livingwithablackdog

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B-B-B-Budget: The Cost of Medication. Is It Worth It? 02/10/2011

Budget.

Now there’s a scary word.

Why is it there?

It goes through my mind on a regular basis.  Like – every time I run out of a few medications at once.  And especially on those really special occasions when they all run out at the same time.  You know the ones?  Or perhaps you don’t.

Me – I have what is known as Treatment Resistant Depression.  It means what it says.  It’s a bastard to treat.  It doesn’t respond to the basics and I go to a psychiatrist who is a specialist.  Yay me!  It also means that what works is an interesting combination of meds.  This is complicated by the fact that my depression is the result of surgery that I had in my early 20’s that also left me with a tendency to partial seizures (now controlled – by medication…).  I also have a history of really nasty and persistent migraine that I resisted medication for until the summer when I had them for 4-5 days a week every week for about 5 months and found myself at risk of losing my job over the number of sick days that I was accumulating.  I also have low levels of vitamin D and a back injury that has resulted in the growth of osteophytes (essentially arthritis).

I figure that I am lucky to live in Australia where a large proportion of the cost of most medications is subsidised by Medicare – the government scheme to ensure that health care is affordable for everyone.  It says something that I generally reach the threshold of what people are expected to pay without further subsidy (Medicare’s safety net) by about October or November each calendar year.

My meds for Depression include Lexapro (also known as escitalopram) an SSRI, Edronax – a SNRI, Lamictal (lamotrigin) which works as a mood stabiliser but is also an anti-seizure medication and Valdoxan – which is only new.  I’m taking Valdoxan at a low dose as an augment to my other anti-depressant medication.  I’ve tried to go without an augment several times, but it just isn’t enough to hold me – I relapse with the slightest of triggers.

Valdoxan is expensive however because it is not PBS listed (ie not on the Medicare Pharmaceutical Benefits Scheme list) but is sooo much better than Lithium which is what was what was used as an augment before.  Valdoxan wouldn’t replace Lithium for someone whose primary medication need was for Lithium – but as an augment it has been great.  It helps me sleep at night, doesn’t leave me drowsy through the day, doesn’t put on weight or make my hair dry and frizzy – just costs a lot of money.  But it allows me to function so much better than the Lithium did that I don’t begrudge a cent.  I also take a very small dose of Abilify which has helped with some other weird symptoms that used to come when I was low on sleep.

Next, I take Topamax to prevent migraine.  Much as I hate to admit it – this has proven very worthwhile.  While I still get an occasional breakthrough migraine a few times a year – they are nowhere near as severe, don’t last more than a day and don’t leave behind the ghost migraines for days afterward.  In short – I can function.  On top of this I take Vitamin D supplements and Glucosamine with Chondriatin (and I notice the difference with my back stiffening if I stop taking it).

Finally, one of the fall out effects of my depression has been the decrease in concentration and attention span that has come with it.  This year to see if we can improve that my doctor has been prescribing me a low dose of dexamphetamine – and I think it’s working.  The catch has been that it gave me tremors in my hands and, in the beginning, headaches – I had finally managed to get rid of all antidepressants that caused this – so it was back to the Propanolol for me to get rid of the tremors.  Propanolol also helps with prevention of migraine too, so it adds a bit of reinforcement to the Topamax (not that I would take it if it wasn’t for the tremor!).

That, ladies and gentlemen, totals at eight prescription medications and two over the counter alternative medications.  Not what I would call ideal – but they all serve a specific purpose and thinning them out would leave me very vulnerable to relapse – trust me, I’ve tried – under the supervision of my doctor whom I’ve told point-blank that I won’t take something or other … several times.  One day I hope to successfully reduce them, but I think that it will take a lot more skill in managing my depression on my part, more research time, planning and preparation.

I buy the Vitamin D and Glucosamine at discount pharmacies.

The rest I go to the same pharmacy for all the time.  This helps if I run into any trouble with any scripts or if I’m physically ill – they’ll run it around to my place for me.  Also if I get prescribed something else or go to buy something over the counter – the pharmacists there know what else I take and can tell me if it will cause me any problems.

Recently I had to get all my scripts filled at once.  It cost a lot of money.  At first I cringed.  But really, I’ve done this before and its nothing new.  It’s about four weeks medication that I’m paying for.  I know how much my medication costs.  In the end I just shrugged my shoulders and paid.  I said to the lady who served me the same as I’ll say to you.

“A day’s wages is not a lot to pay in exchange for the ability to function for a month.”
 

Seasons Come & Seasons Go 29/09/2011

Some people are Summer people.  Some people, spring people.  Some are winter people.  Some love autumn.

No, I’m not talking about people’s colouring or the things that they like to wear (that is something that I, in fact know very little about).  I am simply talking about peoples’ favourite times of year.  Some people like to soak up the sunshine in summery garb out in the garden, down at the beach or over at the local pool.  Others love to curl up by the fire in their favourite jumper under a rug with a good book and a cup of hot chocolate – or put a movie on.  Some love the colours of autumn and the beginnings of that lick of ice in the early evening.  And some the radiant brightness of spring, its scents, the new life, the slow steady warmth, the magpies diving at you from overhead…

I never settled to a favourite time of year.  I really do enjoy almost all of all seasons – and by the time one ends I am ready for the next.  I am not fond of the days that exceed 40 degrees celsius with no cool breeze for long stretches at a time.  Hot winds are their own breed of evil in Australia for reasons far beyond temperature tolerance.  I’m not a great fan of temperatures at the other end of the spectrum either – especially if they come with a wind.  Actually – wind bugs me more than temperature.  But seasons – apart from the odd bits like getting up in the dark to go to work in winter – seasons are a delight.  Full of life.  At least, I always used to think so.

My dog pays attention to the seasons too.

Unlike me, the dog has clear preferences for different times of the year.  It took me a while to work this out, but its consistent.  The dog is stubborn in winter.  He moves slow.  He needs more time.  He takes more time and holds me up whether I plan it or not and he wears me out more easily than he does during the warmer months.  I think he’s arthritic.  He gives me no trouble if I allow for the arthritis though.  A bit more sleep – 1/2 hr or so more than I need in summer and I’m fine.  I just need to be patient.

Summer is usually the dog’s best time of year.  He still needs discipline, but he’s more content to walk at heel and doesn’t drag and tug away at the lead.  Spring and Autumn are strange.  Most of the seasons fall in with the winter and summer behaviour for Dog according to temperature and what the light is doing.  In each of these season there comes a point where the light changes – and over these few weeks the dog goes nuts.  He is unpredictable.  I can not afford to let my guard down for more than a few moments at a time.  My sleep gets poor – this starts the ball rolling.  My energy levels become low, my motivation to maintain routine relapse prevention strategies gets sloppy and I soooo don’t feel like doing anything about it.  It at these times that I have frequently relapsed (almost without exception).  I made it through autumn this year.  So far I have struggled this far through the last few weeks.  Another 3 – 4 should see me through the worst of it.

Until then, its keep on keeping on and stick to the programme.  Watch for warning signs – the very time of year in and of itself is a trigger – even without the presence of other factors.  Light does funny things to my health in other areas too.  It’s like the dog becomes delirious.  Here is a time when I need my friends and family – my supports more than any other time of the year.  I’m struggling to get to work on time at the moment, but so far my boss has let me cover with time in lieu.  Still, I’m determined to conquer that one too.  I get there on time more often than not – just not as often as I should.  Just now – when I least feel like it – discipline becomes oh so important.

I had my last review with my Psychiatrist this week.  We agreed that it would also be possibly a beneficial thing to increase one of my medications for 1-2 months during the peak risk zone while I’m wrestling risk factors and wavering – just for that short-term – and then go back to my current dose afterwards as the weather and season stabilises a bit more.

Hopefully the combination of ‘personal medicine’ or monitoring of triggers and early warning signs with the kind of action plans that are outlined in my post “Better Medicine”  with the temporary medication adjustment will prove to be a good protective measure.  I’ve had a good year.  I’d hate to mess it up now.  I’m hoping to get to at least a whole year without a relapse this year!

So roll on to the latter end of Spring.  Because despite all of this, I really do love spring.  There’s a certain level of hope and promise in the air in Spring that’s unique to this time of year.

Come Dog.  Heel.  Walk.  Heel.  Walk.  Heel …

 

Black Dog, White Knight 03/08/2011

If there is one thing more frustrating than the battle with the black dog, it’s the battle with the white knight.  The overprotective protector.  Oh to be able to call the white knight to heel along with a well-controlled dog!

Take for instance the plan to return to work.  A sensible return to work plan is graded with appropriate supports according to the nature of the illness or injury.  My most recent absence from the work place involved an epic trial to accomplish reentry.  It took five months to the day from the time my psychiatrist of eight years cleared me for graded reentry to the workplace – and almost two months after he cleared me for full hours – for my employer and independent occupational physicians (not psychiatrists) to clear me for a very slow and protective graded reentry programme, more suited to someone with chronic pain or active symptoms.  I, however, have an episodic illness – certainly, with excessive stress and sudden change as triggers – however having been all but symptom free for some time now, the rate of change laid out was a looooooong way from sudden.

The starting plan was laid out as 4 weeks of 3 days of 4 hour days.  This would be followed by 4 further 3 day weeks where hours increased by an hour a day per week.  Finally, a half day would be added on the ninth week to bring me to full hours.  Such a programme would have been appropriate in at the beginning when I was cleared for graded return to work by my doctor.  But five months later?  I had been stable for some time.  Depression is an episodic illness, not a static one.  I would agree that grading is wise for maintenance purposes, but given the amount of time that I’d been stable for it would have been feasible to start with a 3 day week at 4 hrs, progress from there to 6 hrs, then 8, before returning to full hours.  And that would be conservative.

The key factor that will make or break the return to work will be the provision of personal support within the workplace throughout this and over the coming months.  A clear plan for what to do with symptoms in the workplace.  A way of taking control of the situation when things get difficult.  I speak here both as a clinician with experience in work rehabilitation and as person who has treatment resistant depression.

The white knight needs to step back and stop blocking the path.  There are no dragons.  It’s a dog.  A black dog that is currently walking patiently at heel.  Please don’t let it get so bored that I trip on it.  A worthy helper walks beside, notices when the going is hard or easy and helps me to adjust the burden so that I can continue at a pace with just the right level of challenge and focus.  They are about helping me engage with what is around me without losing track of my dog.  The white knight will ultimately drive my dog crazy with all the attention and fuss.  If I don’t trip over the dog, I’ll trip over the knight – although they’ll default all responsibility and blame the dog.  Get rid of the protective sword, the suit of armour and all the pomp and ceremony.  Rather put on your hiking boots, pick up a pack, bring me a spare map and compass for if I lose my way and throw in my dog handling manual in case I lose mine; then come and walk alongside me.

 

 
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