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  1. levomilnacipram (Fetzima) 120mg — depression Adderall IR 60mg (20mg TID) — ADHD finally changing back to Adderall IR 80mg (20mg QID) in the next half-week or so temazepam (Restoril) 30mg QHS — sleep issues diazepam (Valium) 10mg (5mg PRN BID) — anxiety bicalutamide (Casodex) 50mg — gender dysphoria/gender identity disorder estradiol transdermal system (Vivelle-Dot) 0.2mg/24h BIW — gender dysphoria/gender identity disorder pantoprazole (Protonix) 40mg — antral gastritis (idiopathic/chronic) sumatriptan (Imitrex) 50mg PRN — migraines So after three very miserable months on Adderall IR 20mg (10mg BID) thanks to a stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked, I finally managed to flee to the only other psychiatric practice in the area, which luckily has a so far seemingly decent psychiatrist, although he's remote (it's via telepsychiatry, which is weird), he's less accessible, and it took me almost two full months to get in to see him. Still, he agreed to take me on as a patient, and he restored the ADHD meds to something more or less functional (Adderall IR 60mg (20mg TID)), although I still unsurprisingly couldn't seem to manage to get the intended 12 hours out of TID dosing without some nasty crash-like effects towards the tail end of doses, which is a bit of a major issue. Still, it was enough for me to return to my part-time software development job at a startup, which I'm glad about. Today after close to a month on Adderall IR 60mg (20mg TID), I had my first follow-up appointment with this new psychiatrist, and we discussed the remaining issues I was having with TID dosing and what to do about them. Switching to Vyvanse was discussed, but it just wasn't that good of an option in a number of ways, so we're keeping it as a reserve option instead for if I ever need to switch ADHD meds in the future. The psychiatrist agreed that going back to my full old dose of QID IR Adderall (I had previously been on QID 20mg from August 2016 to December 2017 before the stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked decided to screw with the dose) was probably the best option available to resolve the remaining issues, but due to it technically being an "off-label" dose, he wants me to go get an EKG done once I'm back on the full "off-label" dose in order to rule out any arrhythmias despite having at least two negative past EKGs (although this is apparently because I wasn't on as high a dose of IR Adderall specifically for any of said past EKGs). So I've got to go get that EKG done next week — hopefully my insurer will cover that, their site says it should be between $26–$95 if the EKG is covered and in-network, but they could be a dick and reject it for being technically somewhat medically unnecessary if they wanted to. And hopefully nobody decides that my relatively high resting HR on meds (it's high off meds too, just less so) counts as an arrhythmia... I'm probably worrying too much over nothing again though. On the bright side, I've been hearing interesting rumors through the grapevine about my previous stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked. Apparently his practice has been virtually unreachable for patients and providers recently (heard this from both my therapist and secondhand from someone else), and according to someone else (secondhand) he and his practice are apparently under investigation for Medicare & Medicaid fraud and overprescribing/misprescribing (although I'm not sure if these particular accusations are fully true because while they do fit the picture I saw almost perfectly, I can't find any independent proof yet beyond this single person's second-hand claims to corroborate these claims — however if he is currently actively under investigation there won't necessarily be any open public records of it until after the fact).
  2. A LOT better until I stopped the Adderall. Even the turmoil from resuming the hormones after the abrupt extended breaks was finally evening out. I was feeling good enough to actually finally go back to work and was somewhat looking forwards to continuing (which of course that had to happen literally right before the whole mess with my psych started! I must look like a total fucking idiot reappearing after being gone for so long, apologizing, being back to normal for a day, then suddenly vanished completely again. I am very lucky that this is a very loose part time job where they let me mostly set my own pace and that they were fine with me being gone for so long, but I feel like I'm pushing it way too far and, and it being totally out of my control right now and entirely thanks to this fucking psychiatrist casually fucking me over for no clear reason is really not helping and I feel super guilty even though there is really nothing I can do)... So yeah, it got rather shitty again, but purely because of stopping the Adderall due to the mess with the psych. I completely stopped taking the Vraylar at all though when I stopped the Adderall, I was too depressed to care about that even when I was super suicidal and should have taken it, on Adderall I was still rational/aware enough to stop myself and take the Vraylar when I saw the warning signs, apparently I'm not (at all) when I'm off of it (no big surprise considering my pathetically poor executive functioning and the fact that stimulants are known to range from good to great at improving executive functioning in general, among other things). One of the things that's become super clear is that the Saphris was never really tolerable and stopping it was an excellent move. I think maybe the very first few days I was on it in the hospital it helped pull me out of the depression (although my therapist is pretty confident that there's a strong positive temporary psychological effect just from being in the psych ward temporarily removed from the situation "outside" and in a supportive atmosphere, and I think that makes teasing out the actual sustained efficacy of most meds started in the psych ward wayy harder to estimate), but after that, it was just a shitload of unpleasant side effects with no clear continued benefits from taking it. I'm STILL trying to figure out WTF happened with the psych. The past fucking ~1.5 months have been such a weird mess. I thought things were finally stabilizing and starting to become okay again other than the lingering on-and-off depression and that the worst things I'd have to deal with would be telling my PNP that I had dumped Saphris, figuring out the long-term solution for mood stabilization, and dealing with the health insurance uncertainty. Then this whole mess with the Adderall comes out of left field. I'm trying to decide which combination of the following potential theories might help explain the situation: Dr. ["actual" psychiatrist] being mad at my PNP for resuming the benzos (specifically the diazepam) after I was discharged (since he had abruptly stopped them while I was in the hospital for idiotic reasons ("too many narcotics", "coping skills are better than pills", "time to practice those coping skills", "the benzos were never meant for long term use", etc)) — however that's entirely my PNP's decision to make and she strongly disagreed with his rationale Dr. ["actual" psychiatrist] being mad at my PNP for putting me back on 20mg QID of Adderall instead of keeping me at the 10mg BID he had chosen in the hospital for god knows what reason — however in the hospital he said explicitly that my PNP would handle the psychostimulants again once I was discharged, in the past he's been quite clear that he wants her to handle them fully and has even said to me in the past that he doesn't care how she's prescribing (he literally said "[she] has her own DEA license and can prescribe however she wants"), plus he should already be well aware that she immediately returned me to 20mg QID after previous hospital visits in 2016 (which he apparently never had a problem with) and has had me on this dose for over a year (which he also apparently never had a problem with as long as he wasn't prescribing it directly), so this doesn't fully make sense... My PNP saying something to Dr. ["actual" psychiatrist] about or related to the hospital stay or my case in some way that ticked him off for whatever fucking ridiculous reason (she was not very happy with him after hearing about the utter mess he had made of virtually all my meds while I was there, was particularly annoyed that he interfered with the hormones and was still entertaining his odd and persistent pet theory that taking estradiol is a major factor in my depression while utterly ignoring the fact that stopping estradiol or the T blocker abruptly is much more likely to cause depression than taking it is (she also thought taking me off the estradiol just made no sense whatsoever and was outright stupid), made it clear that she viewed him as at least somewhat sexist (a view shared by several people at this point — the same people also made it clear that they think he has some sort of weird issue with me being transgender, although my PNP thinks that's just his sexism and ignorance in this area), etc)... I have a feeling (which a few people strongly agree with and actually feel much more strongly about it than I do) that Dr. ["actual" psychiatrist] is rather egotistical, has more than a bit of a God complex going on, is quite hubristic, and has massively overstretched himself. He's a very successful doctor in a hard and somewhat unrewarding job, comes from an immigrant background (foreign medical degree with residency in the US), and he's seemingly pretty smart, but he seems very blind to his own flaws and I question the wisdom of him simultaneously having privileges at every hospital in the area, running his own practice & seeing patients directly, having two PAs, a FNP, and a PMHNP-BC (PNP) attached to him/his practice (all seeing patients), operating a busy ~30-bed inpatient psychiatric unit (with him and his sub-practitioners all seeing patients there as well — he is not only the sole psychiatrist at this inpatient psychiatric unit but is also its Medical Director to boot!), teaching residents, and somehow has a family too. I noticed a disturbing number of inconsistencies and weird issues while observing him during my recent psych ward visit — he's acting weird, not the same as he used to — he keeps forgetting everything, he made some absolutely bizarre decisions (most notably randomly changed the Adderall from 10mg IR BID to 5mg XR BID one day) that he didn't even seem to recall making when asked about them the next day (acting utterly confused about it and had absolutely no idea why he'd have even done that!), he tried changing my Fetzima from 120mg to 80mg despite it not being on the formulary at the hospital at all (like the bicalutamide) and thus I was only able to take it because it had been brought from home (unfortunately the bicalutamide couldn't make it) but he didn't seem to understand that this meant I only had the 120mg dosage, which is a single completely sealed XR/DR capsule that is obviously utterly impossible to split (let alone split into thirds!) — but he didn't seem to notice the issue at all even though I know he was repeatedly made aware of it by the nurse in charge of medications well before I finally brought it up to him directly when I realized that he hadn't stopped the Fetzima (which is what I had assumed when after a single day back on 120mg I wasn't given it for two days — since he had been randomly discontinuing pretty much everything at the time I assumed he had decided to discontinue that as well (did I mention that he was absolutely terrible about communicating med changes with patients, or even communicating with patients at all? he's always been bad about it but this time he was way worse than usual), I think it was on the third day that I finally learned that he had actually ordered it for 80mg and apparently nobody ever bothered doing anything about it beyond than the nurses notifying him repeatedly about the issue), at which point he muttered something about samples (which never happened — not sure why, he should have had sample packs of it, I know they definitely used to have some at their main office because I was given several sample packs when I first started Fetzima before we decided to stick with it (which required a prior auth that was delayed until I flat-out ran out of the sample meds during the worst possible time (a brief period where I had absolutely no way of getting to the psych's office to get more samples — after several days of being out of Fetzima and unable to get more unless the prior auth was approved so I could fill the RX, my case worker at the time from the insurer called for a scheduled follow-up, and when I mentioned the issue to her she managed to very speedily resolve the prior auth so I could fill the RX and get back on the med)), and I've been on non-formulary meds taken from sample packs while there previously, so IDK what happened) and after I told him the next day that I still didn't get it the prior day, he finally switched me back to 120mg. This is just the tip of the fucking iceburg. IMO he's bitten off wayyyy more than he can chew and it's finally catching up to him. Either that or he has early-onset alzheimer's/dementia. I am so fucking off topic now. Tl;dr: He's acting weird as fuck. Dr. ["actual" psychiatrist] being mad at my PNP for giving me a 10mg BID RX at the follow-up but instructing me to take it as 20mg QID (she claimed she just needed Dr. ["actual" psychiatrist] to approve physically changing the RX back to 20mg QID and verbally informed me that this 10mg BID RX was a "stopgap"/"temporary" prescription that I was to actually take as 20mg QID after filling, and that as soon as Dr. ["actual" psychiatrist] responded to her message to him requesting approval of the RX change she'd issue the normal RX and have them call me to pick it up. I then asked her specifically about potential issues with conflicts from the apparent early fill that this could cause (as I'd be filling the normal RX a mere week or two after filling the "stopgap"/"temporary" RX since 10mg BID for 30d would last only 7.5 days if taken as 20mg QID like I was told to), and she explicitly said "because it'll technically be a dose change, there won't be any issues at all with filling the 20mg QID RX soon after the 10mg BID RX". So it was made very clear that I was to disregard the original written instructions on the 10mg BID RX. Of course then I never got the promised call from the practice. I finally followed up on November 29th by phone since I was getting low on Adderall and wanted to figure out what was going on. I was told that there was actually a RX waiting for me there already (so of course I immediately assumed they just had never called like they said they were going to and otherwise everything had worked out like I had been told it would). The next day I go to the practice to pick it up and am extremely surprised to see that it's inapplicably another RX for 10mg BID instead of the 20mg QID RX that my PNP had told me it would be — so I explain the issue, they go into the back and talk with some of the other staff, eventually after having to repeat everything several times to other staff members and trying to explain that the 10mg BID RX was literally 100% useless due to my PNP's instructions w.r.t. the previous one and w.r.t. the dosage I'm supposed to take making it utterly impossible to fill anyways I finally find out that Dr. ["actual" psychiatrist] had never fucking responded to the message that my PNP had sent him on November 15th (two weeks with no response! utterly ridiculous!). I'm then told that they're going to message him again, they're putting in a priority request, the issue will be fixed ASAP. Great! I assumed the issue would be resolved within a few days. Monday morning they call me and tell me that "Dr. ["actual" psychiatrist] wants me to remain on 10mg BID". In addition to being half-asleep I'm now extremely confused. Dr. ["actual" psychiatrist] is not my outpatient psychiatrist and never has been. That is my PNP's job, and it's been that way since January 2016. The only time I ever see Dr. ["actual" psychiatrist] is if I'm in the psych ward, which I (thankfully) no longer am. So why is he issuing instructions instead of my actual provider? What happened to my provider's instructions? Why would I be instructed to suddenly and radically change my dose after being on this dose for over a year? Could they please talk to my PNP about this to get a clearer answer? Etc etc. I get no real answer whatsoever outside of the person calling repeatedly and blatantly reframing my questions in real time into a bizarre narrative of "me requesting for them to communicate my desire to increase my dosage to 20mg QID to Dr. ["actual" psychiatrist]", which was not at all what I was asking about (when did he become my psychiatrist again? last time I checked it was the PNP in charge of my psychiatric care, not him. why would you be talking to him about an issue that you should be talking to my PNP about, or at the absolute least, to both of them about? why do you keep reframing things as me requesting a dose increase when I am actually requesting information and confirmation regarding this abrupt and dramatic dose decrease relative to the dose that I was currently on, that my PNP had told me to take last time I saw her, and that I had been taking for the past year?). Eventually I gave up. Later in the day I decide I need to call back and clarify things properly since I'm no longer half-asleep and have had some time to digest what I was told that morning. I wrote up a very brief summary of events with dates as a reference tool, and started calling. Of course it's just my bloody luck that every time I called, the phone was busy or nobody picked up and I was shunted to voicemail. I'm not a fan of voicemail at all, especially when trying to get immediate results (I was after all going to run out of Adderall the next day — something clearly needed to be done about that), so I keep trying on and off throughout the day. I had a scheduled follow-up appointment with the case worker from my health insurer in the afternoon, and by the time that arrived I'd called my provider's practice a half-dozen times at least with absolutely no luck. I went over these odd developments with my case worker, who decided to call them after we were done talking. I wanted to try calling them as well so she gave me leeway for me to try first. I finally got through to someone on one of the first few attempts (a minor miracle) and communicated the situation along with my desire to clarify things further as I hadn't gotten much of an explanation in the morning at all and wanted actual answers this time. I am then told that "[my PNP] is no longer making treatment decisions with regards to stimulant treatment for adult patients and if you want to [pursue that] you will have to set up an appointment with Dr. ["actual" psychiatrist]". After that bizarre and troubling revelation, I decide to try to call my case worker again before she called them. I then relayed what I was told and we discussed the situation. It was not promising at all, but I was at least able to use her help to figure out the very rough bare bones of what I needed to do next. The case worker was more than a bit perplexed at the whole situation, and she decided to continue with her earlier plan of calling the practice directly to try to get more information. She then called me back and explained that she was given essentially the same bizarre explanation that I was, and I guess she asked a few more questions than I had thought of or was willing to ask because she also found out that: • Their immensely-simplified and pointedly skewed (not to mention inaccurate) view of the entire matter was that when I went to pick up the RX last week, I was then apparently "instructed" to take (or maybe switch to taking?) 10mg BID (inaccurate, nobody ever told me that at all when I was there, the only point where that was even hinted at was on the inaccurate RX they had, which was identical to the one I had been given by my provider on November 15th, who had explicitly told me that it was a one-time-only temporary RX and to completely ignore the instructions on it as I was supposed to resume taking 20mg QID immediately and would keep taking 20mg QID using the remaining Adderall from my prior RX, that RX, and a forthcoming proper RX for 20mg QID. I was absolutely unambiguously instructed that the next RX would be for 20mg QID due to the clear-cut conversation with my provider about my concerns about a possible early fill, which explicitly ruled out any chance whatsoever of the next RX ever being intended to be 10mg BID. Thus every bit of the evidence available to me overwhelmingly pointed towards the 10mg BID RX being a glaringly obvious mistake on someone's part.). I then refused the RX (technically accurate — but I had actually stated that the RX was "completely worthless to me due to it clashing [violently] with my provider's last set of instructions regarding the Adderall" and thus, there was absolutely no point in picking it up at all so "they might as well just go ahead and shred it because I certainly can't fill it!" (and the overwhelming weight of the evidence had already made it quite clear enough already that the whole thing was just a mistake on someone's part in the first place — a notion that absolutely nobody made even the slightest effort to disabuse me of, in fact, it was quite the opposite!)). • Since I refused the RX, they had nothing available for me. • No, they would not issue a different prescription. • They did not care that I was about to run out of Adderall — that was apparently entirely my problem to deal with, and not at all their responsibility. • If I wanted to do anything at all related to the stimulants, I would need to make an appointment with Dr. ["actual" psychiatrist] to discuss it with him. • Yes, I still had my scheduled & upcoming appointment with my regular provider (the PNP) — she was simply no longer allowed to handle any prescription for stimulants with her adult patients, but she was allowed to manage the rest of my meds. ---- Now it's worth noting that it's highly odd and curious to note that my PNP had been apparently specifically banned from managing stimulant treatment in adults only. She had told me before that she treated a lot of kids for ADHD and really liked working with children (as well as apparently hating any inpatient psychiatry work — unlike the other PAs/NPs associated with Dr. ["actual" psychiatrist] she only saw patients at the inpatient psychiatry hospital ran & managed by Dr. ["actual" psychiatrist] on one day per month, and that was more than enough of that for her), but it was also clear that she had plenty of adult patients. Were all of the adult patients previously being treated by her with stimulants for whatever reason also now being forced to see Dr. ["actual" psychiatrist] directly for management of that specific type of medication? It seems dubious. And why would she be banned from managing stimulant treatment for adults but not banned from managing it for kids? ----- At any rate, my case manager didn't know what to do or say at this point beyond suggesting that I look into what other psychiatrists in my area are in-network for my plan, and to schedule an appointment to see Dr. ["actual" psychiatrist]. She was clearly confused over the blanket refusal from them to do anything at all about me running out of medication (despite this mess being their own damn fault), but had no idea why they'd do that. My PNP misprescribing stimulants (and/or other meds?) for other patients (could be anything from Dr. ["actual" psychiatrist] judging her prescriptions to be slightly too far out of line with his prescribing philosophy for his comfort to an actual full-blown DEA investigation in progress, although the most likely reasons would all likely lean far closer to the former extreme than to the later extreme given that the available evidence does not suggest anything even remotely serious could have happened without her at the absolute least being barred from prescribing stimulants for kids too, and more likely suspended from prescribing far more than just stimulants). If this was the case though, there's really very very few possible rational explanations for allowing her to continue to prescribe stimulants to kids, so it still doesn't make much sense. Dr. ["actual" psychiatrist] greedily hatching a nefarious scheme to scam patients and insurers alike out of even more money while boosting his practice's revenue by requiring that all adults with stimulant RXs see him personally (as well as their normal psychiatric provider within his practice if they're on any other psychotropic meds) for an appointment that requires him to spend next to no effort (essentially getting away with "managing" just a single RX, and a relatively easy one to manage at that compared to other psych meds), allowing him to rake in an extra $50–$100/patient/month (or more) from a decent-sized pool of patients. However I'd think that Dr. ["actual" psychiatrist] is already making plenty of money already from having his fingers in virtually every psychiatric pie in the region (metaphorically speaking)... If he's actually pulling a Medical Director's salary and even a small part of a typical psychiatrist's salary, to say nothing of his earnings from his practice and other stuff...he's got to be making at least $300k+ even accounting for the typically lower salaries in rural areas. Could be as much as $500k+. So he's not really hurting for money. But who knows. Any fucking crazy idea I could guess at. Sorry for clogging up this thread with my bullshit. I'm just going nuts dealing with this situation and need to vent and organize my thoughts somehow, and this helps a bit.
  3. Still off of it... Appointment with Dr. ["actual” psychiatrist] is next week (not expecting it to go very well but at least maybe I can find out something about WTF happened and get back on some hopefully-reasonable amount of Adderall), then an appointment with my PNP (who can address the antipsychotic issue and hopefully further elaborate on WTF happened). This break has certainly illustrated how utterly miserable it is to be unmedicated. My doctor had to cancel the appointment to follow up about the hormones — gotta wait until mid-January for that now... Oh well. Interestingly, a bill was signed into law back in late September (and it becomes effective in Jan 2018) that expanded the scope of practice for APNs/APRNs (i.e. NPs) in my state. Now if they have 4000 hours of clinical experience and 250 hours of continuing education, they get "full practice authority", which means they can practice without a written collaborative agreement, although they must still be in a "consultation relationship" with a physician to prescribe Schedule II narcotics (this term apparently only refers to opiates) and benzodiazepines, and if they prescribe opiates or benzos they must discuss the case monthly with the physician that they have a "consultation relationship" with. In contrast, the current situation required a written collaborative agreement in all cases (irregardless of level of experience), and only allows prescription of specific Schedule II controlled substances that the collaborating physician explicitly delegated prescription for with limitations like only 30 day supplies can be dispensed, any continuation beyond 30 days must only happen with the prior approval of the collaborating physician, and the APN must discuss the condition of any patients for whom (any?!) controlled substance is prescribed with the delegating physician every month. Now this of course means that my PNP (an APN/NP/etc) could theoretically be able to get full practice authority next year, as she has at least 7 years of clinical experience and I am fairly sure she meets the continuing education requirements. While I certainly don't expect her to necessarily go and obtain full practice authority, it's still an intriguing possibility, as it'd neuter the influence of this annoying Dr. ["actual" psychiatrist] w.r.t. everything but benzos...but a solution that damn slick likely won't happen.
  4. Oh Jesus fuck. Today has been hell. My psychiatrist is a PNP (psych APN), which in this state means that she needs to work with an “actual” psychiatrist to prescribe certain medications, most notably schedule II medications, despite having her own DEA license. Essentially the psychiatrist she works with has to sign off on her schedule II RXs to some extent and they have to co-manage cases to a limited extent. Since August or September 2016 I’ve been on 20 mg Adderall QID. Whenever I’m in the psych ward the inpatient psychiatrist (who happens to be the “actual” psychiatrist that my PNP works with) temporarily drops my Adderall dose down severely. Whenever I exit the psych ward I’m instructed to have the PNP handle the Adderall, and she inevitably resets it to the same dosage. This has worked fine until now. After the last psych ward stay, I was as usual instructed to resume my normal 20mg QID Adderall dose by my PNP at our follow-up, and was given a “temporary stopgap” prescription for the 10mg BID that I had been on in the psych ward, with the instructions to fill it and take it as 20mg QID (not as the labeled 10mg BID dose) while she got me a regular RX for 20mg QID again (was told that this was simply waiting for the “actual” psychiatrist to confirm her request - entirely routine). The fact that filling a 10mg BID RX would only give me 7.5 days of medication at 20mg QID was not supposed to be an issue because I would be changing directly back to the old 20mg QID RX, so no early fill issues should have came into play. Last Thursday I inquired as to what was happening as I hadn’t heard from them in two weeks and was running out of Adderall soon (this Tuesday to be precise). I then discovered that the “actual” psychiatrist never bothered responding to my PNP's message (despite two weeks having passed). I was told that they would sort out the issue and have the RX ready ASAP. This morning I get a call from the office saying that I was supposed to remain on the 10mg BID by orders of the “actual” psychiatrist (not the psychiatrist I’m seeing). Remain? I wasn’t even actually on 10mg BID! I had been instructed by my psychiatrist when I last saw her not to take the 10mg BID script as labeled and instead to take it as 20mg QID! They were then uncertain if things were correct or if something got mixed up, so they said they’d contact both practitioners and try to sort it out. This afternoon I call again to try to clarify what the heck is actually going on, since the morning's call didn’t exactly yield any clear answers. I am then told “[my PNP] is no longer making treatment decisions with regards to stimulant treatment for adult patients and if you want to [pursue that] you will have to set up an appointment with Dr. ["actual" psychiatrist]". WTF?!? Keep in mind that Dr. ["actual" psychiatrist] is the same inpatient doctor who is overly fond of cutting my Adderall dosage for no good reason, has stated openly many times in the past that he does not want to prescribe these meds for me at all and that the PNP should exclusively manage them instead, and has made it clear that he is flat-out unwilling to prescribe the normal dosage that my PNP has had me on for well over a year at this point. He is also kinda a poor practitioner in general - far too fond of screwing with things that work, poor listening/comprehension, strong accent, inflexible opinions, etc. Soooo now I guess I’m just utterly fucked on every level? Thanks to this mess I’m guaranteed to be stuck off of Adderall entirely for at least two whole weeks, and will have to set up an appointment with Dr. ["actual” psychiatrist] (god knows when that’ll happen considering how overbooked/overstretched he typically is) to discover how exactly he plans for me to function effectively on essentially 25% of my normal & optimal dosage that was working perfectly fucking fine for over a year. I’m going to loose my fucking job at this rate, and even if I somehow don’t outright loose it I cannot afford not to be working right now, and this is all apparently thanks to Dr. ["actual” psychiatrist]'s bullshit, since he seems to be the sole factor behind things going pear-shaped so quickly and dramatically. I feel hideously terrible. In one fell swoop I’ve all but lost one of the most important medications I’m on, with next to no hope whatsoever of it getting restored. I’m hopeless and suicidal, as much so or more than when I was in the hospital last, but the psych ward certainly wouldn’t help me with this, especially given that it’s ran by the bloody fucking Dr. ["actual” psychiatrist] (who doubtlessly would love a chance to make even more money from further worsening my misery via random med changes).
  5. Unfortunately there's no intermediate doses between 120mg and 80mg for Fetzima. I don't think I want to reduce it anyways. That's quite interesting. Yeah, I get the feeling. I restarted the Vraylar this week due to the depression worsening, which improved things a bit. However I learned that we're likely switching insurance providers next year (a relatively unexpected last-minute decision), and the other insurer does not have Vraylar on their formulary. So much for the one and only tolerable antipsychotic I've ever found... Fuck!
  6. Hmm, that's possible, although I'm hesitant to assume any single factor is at fault without clear evidence. I took a break from the Adderall for several days, which reduced the irritability a little bit while I was off of it, but it definitely didn't eliminate it, and it significantly worsened the fatigue (duh!). I guess there's always the option of reducing the Fetzima to 80mg...which might have negative trade-offs involved... Saphris should be basically all the way gone from my system now, so only Vraylar can still be sticking around at this point. I'm not sure what to do med-wise. I feel better than I did a week ago, which is certainly good. One major stressor is now behind me and over with (although there are too many more left). I'm still pretty firm in my decision that Saphris is a horrible med for me. I suppose for now I'll stick with my plan of "no antipsychotics unless absolutely necessary, and if absolutely necessary, Vraylar first", wait to see what my follow-up blood testing reveals about my hormone levels when I have that done, and hope that my psychiatrist doesn't have an issue with me having decided to take myself off of the antipsychotics (I think she'll probably be fine with it, but you never know). I can't decide if I should try moving up my follow-up with the psychiatrist or not — it's not as if there's anything urgent to do or discuss, but I feel maybe I should move that up anyways so that she knows what the situation is and so that we can agree on the best way to move forwards (keep Vraylar as standby? resume Vraylar? switch antipsychotics? change other things (Fetzima for example)?).
  7. My mother keeps on pushing for me to try it, usually because “it’s supposed to be amazingly effective for autism” or similar bullshit. Not interested in ever touching it. I’ve read too many research studies on it and am well aware that it’s far from the harmless medical panacea that the general public seems to believe it is.
  8. I was going through my room recently and found the documents from a extremely brief (literally one day long) psych hospital admission a year ago. When I was there I saw a psychiatrist all of once, who said “the only medication that works for treatment resistant depression is Effexor”, then got irrationally pissed off when I politely disputed his laughably incorrect claim and indicated that I was reluctant to take venlafaxine in particular because of its well-known severe withdrawal symptoms. He accused me of being unwilling to be treated at all (rather amusing, given how I was there voluntarily in the first place, had been voluntarily seeking out psychological and psychiatric help for quite a while, and voluntarily trying medications even after some spectacularly bad experiences (like my little encounter with serotonin syndrome the very first time I tried a SSRI!) and entirely too many therapeutic failures, etc) and promptly discharged my still-very-suicidal ass. I obviously ended up back in the hospital within days (this time at the significantly better psych ward that I usually got sent to). What a utter waste of time and money. Anyways, I was surprised to notice that the documentation for that extremely brief stay had a diagnosis of schizoaffective disorder on it. Schizoaffective disorder? I don’t even come close to meeting the DSM-V criterion for that! And of course they never bothered mentioning this diagnosis to me. The first time I was ever in a psych hospital I was diagnosed with BPD. I was never told, it wasn’t until I saw the discharge paperwork that I found out. When I saw my regular long-term psychologist and told him about it, he thought it was a hilariously inaccurate misdiagnosis and said I was nothing like the BPD patients he had. When I eventually switched to a different therapist and we reexplored the borderline diagnosis, she took a different approach, looking at it more strictly from the DSM-V criteria. Eventually we concluded that I did actually technically fit the diagnostic criteria, but not in a very typical fashion at all. We started DBT and I was referred to a DBT group in the hopes that DBT would help with it, which was all somewhat helpful, and thankfully my psychiatrist didn’t give up on treating me or treat me any differently because of the BPD diagnosis (which both my therapist and psychiatrist agreed was only one small part of a complex diagnostic picture, each part of which should be addressed individually). However I remain painfully aware of the stigma associated with BPD, and always cringe when I get to that point in my list of diagnoses.
  9. Experiencing a massive amount of irritability, possibly continued akathisia, and odd tiredness even on Adderall with caffeine (caffeine definitely isn’t solely to blame for irritability, it seems to be mostly from something else or a complex combination of things) and (still) no Saphris/Vraylar (outside of whatever is still lingering in my system, which may be significant). Also, I’m observing that the benzos haven’t been working as well as they used to in general since resuming them, although they’re being asked to do more than they did before, so maybe that’s part of the reason for that? The Adderall's efficacy has also been more variable than usual. I’ll try taking a minimum day-long tolerance break from the Adderall, which should at least temporarily improve the efficacy. Not sure what to do about the rest. I’m feeling depressed and have been tempted to resume one of the antipsychotics, but when I think of the Saphris I just have to glance at the sheet with the partial list of side effects I was experiencing written on it to dissuade me from pursuing that option further (although the thought always crops up again later). The Vraylar I’m just ignoring for now because of the nausea, sleepiness, screwiness with Adderall, etc. I’m hoping that this will just stabilize somewhat with time, but that's probably far too optimistic. My PCP ideally wants me to get an orchi (orchidectomy) so that I can go off of the anti-androgen (bicalutamide) and at least partially lower the dose of estradiol, but: I don’t think there’s any way I could afford/pay for an orchi right now (it’s like optimistically $5k but could be anywhere from $3k to $10k+). An orchi is all but guaranteed to cause additional problems down the road if I ever manage to save up the money for SRS (problems like poorer outcomes, additional costs, and the issue that some surgeons flat-out won’t even perform SRS at all if you have had an orchi). Theres a good chance it would not be covered by insurance (or would only be covered by an in-network provider) => this could also potentially make me ineligible for insurance-covered SRS in the future. It can be quite difficult to find a trans-friendly surgeon willing to perform an orchi (significant travel is usually involved) To reduce future SRS-related issues (and complications in general), I’d have to find someone who can do an inguinal orchi, which is even harder to find. Different providers require differing levels of documentation from trans patients getting an orchi, which is often just as stringent as the documentation for fucking SRS (i.e. letters from two separate therapists and documentation of 1+ year of RLE (real life experience, i.e. “living openly as the gender you are transitioning to”, which is ambiguously defied and reinforced to varying degrees - some clinicians want this to involve being the most stereotypical over-the-top fake idealization of what idiots think all trans women are like, while others are content with proof of you living in a vaguely female role, and still others don’t give a shit as long as you've been on hormones long-term and have two therapists vouching for you)). There are of course various benefits to an orchi, but you can achieve much of the same effects with much less trouble just using anti-androgens and estradiol. However if the issues of cost, documentation, and downstream negative effects for SRS didn’t exist, I’d go for it without a second thought, the benefits would absolutely be worth it.
  10. Loxapine's primary receptor binding affinities aren't very favorable at first glance — too much H1 activity, too much mACh activity, some concerning α-receptor activity, etc. However, the SERT/NET/DAT activities for the active metabolites are very intriguing. I'll definitely consider it. I know, it's bizarre that it'd be sedating. I can kinda put together a very rough hypothesis for why it'd be somewhat sedating based on receptor activity (H1, maybe α1A, maybe some of the 5-HT receptors, and a somewhat too strong bias towards antagonism instead of agonism for the D2L/D2S/D3 receptors (where it's a partial agonist)), but it's nowhere near clear-cut (and this is for an antipsychotic with one of the cleanest receptor binding profiles I've ever seen)... The intolerability to higher doses than 1.5mg is also somewhat odd, but I've never tolerated antipsychotics well, so maybe it's just an extension of that?
  11. I'm not sure if it's helping or how much it did help...its efficacy has always been something I was unsure of. It's causing some pretty significant nausea already, hopefully this will go away like it did last time... Thank god for Zofran. I'm still quite concerned about the estradiol as I do feel like my mood has gone a bit downhill since resuming it, although I don't feel that my mood was really all that great prior to resuming it either... Not sure what to think. I switched from sublingual/oral estradiol to transdermal patches in late August, which is also roughly when I first started the Vraylar following a particularly nasty bout of suicidal ideation. The Vraylar seemed to pull me out of the depression, and the estradiol didn't seem to be an issue at all... My memory is a bit blurry, but I think I finally returned to work part-time again in mid-September, and was doing very well in general (at least by my standards of "very well") until I suddenly hit a huge unexpected stressor/incident in mid-October that utterly ruined my motivation, turned the depression up to 11, and brought the suicidal thoughts back with a vengeance... I took a week off of work because of this, managed to return to work again the next week, but at that point I was in really bad shape and after seeing my therapist on the 27th I ended up in the hospital. I suppose that proves that the issue lies less in the hormones and more in the mid-October incident, which is still unresolved and definitely part of the reason why I'm feeling depressed. But maybe the hormones are still worsening the depression even if they didn't cause it? Stahl's Essential Psychopharmacology makes it clear that depression and estrogen levels are well correlated, and due to my hospitalization I was unable to get the planned follow-up blood testing done to determine how the switch from sublingual/oral estradiol to transdermal patches affected my hormone levels, so I have no idea what those are like -- maybe we overshot the target a bit? Those labs were rescheduled to December 11th, so now I have to wait 3+ weeks to find out...which unfortunately is an unavoidable delay since we're not going to get valid results without waiting until my serum levels of everything are at least somewhat stabilized... I know there are also a handful of other (new/upcoming) major stressors that are worsening the depression right now, so that helps explain things a bit more... The fluctuations in hormone levels due to having recently resumed the estradiol/bicalutamide after an extended break can directly worsen things, and probably are, but the uncertainty remains. I should probably shut up and take some diazepam. But I'm already feeling sedated from the two different antipsychotics in my system, so adding benzos will just put me to sleep, and unfortunately I don't have the luxury of being able to sleep away the next few weeks no matter how badly I want to. The sedation in and of itself was still a significant issue with Vraylar anyways. I remember that I had to resort to taking days off of the drug here and there in order to function well enough to work. Maybe I should just dump the antipsychotics entirely - I've certainly had more than enough failures and unpleasant experiences with this entire category of drugs, and I'm only taking them for depression/mood stabilization anyways... The only ones I've ever tolerated for more than a few days before ditching were aripiprazole (dumped it after a short time due to side effects), asenapine (trying to dump this now due to side effects), and cariprazine (can only tolerate at absolute lowest dose of 1.5mg, and still had to skip days even on that dose to function). I've tried several of the more traditional mood stabilizers, but they were mostly useless and had nasty side effects. I'm relatively happy with the rest of my cocktail, I just seem to need something extra to help with mood. I guess there's technically the option of adding bupropion to burn through the sedation from Vraylar and augment everything -- I swore I'd never take that damn drug again last time I stopped it, but maybe in combination with Vraylar it would be tolerable? Not sure. It'd probably be too much additional NET inhibition to handle with the Fetzima... I don't particularly want to try lurasidone, but it's one of the few last remaining options until esketamine and ALKS-5461 are approved in mid-2018 (esketamine in particular is something my pdoc has previously brought up as a future option to try once it's available, and it looks relatively promising for my case in particular)... Well, I think I'm going to skip the Vraylar tonight and see if that changes anything. If my previous experience holds true, I'll be able to stay off of it for a few days at most before I start veering too far towards depression and decide to resume it. That will at least let the asenapine work its way out of my system without the Vraylar complicating things. And if I don't veer too far towards depression, maybe I can stay off it entirely for a while, although I'll of course resume it if the depression overtakes things too much (and switch back to asenapine if Vraylar doesn't work).
  12. 1.5 mg, the same dose I was on before being switched to Saphris. The amount of akathisia from the Saphris far outweighed any akathisia I've ever experienced on Vraylar, even with benzos blunting it, so I'm not worried about that particular side effect. My primary concern is the depression - and I'm quite worried about it. To make matters worse I was off my HRT for weeks thanks to being in the fucking hospital (off of the bicalutamide for ~2 weeks, off the estradiol for ~3 weeks), and have only been back on those for ~1 week (bicalutamide) & ~3 days (estradiol). While resuming the HRT has definitely improved some things already even though it'll be a while before my serum levels of bicalutamide and estradiol fully stabilize again, I was instructed by my doctor to watch carefully for signs of depression after resuming the estradiol in case it's actually contributing to the depression, so I have to be paying very close attention there as well... Of course any depression can be situational as well (and part of it quite definitely is!), or from various other meds, or from the massive fluctuations in my hormone levels (since any change in those can cause transient issues), so teasing that all apart is an utter bitch. All I know for sure is that independent of everything else, Saphris persistently caused entirely too many side effects and problems while seemingly doing very little to actually help me (and in fact I was off of it entirely for roughly 4-5 days after being discharged from the hospital due to insurance issues, during which time I actually felt better than I did when resuming it again, so I'm quite suspicious about how helpful it really was). Either way, Saphris should be essentially gone from my system within 5 half-lives (i.e. 5 days since it has a 24 hour half-life), so I guess how the next week goes will determine my next move. I guess I need to move my next pdoc appointment up as well since I'm screwing with my antipsychotics.
  13. After far too many frustrating side effects, doing some research, reviewing Stahl's Essential Psychopharmacology yet again, and nearly loosing my shit a few times too many, I have concluded that Saphris is definitely not at all a good med for me, and have (possibly foolishly) returned directly to Vraylar. While I'm not convinced that Vraylar is the right med, I am very convinced that Saphris is not the right med at all and have no desire to ever take it again (although if I deteriorate significantly on the Vraylar I suppose I will reluctantly resume the Saphris temporarily as a stopgap measure). Hopefully this won't blow up in my face.
  14. I've also only taken it once (IM though, not oral) during a nasty little episode of EPS that happened when the inpatient psychiatrist briefly tried putting me on an extra 5mg of Saphris in the morning in addition to the 10mg at night (despite having previously changed me from 5mg BID to 10mg QHS because of intolerable sedation and EPS - I'm not sure WTF he was thinking). It worked pretty well and didn't seem to have any obvious side effects, but I know they only used a small dose, and I'm sure the IM route works differently from the oral route.
  15. I'm on 10mg QHS. My pdoc said to try managing the akathisia with the PRN diazepam for now, and if it's still enough of a problem at the next follow-up, she'll add a low dose of benztropine (Cogentin). I'm not sure if I would want to take benztropine though. I feel like I'm already on a ridiculous enough number of meds as it is.