First Visit With a New Psychiatric Nurse Practitioner

Wednesday. Tabitha has her own PNP practice just a couple miles from my house, a small office with a couch and an easy chair. She sits on a large exercise ball and types into her laptop as we talk. She’s serious, but in a friendly way.

“So tell me why you are here,” she says.

I tell her I’ve been on psych meds for maybe 16 or 17 of the last 20 years, and although I’ve often functioned at a fairly high level, I’ve rarely felt well. I have been doing worse than usual since at least the middle of 2014, with ups and downs. I’ve about given up on meds and was thinking maybe I should come off entirely, although I was still willing to discuss other options as well.

Tabitha takes my history, mental health issues in my family, suicides? Birth order, well-being of my siblings. When I think about it that way, I realize I have one sister who lives in deliberate denial (“I don’t like to reflect on my life.”), one with an obvious anxiety problem and possible eating disorder, and a brother with depression and PTSD. I hadn’t really thought about our collective struggles that way.

She goes on, physical health, medications. She is impressed because I was able to bring her a list of all (well, maybe most) of the psych meds I have tried since 1995 and my reactions to them. Yes, I’m a researcher, and I collect and organize data on everything; it’s my nature.

It feels easy to answer her questions. She’s low-key and reacts to things at most with a sympathetic murmur. I realize how much it helps me to have psychologists and psychiatrists not show too much reaction to what I tell them. That way I don’t have to worry that I’m shocking, upsetting or disgusting them.

She’s surprised I am on such a high dose of venlafaxine (Effexor). She thinks it could be part of the problem. “You started it in October 2014 when things were getting hard, but it doesn’t sound like it’s helped.”

No, though I’d never thought to link it to the fact that the past couple of years have been worse than typical. I did, however, ask for a second opinion back in October of 2015 because I didn’t feel things were going well. And Sue, my previous psychiatric nurse practitioner, had dismissed that doctor’s suggestion that the venlafaxine wasn’t a good idea. I show Tabitha the results from the genetic testing that second opinion doctor conducted.

She glances at it and says she will review further. She would also like me to have adrenal and neurotransmitter testing. She says some people with treatment resistant depression don’t get a benefit from SSRIs because their bodies aren’t able to make the neurotransmitters in the first place, so working on the transmission is not sufficient. She talks about eating protein and vegetables, limiting even fruit. She talks about diet and supplements as a way to affect the way my body uses amino acids.

It all sounds very scientific, but I don’t have the background to know how to evaluate it (I’m a social scientist, and my knowledge of biology is not very sophisticated, unfortunately.) She says we’ll start with the adrenal and neurotransmitter tests (not covered by insurance) and some blood work (probably covered by insurance). I am to cut the venlafaxine by 20 percent starting this week. First goal is stabilization (getting out of bed before noon, eliminating suicidal thinking). Then we’ll work on building energy, adding in exercise, and further tapering off the venlafaxine. It’s a hard medication to come off of, she tells me. We’ll take it slow. I’ll see her every two weeks for a while until we know we’re moving in a positive direction. Over time we can think about different anti-depressants. Lamictal has been great for some people, but there are other options too.

“I’m hopeful things will get a lot better for you,” she tells me as I leave.

I raise my eyebrows skeptically, but I have to admit, I leave the appointment feeling that perhaps she’ll be helpful. She did radiate knowledge, professional confidence, and stability.

***

Friday. Two days with a lower dose of venlafaxine, and I’ve had some strange dreams but otherwise don’t notice much difference yet.

I realized yesterday that I’d not mentioned self-harm during my intake with Tabitha. It wasn’t a deliberate omission. She didn’t ask about it, and it slipped my mind. I wonder whether that makes a difference in how she thinks about medication.

I still want to be hopeful about Tabitha. On the other hand, she told me she would send me an email with a list of the blood work she’d like me to request from my primary care doctor. It’s Friday afternoon, and there’s nothing from her in my inbox. She said she’d send me a receipt from the appointment, and that hasn’t arrived either.

Maybe she will get to it over the weekend; she might be the type who does her follow-up paperwork and messages at the end of the week. Or maybe she is the kind of person who talks well in appointments with people but doesn’t have good follow-through. I’ll delay judgment a bit longer.

 

22 thoughts on “First Visit With a New Psychiatric Nurse Practitioner

  1. Hmmmm, she sounds good which probably means she is busy. Hopefully you’ve heard back by now. Interesting about the protein and diet component. My psychiatrist just told me yesterday that eating a bowl of chicken noodle soup would most likely do me more good than taking any medication. I couldn’t process that yesterday because I don’t eat soup and got stuck on not being able to stop eating if I was to start and ughhh. But today after yoga I went to the market and bought some locally raised chicken breasts, organic rainbow carrots, leeks and parsley and some bone broth to add to the pot of soup I made. She said the microbiomes in my gut would be smiling but really I have a massive headache now and I’ll see how I feel tomorrow.
    I never took Effexor but I did take Wellbutrin for a long time which is also difficult to come off of.
    I hope she had lots of good ideas for you and possibly you could ask to see her weekly while making all the changes and adjustments? It’s only money right and if you find her helpful it could be totally worthwhile. I just had lots of blood drawn on Monday and everything was right on target. I also got an ekg and I’m “in shape” according to the tech and just fine.

    The mind is a funny thing and it’s complicated to feel like crap when “nothing is wrong” yet you feel like you can barely function or as if everything takes so much effort because everything really is wrong. That makes no sense but none of this does.
    BTW, I also love practitioners who do not overreact, makes everything much easier. I’ve been able to share what I thought are horrific “behaviors” and my psychiatrist did not react or judge…something about how my body found a way to gain some sense of control in a scary, senseless world. My body was doing the best it could (nothing eating disorder eating disorder related but something totally awful that I did and still do.)
    So I guess I’m sharing that because I’m pretty certain Tabitha won’t judge or change her mind about you or the meds based on your self harm.
    Maybe rainbow carrots will explode with compassion in my tummy, who knows but I ate a bowl of my soup and was able to stop but feel like crap, oh well. Life goes on.

    Love you Q 💜

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    • I’ve missed you, you know? I think you made your blog password protected at some point when I was traveling and away from WP for a while. If you are willing to share it with me, will you email it? same email as before: laquemadasola@gmail.com

      That soup sounds kind of good to me. I’ve been hearing a number of people tout the benefits of bone broth recently. I hope your stomach settles down. And I’m so glad to hear the EKG and blood work looks good.

      Love to you, xxoo.

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  2. This sounds promising – I hope she can help you. Would you willing to share what the neurotransmitter and adrenal tests are? Might be something I’d like to ask my psychiatrist about.

    As for the Lamictal, it is working for me (probably because it’s a bipolar med primarily and I actually have bipolar). Seven years of antidepressants didn’t touch it and even made things worse. Lamictal isn’t for everyone but it sounds like it might be a good option for you!
    This is all overwhelming, I want to validate that, but also say that I feel hopeful for you. Xoxo

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    • It’s interesting though, isn’t it, that the same medication can be useful for different conditions. I wonder what is similar and dissimilar between bipolar disorder and treatment resistant depression, in terms of what is happening in the brain?

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  3. She sounds nice. It’s wonderful to have someone who listens well and sometimes a fresh approach can be very helpful.

    I’m a tiny bit skeptical about blood testing in psychiatry – some tests have a good scientific basis (e.g. testing for conditions that contribute to depression such as thyroid disease, checking blood levels of lithium, monitoring liver/kidney function and blood counts when on drugs which affect these), but other tests are very much at the experimental stage and while they may contribute to scientific knowledge as a whole their usefulness at an individual level is questionable. Sometimes equivocal scientific research or individual test results are interpreted to fit with the particular theory or treatment direction the practitioner already wants to take (this applies to other medical testing as well – the sleep studies I had done come to mind). If it was me I’d want to know exactly how the results of any given test would influence my management before having them done, especially if they are expensive.

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    • Right, I do agree with you. She suggested these blood tests: vitamin B12 and vitamin D, iron, ferotin, and liver function. I think these will be covered by insurance but will have to check.

      The adrenal and neurotransmitter tests are not covered by insurance and together cost $279. I’m still thinking about those two.

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  4. She sounds good, I like that she is confident and hopeful! Hopefully you have heard from her by now. I’ll be curious about the tests, simply because I find the way the brain works so fascinating. Keep hanging in there, Q. Xx

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  5. I was coming off Effexor when I went through that very bad suicidal patch in November (when I was going to kill myself in Bali), and I’ve heard a lot of people say that it’s one of the worst drugs to come off. With the frequency of your suicidal thoughts lately, it scares me that they could slip over the line from thoughts to plans. Please will you be ruthless about keeping Tabitha (and E) informed of any changes? No holding back for fear of being a bother.

    I’m cautiously optimistic about Tabitha; it sounds like you are too. I think that’s a good place to start.

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  6. I will be seeing them (Tabitha and E) regularly for a while, so yes, I’ll keep them informed. And I’m going to sign a release so they can talk to each other. I’m crossing my fingers, though, that it won’t be too bad if we take it slow and keep tabs on how I’m doing. How fast did you come off Effexor? I wonder if that made it worse for you?

    I’m cautiously optimistic, too. It was a good first appointment, anyway.

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  7. I never would’ve considered seeing someone like Tabitha. What a great idea! I sometimes feel like nurse practitioners are kinder, have more time for, and listen better to their patients than doctors do. It seems like a good start, perhaps?

    I think delaying judgment is a good idea – at least until you have another meeting, I’d say. 🙂

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  8. Hey, just found your website. Hang in there :). To struggle that long with depression and still be fighting it is amazing.

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  9. Pingback: Effexor. Withdrawal. Brain Games. | la quemada

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