reason I can't do (this includes teaching--separate issue).  And right now it's a struggle just getting through a day at home.

Thanks for checking in,     Laurie