Sometimes people write to me.

“Just checking to see if you’re OK…you haven’t been posting on your blog…”

I really appreciate it! I know as well as you do what it can mean when a generally motor-mouth blogger goes silent.

You’re right. I feel terrible. I can’t think. My imagination, usually fertile, is…somewhere. I don’t know where. I don’t know anything. I’m in The Pit. At the bottom. At least I hope it’s the bottom. I certainly can’t see daylight. If I go any deeper it will be the La Brea Tarpits.

In fact, that’s what depression feels like: black and impossibly thick and sticky. The harder I struggle against it, the more stuck I feel.

I tell you, if my dear Doggess did not need me….but she does. She is dying, very very slowly, but very surely. Each day brings some new sign of it. And there is nothing to do but to swing with it…and I don’t feel like swinging.

Brings back bittersweet memories of my father’s lonnnnnng descent. Years of enjoying him while he slowly faded, then the horror of the final months.

So I spent some time researching the latest treatments, beyond the drugs that have never worked or had side effects that laid me flat. And I found something I’d never tried before: ketamine.

Now, ketamine is a drug I’ve never had the slightest inclination to try. I saw plenty of its effects when, as a medical student in the 1980s, I had the unpleasant task of sitting with babies as they emerged from ketamine anesthesia. My job was to keep them from eating parts of their own bodies. For some reason, ketamine does that to infant brains: makes them try to gnaw their paws off, like an animal caught in a leghold trap. So my impression of the drug was somewhat colored.

Likewise, I’ve had my share of human teenagers stoked up on K in the emergency room. Not a pretty sight. I have not yet figured out what the draw is.

But I’m so damn tired of being depressed, I’ll try anything. There’s a ketamine infusion center in Tucson. I read up on the stuff and its use in depression treatment. It looked hopeful. I called.

The intake process took a week. I liked that. It wasn’t like, Oh yes, come on in, we’ll hook you up and take your money. I had to take numerous inventories: depression, of course, and personality, and a screen to rule out psychotic illnesses. Three different interviews. And in the meantime I went on Medline and read the handful of papers I found. I asked my questions, was satisfied with the answers I got.

And yesterday I had my first ketamine infusion.

I was petrified, but I’m so sick of being depressed that anything else, no matter how bizarre, felt like a good idea. I can’t be dead right now, because I can’t do that to my Doggess. So I marched into the infusion center and allowed myself to be hooked up to an IV pump full of the evil drug. I resigned myself: at least I’m Doing Something. If nothing else.

They put me in a comfy recliner in front of a TV screen that played continuous, seamless nature films. It reminded me of the endless loop of bird videos a friend of mine plays for her cat when she goes out. I synced my phone with a Bluetooth speaker and cued up a playlist I’d made for the purpose: dreamy Sikh chants. If I’m going to trip out, I want it to be holy.

The stuff flowed into my veins and I breathed, wondering what was going to become of me. I held no expectations. How could I, when I had no idea what to expect? I hoped that they would watch closely and not let me gnaw my paws off.

A warm, cocoon-y feeling enveloped me. That was all right. It was comfortable, safe, relaxing. OK, I can go with this. They asked me how I was feeling; I told them this. They turned up the rate.

The nature films flew over the Grand Canyon, Bryce Canyon, Monument Valley…all places dear to my heart, and right here in Arizona. The holy music spoke of beauty. The nurse (a man) wondered how I had chosen just the right music for the film….really.

My reptile brain flashed back to 1970, such a year full of terror and beauty, flashing like the red cherry on top of a police cruiser. The many trips on LSD, mescaline, psilocybin, peyote. “Wasted on a 16-year-old,” I observed. The nurse chuckled.

It went on forever, which turned out to be 90 minutes. 90 minutes’ worth of Eternity. I hope Eternity turns out to be something like it. Incredible beauty. No pain, not from the body and not from the brain. The best vacation I’ve had in a long time.

The dose of ketamine for this kind of vacay is 0.5 mg/kg, which for my weight turned out to be 29 mg. For comparison, the anesthetic dose is 3.0 mg/kg. Yep, that would knock you out. On the brain-pain dose, I could, with extreme effort and advance planning, make purposeful movements and even speak, after a fashion. Standing up was out of the question. At about 45 minutes into the trip I needed to pee. They turned off the infusion and, after a couple of minutes, helped me/dragged me to the bathroom, where I made use of the generous handrails to navigate to the pot. Getting my clothes down was an exercise in logic. Peeing felt incredibly great. Afterward, somehow empowered by this, I enjoyed the remainder of my ketamine+ music+ visuals treat even more.

Will it work? Is there some kind of durability to the brain reset? I don’t know, and at this point I’m withholding hope/expectation for the future. The protocol at this center is four initial treatments at every-other-day intervals, followed by another one ten days out, and reevaluate after that. I’m OK to roll with it. It’s an expensive vacation, at $500 per treatment, but I can’t use the money if I’m dead, and that’s where things are headed if I don’t do Something. I sold my Walmart stock to pay for it. That’s what money is for, right? Living.

I’m trying.

Back on the Ketogenic Diet, Modified Atkins Variety

I’m disgusted with a lot of things: my meds, my perpetual brain fog (meds?), my recent 15 pound weight gain, which, on my 5 foot tall person, is a lot and is quite demoralizing, adding to the general feeling of gloom in my environment; my lack of energy, my lithium-induced tremors and muscle weakness, and I’m sure there’s more, if I could only think of it.  Oh yes, that’s it: word-finding difficulty.

At one point in my bipolar journey, nothing was working, med-wise, and my shrink planted an idea in my brain that had consequences I don’t think he intended.  There is a great deal of similarity between bipolar illness and seizure disorder: both share the phenomenon of kindling, where a little spark gets going and if it’s not stopped, it spreads until it causes generalized dysfunction.  In Bipolar-land we usually call that a trigger, but there is functional MRI evidence that demonstrates similar changes in brain metabolism during the moments leading up to a seizure, and the moments leading up to a bipolar decompensation.  So it should be no surprise that anti-epileptic drugs also treat bipolar symptoms.

When my son was a teen going through a bipolar meltdown, his psychiatrist told me, and showed me clinical papers to back his words up (which unfortunately I do not have and am not in the mood to dig up), that if, in the young brain, bipolar disorder could be suppressed for a two-year period without a breakthrough, it could be considered cured, just in the same way as epilepsy.  The theory is that in the growing brain, suppressing the kindling effect for that long gives the brain a chance to literally “grow out of it.”  My son, now 28, recently went through a battery of neuropsychiatric testing which showed that although he does have Major Depressive Disorder, he has no remaining features of Bipolar Disorder.  Bingo.

Back in the olden days before they had anti-seizure drugs like Depakene and Tegratol and Lamictal, there was very little in the anti-epilepsy arsenal.  The ancient Greek physycians noted that if you fasted a person with epilepsy, the seizures stopped.  Eventually, over a couple of thousand years, this observation led to development of the Ketogenic Diet.  If you look at the Wikipedia article under this link, it will tell you as much as or more than you ever wanted to know about the Ketogenic Diet.

The basic idea is that the brain can function on only two kinds of fuel: glucose, which is a product of sugar and carbohydrate (and in some cases protein) breakdown, and ketone bodies, which are small molecules that result from the breakdown of fat.  Ketone bodies also have the ability to regulate blood sugar, so if the balance of glucose and ketones is correct, the body literally shifts from a glucose based metabolism to a ketone based metabolism.  This has a wide range of effects.  The Atkins Diet  works on this principle: if you stop feeding the body carbohydrates, then it has to break down fat to get ketones to feed the brain and the rest of the body.

For reasons still unknown, ketone metabolism, or ketosis, suppresses kindling in the brain and controls seizures.  It can be a miraculous thing.  If you read through the Wikipedia article you’ll be astounded at the numbers.  I was, anyway.  The only problem is, it’s a very difficult diet to do.  You have to really be committed to it, and one little slip-up can set you back weeks.

So, at the time when meds were not working to suppress my bipolar fire, I was a little overweight anyway so I decided what the heck, I’ll try the Atkins diet, and do the most extreme version just for kicks and chuckles.  It was a bitch to do.  It’s a fat and protein based diet, so you have to pretty much live on eggs and cheese and (at that time I was not religiously observant) bacon, which was my staple food, cheeseburgers (God, I miss those), mayonnaise all over everything, heavy cream (for a treat, I would whip up a carton of heavy cream and eat it), cream cheese, and lots of leafy greens.  Oh man, it’s hard.  But: my BP symptoms stabilized, and I lost 30 pounds in the bargain.  I stayed on the diet for three years, then got religious and couldn’t eat bacon or cheeseburgers anymore, and started eating challah and kugels instead.  The thirty pounds came back, and my brain went wacko again.  Hmmm.

Now my brain isn’t wacko, really, thanks to Seroquel, but the problem is, with the Seroquel I just don’t feel anything.  I’d like to feel happy, or sad, or excited.  I was just walking by the river here which is just a couple of feet from flood stage, and in fact did flood last night, and I kept thinking, jeez, I should be feeling fear, this thing is so awesomely powerful and out of control.  But all I felt was, I should feel fear but I don’t.

So I decided to go back into the land of Ketosis, just to see what will happen.  At the very least maybe I’ll drop those two pants sizes I picked up over the winter, and if I’m lucky, my brain might start working better and I might be able to drop part or all of the Seroquel so I can feel things again.  Stay tuned!

N-Acetyl Cysteine Effective for Bipolar Depression (mobile format) Well, dear readers, I have some really good news for us all. I am particularly personally pleased about this, because today I began having those nasty creeping feelings of incipient depression. Having had a nice long remission (thank G-d), with a bit of hypomania to spice things up, I am not looking forward to the down side of the equation. But there is hope on the horizon! Just today this article on the efficacy of n-acetyl cysteine (NAC) flashed across my medical literature radar. I pounced on it like a hungry lioness. As a pediatrician, I’m familiar with NAC from its other uses: intavenously, for protecting the liver after acetaminofen overdose; and inhaled, for liquifying sticky lung secretions in cystic fibrosis. There is a growing fan base among athletes for NAC, as some feel it enhances performance. According to the above linked article, there is now good evidence to support that. NAC assists essential metabolic processes that enhance the function of the body and the mind. As is my previous post about metabolic syndrome in the brain, scientists are finding that the biochemistry of the brain is a lot more similar to that of the body than was previously thought. For instance, we know that inflammation in the body can cause all kinns of ills, so we might take antiinflammatory supplements or, even better, eat an antiinflammatory diet. This article points out that inflammation can also happen in the brain, setting off a cascade of ill effects, including triggering bipolar depression, which is notoriously difficult to treat. This gives us a window to wonder whether perhaps the biochemical/electrophysiological profile of bipolar depression might be different than that of unipolar depression. Bottom line: NAC was forms to be very safe and effective as an ad-on to the meds the patient was talking already. The dose in the study is 2000 mg, once a day. I have seen other dosing schedules that also worked, in some very promising studies on using NAC in autistic children to reduce distressing behaviors instead of using antipsychotics. The biggest challenge right now seems to be getting hold of the stuff, since it is so popular with the athletes, who no doubt feel like a million bucks. I’m definitely going to try this one. I sure hope it saves me from another round of rTMS. The old brain is not sure she can take that kind of pounding any time soon. If you decide to try NAC, I’d really appreciate it if you world keep in touch and let me know how it goes.

Copyright 2012 Laura P. Schulman all rights reserved