A Mental Health Odyssey

I’ve written before about my struggles with mental health. I’m diagnosed with major depressive disorder, generalized anxiety disorder, and social phobia. Many are surprised to learn this about me in contrast with my chosen profession of EMS, where I am routinely confronted with high-stress situations and interfacing with the public and unknown groups of people on a regular basis. At baseline, I’m a pretty easy-going guy. Through a combination of a lifetime of therapy and the right medications, I am able to live a happy life, and function well at work, providing professional, courteous care to my patients, and working well with my peers and supervisors. Over the past year and a half or so, I lived and worked through some very difficult changes in my mental health. They affected me, my family, my work life, my home life, everything around me changed as a result. I am writing this (very long) blog post to share my journey into, through, and out of one of the worst times of my life.

Please be forewarned that I share very personal information and thought processes, some medical information, and thoughts pertaining to suicidality/self-harm in this post.

The Story So Far

For the roughly ten years leading up to the events in this blog post, my depression and anxiety symptoms were well-controlled through a combination of Trintellix (vortioxetine, a newer SSRI) for depression and Buspar (buspirone, a classic anxiolytic) for anxiety. Slowly, over the years leading up to this time period, these medications were gradually increased to their max permissible/effective dose. At the time of these events, I was on 20mg a day of Trintellix and 30mg twice a day of Buspar. These medications seemed to work well together, were both prescribed by the same psychiatrist (who eventually “graduated” me and we stopped seeing each other since I was also in therapy at the same time), and had no bothersome side effects for me. At the same time, I have, since 2015, been seeing Michelle, a licensed therapist. I was able to find her because she advertised that one of her specialties is working with public safety employees and the stresses involved therein. Michelle has been a great help and source of comfort as I navigated many ups and downs through the past 10 years of my life, and I recommend that everyone should have a therapist to talk to, not just for mental health disorders, but because having somebody with outside perspective in your life is a great benefit.

I have, at times in my life, even with medication and therapy, struggled with various manifestations of my depression and anxiety, including seeking seclusion, over- and under-eating, panic, apprehension, and anger. The anger is what tends to get me in trouble at work at and home the most. Misdirected anger, or more often snark, is what goes unappreciated the most, and leaves me in hot water with those around me. You know how they say people will forget what you said, but will always remember how you made them feel? Seems like everyone can recall verbatim what I said to them when it comes time for a write-up, and it really doesn’t look good on paper when I have one of my bad days. I went through some pretty dramatic job changes in my life, partially related to my personal behavior, and I decided I needed to do something about it. I consulted with my primary care physician about what medication options might be available to me to help control the anger and anxiety that were really affecting my quality of life at times.

What Started It All

In October 2023, after a productive conversation, my doctor started me on Vraylar (cariprazine). It’s an atypical antipsychotic, and in the presence of major depressive disorder, is approved on-label as an adjunct. It acts as a dopamine and serotonin agonist in the brain, although the exact mechanism isn’t entirely known. We followed the standard half-dose (1.5mg) to full-dose onboarding schedule, and within a month I was taking the regular prescribed 3mg daily dose. Initially, it was like fireworks, like magic. I felt almost manic. Marina, my wife, couldn’t believe the improvement in my quality of life. I was awake more. Engaging with my sons more. I was getting chores done around the house faster. I was knocking everything off my honey-do list. I was literally begging for more stuff to do at work. I felt fantastic. Better than fantastic. It seemed like the Vraylar had solved more than just the anger/agitation, it had improved so many avenues of my life. When my doctor sent me follow-up messages on the patient communication portal, my responses were gushing with thanks and praise for suggesting the medication, happiness with the results.

Around late December 2023, things started to change just a little bit. A shift in the wind, if you will. I started to have what I would describe as an itch in the back of my mind. A little feeling, like a voice telling me “you can’t do this” – something just barely sapping away at my confidence. Slowly that magic feeling started to fade away. I started to lose a little bit of focus at work, drug doses that typically came easily to me had to be recalled in an iPhone app. My hour and a half drive to my job in the county that I typically filled with a podcast or two started to feel like a burden rather than a pleasure. I started to not enjoy going to work.

Traveling

I was distracted from all of this by two big trips we had coming up, though, in January 2024. We had trips planned to visit family in Pittsburgh and Chicago. First up was Pittsburgh. From the very get-go I felt off. Traveling with small children can be stressful but usually Marina and I make a good team and hand-off managing melt-downs, bathroom trips, snack runs, and who sits with who on the plane pretty well. This trip I felt stressed and out of sorts from the moment we left for the airport. I could tell I was short with the boys, worried about getting where we needed to go, being on time, worried about losing them in the airport, just generally feeling afraid of things happening that had not previously been big concerns for me in the past. The big one for me was when we finally arrived in Pittsburgh and got our rental car. It was a huge SUV, bigger than the one I normally drive daily. Combined with the poor weather and road conditions, I felt like I was white-knuckling it the entire time I was driving. These were roads I learned how to drive on, grew up driving around the city, had driven on hundreds or thousands of times. I am a professionally-trained driver and I drive every day at work; ambulances, trucks, vans, you name it. These feelings of being afraid of driving were very foreign to me and very confusing, but every day they only got worse, more intense. My behavior on the trip was agitated, strange, sometimes quiet and removed. I had trouble concentrating and focusing at times. There are large parts of this trip that I don’t remember at all. I do very clearly remember a huge feeling of relief when we returned the rental car, feeling as if a weight had been lifted.

We got back to San Antonio and it was right back to work. I felt the same sluggishness, fogginess, lack of confidence. I tried to hide it, but I could tell that my crew saw through me. There was a lack of cohesion on my shift. Driving larger vehicles became more of a struggle each day. I avoided driving emergent whenever I could. A couple weeks later and it was time for our trip to Chicago at the end of January 2024. The plan was different for this one. We would all four fly there together and rent a car, but Marina and the boys would stay there for an extended trip, while I would fly home by myself after a short visit so I could return to work on my regular rotation. Again I felt off – distant, agitated, unsettled, unsure of myself, unable to concentrate, tired all the time. Marina remembers that I did not engage anyone in conversation pretty much the entire time I was there, but I barely have any recollection of the days I was in Chicago beyond renting the car and getting the bags into the house. It’s a blur of airports and meals and sleeping. What I do remember from that trip was the drive home from the San Antonio airport by myself. Having flown home from Chicago without my wife and sons, even knowing, logically, that they were safe and sound with family in Chicago, I still couldn’t help but notice the empty seats in my car in the dark, and I cried nonstop the whole way home. I listened to Nocturnal by Billy Jonas on repeat because my son, Trevor had been requesting that song a lot lately and it made me feel close to him. I hadn’t felt this much depression seeping in in a long, long time. I felt so low. So alone. I imagined my family never coming back. Staying in Chicago, forgetting about me. I cried on the phone with Marina that night, missing all of them so much. Later, Marina shared with me how surprised she was at this because it had seemed, at the time, that I didn’t care at all to spend any time with them in Chicago because of my distant affect.

Affecting Work

With no time to lose, I was back to work the very next day. I could feel the depression pulling me under. I talked to my crewmates about it, said things like “I left my heart in Chicago” and told them about how Marina and the boys were staying in Chicago for a longer trip because, at the time, Marina was on sabbatical from her position and I needed to get back to work. They seemed to acknowledge that this must be hard, but didn’t really grasp that I was truly struggling with being so distant from my family. I had to take frequent breaks in my bunkroom to wipe away tears, take a few breaths, and then return to my shift duties. One of the benefits of working a 48 hour shift in EMS is that when station duties, shift duties, and “other duties as assigned” are completed, if there are no calls pending, naps are permitted at station. Previously, I would busy myself with other projects, or read, or watch EMS podcasts on youtube, rather than spend all day in bed, but now I felt different. I felt tired. Sluggish. I wanted to be alone. I didn’t want to be around my crews. I spent most of that shift, and the next one, hiding in my bunkroom after duties were completed. If I wasn’t needed on-scene, I didn’t elect to go on more calls than were required of me as a supervisor. My superiors started to notice. Frequent comments of “Are you ok?” and “Everything alright, Dave?” replaced the typical “Hey, how’s it going?” or “Nice to see you!” that I would normally receive. I brushed off their concerns and tried to assure them I was fine, just tired. I did my best.

I really tried to just grin and bear it, but I was white-knuckling every moment that I was driving a company vehicle, and every drive to and from work was torture. I told Marina that I was having trouble driving and concentrating, but didn’t really let on how severe it was. During all of this time, because of my stubbornness and lack of scheduling ability, I had missed a couple of therapy appointments and had failed to reschedule, so it had been now a couple of months since I had last seen Michelle, my therapist. Marina encouraged me to reach out, but I dragged my feet and just kept sleeping all day. Eventually it got to the point where on my days off I was sleeping for sometimes as much as 18 hours a day, only waking up to go pick up the boys from school and make them dinner, then going right back to bed as soon as they went down. I called off from work a couple times here and there when I would wake up and feel just totally unable to drive to work. Just the thought of having to drive to work was enough to make me want to vomit, thinking about having to control my vehicle and potentially getting into a wreck, or possibly falling asleep while driving, there were so many disaster-type scenarios I pictured in my mind’s eye that caused me to feel panic inside that I couldn’t handle the thought of driving. I never offered an explanation, just that I didn’t feel well. Fortunately at this time I was salaried and not subject to PTO or vacation hours, or else I would have burned through them rather quickly. It went like that for a few weeks for the rest of February 2024, struggling through work, get through a shift or two, then call off again.

The Sentinel Event

Then came March 5, 2024. My alarm went off at 0400hrs for work. I got up with the same feeling of dread that I had been having, not wanting to get showered, not wanting to do anything. I could tell my heart rate was elevated, I felt off. I set my uniform out on the bed and went into the bathroom to shower. Marina was still asleep in bed. I remember in the shower I forgot if I had washed my hair or not a couple of times, I think I must have done it at least twice and kept getting frustrated with myself. I don’t think I’ve ever felt that kind of confusion. At the same time, my mind would wander in the shower and I would think about what came next – putting on my uniform, gathering my backpack and my shift bag, and DRIVING TO WORK. My stomach turned in knots. I started to feel hot. Dizzy. Panicked. I finished my shower, got out, and dried off. I remember the room started to spin and I could feel myself breathing faster the more I thought about driving. There was a level of my brain, as an EMS provider that thought to myself, “oh, so THIS is what a panic attack feels like” just before I passed out and hit my head against the door of the bathroom. I was unconscious for probably only about 5 minutes or so because the bathroom fan was still running on its timer when I woke up. Everything felt heavy. I had a hard time moving. I felt sluggish. I felt clammy and cold. I was covered in sweat. I knew I was on the floor but at first I couldn’t process how I got there. I sort of felt OK being on the floor but at the same time I was frightened at the lack of knowledge of the events that caused me to be there. Eventually I got up, got the door open, and found Marina on the other side, completely freaked out from being awoken by my crash against the door. I told her I passed out from a panic attack, and I was going to call off from work again. Marina was understandably concerned, said she understood, but insisted that I make contact with my primary care physician and inform her of what was going on and the symptoms I had experienced today, no compromise permissible on that. I agreed, and when their office opened, I called requesting an “acute care” visit to see my physician same day given the circumstances. I was given a time to see her the same day and I was happy to know that I would be able to see her so quickly. Shortly after that, the office called back and notified me that the appointment was cancelled as my symptoms did not qualify as a “sick” visit and would have to be scheduled for a later date. EXCUSE ME? Passing out and major depression and agitation, likely all as a medication side effect, are not an acute symptom? I didn’t know it yet, but this was only the first of many frustrations with the healthcare industry regarding my mental health. After a lot of back and forth, including Marina getting on the phone and yelling at them (she felt I wasn’t being forceful enough, and to be fair, I probably was just exhausted at that point) they made an appointment for me with a PA from the office, somebody I had never met, for that afternoon. I began to feel more worry. More depressed.

I kid you not when I tell you that I scared the shit out of this poor PA. He was in NO way equipped to deal with a chronically depressed, agitated, sleep-deprived, angry patient looking for answers about a medication prescribed by another provider. I wanted Marina to come back to the exam room with me, and at first he didn’t let her come back, he wanted to talk to me by myself. But then he knew nothing about Vraylar, couldn’t tell me if I was experiencing side effects of the medication or some other condition. He asked me about sleep disturbances. Check. He asked me about trouble thinking clearly. Check. Trouble accomplishing daily tasks. Check. Changes in eating. Check. Suicidal thoughts or plans. Check and check. He finally went and got Marina, kind of made the conversation about her, and how difficult this situation must be for her. He asked me about firearms in the home. Yep, this is Texas. Are they secure? Yeah. Do I have access to them? Yeah. Am I going to use it? No, not in my plan. After this question was posed, though, I could see the worry in Marina’s face. The PA diagnosed me with acute anxiety disorder and prescribed Xanax as needed. Well la-dee-fucking-dah. What the hell good does THAT do me? I can’t take a benzodiazepine when I’m on duty and operating emergency vehicles. First of all, they knock me out cold. Secondly, even if I wasn’t sleeping, if I get in a wreck and piss positive for benzos, that doesn’t exactly look good for my record. He also referred me for a psychiatry consult. Probably the only correct thing he did. I asked if I should stop the Vraylar since I was pretty sure that all of this was a negative side effect of the medication, and he said no, to wait until the psych consult could advise what to do with my meds. More frustration. After a little calling around to the various referred offices, I had an appointment at the end of the week with Monalisa, my new psychiatrist. Another new provider, another new office, another new face. More worry. More anxiety. More depression.

Congratulations, by the way, if you’re still reading, still with me. This probably sets the record for longest blog post for me, ever.

Psychosis and Psychiatry

At this point, Marina was driving me to all of my appointments and doing all of the dropoffs and pickups for the boys. I wasn’t driving anywhere. Even being in the car at all made me nervous. If I was awake and Marina was driving somewhere, I was tracking her location on Google maps like a psychopath, worried that SHE might get into an accident, even panicking about her driving, not just mine. I was now sleeping more like 20-22 hours a day, only waking up for dinner, and then going back to bed. I was losing weight from lack of eating. Later in the year, a routine physical and labs would reveal that lack of physical exertion had caused kidney injury. We arrived to my appointment with Monalisa at the prescribed time. The check-in staff were not friendly. They were very matter-of-fact, directing me to fill out forms, register as a new patient, pay the co-pay, and then be seated. I was nervous, and unsettled. I could already feel a cold sweat forming at my hairline. I heard my name called and Marina stood up with me. “No” – they said “just the patient at this time. For vitals.” Marina sat back down. I followed the medical aide to a check-in room. “Take off your shirt” he said. I was instantly very confused. I was here for a psychiatry visit, not a physical. I inquired as to why, and was just told it was “procedure.” Feeling very exposed and uncomfortable, I was weighed and measured, then had my vital signs (blood pressure, heart rate, oxygen saturation, respirations, lung sounds) assessed, and then I was instructed to lie down on an exam bench so that a 12-lead EKG could be obtained. All the time that this was going on, I was thinking to myself how we, as EMS providers, imagine these procedures to be “non-invasive” and at this exact moment I felt so intruded-upon, so scared, and so exposed, it’s no wonder that we have patients that sometimes give pause when we ask about obtaining vitals and an EKG in the presence of minor medical concerns. In any case, the initial assessment was eventually completed, and I was directed back out to the waiting room to wait with Marina. We sat. And we sat. And we sat. Marina played on her phone. I just sat and stewed and wondered how this would go. Finally we were called back to Monalisa’s office. She was warm and welcoming, very friendly. She listened patiently as I described some of the events of the past couple months, getting on the Vraylar, the initial good results, the slow decline into depression, the anxiety, the trouble driving, the agitation, the calling off work, and then the syncope earlier in the week. Marina filled in a lot of the blanks, added her perspective of everything, some of which I knew, some of which surprised me because it was stuff I had forgotten or didn’t know/remember, another strange feeling, like hearing my life played back as if I hadn’t lived it. I was having a hard time answering questions and staying focused, and without Marina there it would not have been a productive visit.

Right away, Monalisa agreed that it sounded like I was having a horrible reaction to the Vraylar, and it was safe to stop it since I was on the lowest full dose, no tapering needed. I felt some relief hearing that. She wanted to look at my other meds, too. I felt confusion at this – wouldn’t stopping the Vraylar put everything back to normal? Her concern was that I had been on the 20mg of Trintellix for so long that I may have acclimated to it, (what she called the “poop out factor”) and we might need to consider changing things up to really see some results. She sensed my hesitation, though, and agreed to wait a couple weeks and see if coming off the Vraylar showed any improvement. (Spoiler alert: it didn’t). We (the three of us) agreed that I was not in a healthy place to be at work, given my inability to drive (easily/safely) and my state of depression. When we got home that afternoon I called my Assistant Chief and had probably the hardest conversation with him I’ve ever had, told him I needed to go on an extended leave. He advised this would be an FMLA (Family Medical Leave Act) leave of absence and the HR department would assist me with the paperwork. Again, fortunately, at this time I was a salaried employee, and not subject to PTO or vacation time, so I was blessed to continue being paid the entire time I was off on FMLA. I worked with my county HR rep (a person who, at the time, was no help at all, had no empathy, and screwed up processing my paperwork more than once – thankfully she no longer works at the county) and Michelle, my therapist, to get the paperwork squared away for my leave of absence. I was approved for 12 weeks off for my medical emergency. So, now I was on the clock to get this shit fixed.

After a week or so of persistent massive depression, suicidal thoughts, sleeping 22 hours a day, not eating, hating myself, only getting up to see the boys at dinner or be driven to my now twice-weekly therapy appointments like a child needing to be carted around by their parent, we were back to see Monalisa again. I was ready to change up my meds. It was now April 2024, and I didn’t want to wait any longer. I didn’t understand why coming off the Vraylar didn’t produce any changes. It wasn’t fair, but there was no time to dwell on it, I only had the 12 weeks of FMLA to get this taken care of and I needed to get this done. Even in my depressed, muddled, foggy state, I still had an underlying sense of urgency and desire to see this through. Monalisa wanted to titrate me off the Trintellix and start me on Prozac (Fluoxetine), in gradually increasing doses, to see if a new SSRI would be the right pathway to less depression symptoms. (Spoiler alert again: it wasn’t). Even after increasing to a relatively high dose, and adding Abilify (Aripiprazole, an atypical antipsychotic used as an adjunct for depression symptoms), we were about eight weeks into the process and still didn’t see the results that I wanted. I was a modicum better off than where we started, I was able to drive myself to therapy, barely able to drive to pickup the boys from school, but driving farther than that, or to new places, was out of the question. If I stopped moving for too long, or sat by myself without going back to sleep, depressive and suicidal thoughts crept their way back in and I felt awful again. Michelle brought up admission to an inpatient psychiatric facility to see if they could better-manage my meds. I panicked. I did NOT want to be “sent away” – I could no more imagine being away from my family, my wife and boys, during this process, than I could imagine just not being alive anymore. It felt like the same thing in my mind. I outright refused to even consider it. I was determined to continue with outpatient therapy with Michelle and working on meds with Monalisa until we got it right.

I believe it was around this time that Marina called our family friends and asked them to come remove the firearm from our house. Marina was convinced she was going to come home from work and find me dead from a GSW. I don’t blame her. From what I remember, I had lost most of my affect, I was irritable, depressed, constantly crying to Marina that I just wanted to get out from under this. To be “done” with this depression. This mess. This tangle of symptoms weighing me down. I felt hopeless. I felt no progress was being made. I was frustrated that coming off the Vraylar hadn’t fixed my symptoms. I was embarrassed that my friend had to come get a firearm that I felt I could still be trusted with, and Marina had explained to them why. Even more so, I felt sick that Marina was dealing with all of this garbage herself, that I was just piling crap on top of her. The guilt did not help with the depression symptoms. I withdrew further, slept more, ate less. Did less. Interacted less.

April came and went. We continued to gradually increase the dose of the Prozac and the Abilify, again with minor improvements in mood and focus, but I still found myself having to basically convince myself that I could accomplish even the most basic of tasks. I needed to talk myself up just to be able to drive to pick up the boys, or make them dinner. Slowly, with great effort, I was able to get back to some basic self-care type stuff like going to get a haircut, doing my own laundry, spending time downstairs more than just for dinner. During this time, I had a routine follow-up with my pcp and a routine lab panel revealed critically high levels of creatinine, indicating that I had an acute kidney injury. Although this was likely caused by my weeks of immobilization caused by depression, and was already being self-corrected, my doctor wanted to refer me to nephrology for a consultation. Great. Another new doctor, and now something else to panic about. Cue more phone calls, more waiting times, more labs drawn, more waiting times, more panicked driving to an unfamiliar location, more waiting, and meeting with the nephrologist, who basically advised me that I need to drink lots of water and increase my potassium intake. Subsequent labs and follow-up nephrology appointments would reveal that my AKI was completely transient and all lab values have since returned to normal since my activity level has returned to baseline. It was all related to lack of movement/mobility and was all self-corrected, as I suspected, but nobody wanted to listen to me.

Happy Birthday to Me

It was now May 2024. My birthday was approaching, I was set to turn 40 amidst all this crap. Happy birthday to me, I guess. The FMLA was running out, with my first day back/return-to-work being May 28, 2024. It occured to me that although my chiefs had checked in on me several times during my leave, nobody from my crew had so much as said hello to me. Not gonna lie, that hurt. I also realized during this time period that I have some friends who were willing to reach out and talk, and understand what was going on with me during periods of illness and difficulty, and some friends who would rather just remain radio-silent and pretend everything is OK. Even though I was horrible at writing back, Tommy, Chris, and Mike never stopped checking on me, never stopped asking how I’m doing, and never gave up on me. I love you guys, and I will be forever grateful for your caring and kindness. In my meetings with Michelle, we started doing EMDR exercises where I would visualize coming back to work, how it would feel, what I would do, how I would explain my absence to my crew, how I might answer questions they would have, what that might be like if they ask me about my mental illness, and would I be willing to be open and honest about it. The day got closer and closer. I was still meeting with Monalisa and Michelle every week. Making tweaks to medications about every other week or so, seemingly without much progress in over a month. I just felt…… the same. I felt like I was….. OK, but not great. I didn’t feel like I was back to being myself. I felt well enough to function, to be a parent, but I didn’t feel like I was present and in the moment, I still felt foggy. I was still nervous about going back to work. I was still worried about my command presence, the ability to be in charge and provide calm, not just be a caregiver for patients but direct others on-scene and keep my head on a swivel and think three steps ahead. I was not convinced that I was ready to go back to work, but hold your nose cause here goes the cold water….

May 28, 2024 arrived and my alarm went off at 0400hrs for shift. I woke up, set out my uniform, showered, dried off, got dressed, kissed Marina good morning and goodbye, grabbed my bags, and headed out to the car. I took an extra few minutes to talk myself through getting my phone plugged in, route selected, podcast turned on, lights on, made double-sure I set the alarm and closed the garage door, then put the car in drive and headed off to work. I arrived to my station to find….. nothing out of the ordinary. Not sure what I expected. I thought at least a “welcome back” sign on my locker or something after being gone for three months? Some recognition of the hell I had just been through? But instead, just “A” shift ready to head out the door and my “B” shift crew ready for brief and to start the day. Nobody really said anything about my absence. A couple of the guys later in the day said “good to have you back, cap” but that was the extent of it. While I was away, our F150 quick response vehicle had been replaced with a brand new F350, now equipped with an 8 foot bed, this truck was as big as an ambulance. I was not mentally prepared for just how big this truck would be. It took me all of 12 hours of driving it before I scraped the front bumper against a parking pole outside the rear bay door and had to do an incident report. Cue feelings of anxiety, inferiority, depression, worthlessness, and so on. Chief assured me there was no permanent damage, and I was able to buff the paint scrape right off, but I was still mortified. Brand new truck and on my first shift back I’m the first guy to ding it. Hell of a thing.

At this point, I believe I was on 20mg of Prozac daily and 5mg of Abilify, still seeing Monalisa every other week, and seeing Michelle every week. I still felt like I was not myself at work or at home. I still heard that little voice in the back of my mind, telling me “you can’t do this” whenever I set myself out to do something – big or small. Get up and shower. Take out the trash. Make dinner. Drive to work. Take a blood pressure. Direct traffic at a scene. It didn’t matter – it felt like no matter what I did, I was doing it for the first time and having to convince myself that I was able to do it, that I still know how to do it. We were also adding new protocols at work, which required memorization and practice of new medications and skills, setting me into a whole new level of panic. I was sure I was going to fail out on the protocol testing and be fired from my position. Basically I was walking around on eggshells, feeling down on myself, still pretty tired and worn out. I wasn’t sneaking off for naps all day every day, but I still racked out earlier than I used to. I wasn’t socializing with the guys like I used to in years past. We weren’t doing Sunday family dinners anymore. I hadn’t cooked dinner for the crew since I’d come back. The guys noticed. I could tell. They weren’t joking around with me like they used to. It felt like they were handling me with kid gloves.

Traveling Again

I stuck with therapy. I stuck with the medication plan. Driving kept getting more familiar. I kept forcing myself to engage with my kids, even though it felt foreign to me. Internally, I craved contact with them. I don’t know how to explain that dichotomy – that on the surface it felt like I couldn’t do it, didn’t know how to engage with my own children but at the same time wanted to spend all day with them. We had a trip planned in June 2024 with our friends to our annual spot in Hot Springs, Arkansas where we all rent a cabin together and spend the week relaxing. It’s a LONG drive to get there. I was not sure how it would go, if I would be able to do it. We split it up into two days, stayed at a hotel in the middle. We made it, and seeing friends in person, hugging them, talking a little about everything that had gone on in the past few months, was cathartic. It was still a strange week, I still felt sluggish, didn’t feel up to engaging in as many activities as I normally did on our trips to Hot Springs, and they noticed. Everyone was gracious enough not to call me out on it, and everyone was very accommodating when I got over-tired or had a migraine. I had to skip out on the 4×4 offroading, and the go-karts; that was just going to be too much for me, but I was glad everyone else had a good time.

We got back from Arkansas, more time passed, more work, more low-level anxiety. More just feeling “OK” and not totally myself, not being completely satisfied with the results of the medication plan. Slowly increasing the Prozac dose. Tried adding Hydroxyzine to the mix; that just upset my stomach, stopped that right away. I hadn’t called off from work in a while, so that was an improvement. There were a couple shifts where I had to cover down on the ambulance and work as a line paramedic, “facing my fear” so to speak of directly having to recall medication dosages and providing direct patient care, not just sitting back and supervising. I’m sure my appearance of sweating bullets and probably appearing very pale did not instill a lot of patient confidence in me but I survived, and delivered my patients none-the-worse for wear.

During the time period after our trip to Arkansas, while I was working my way through telehealth visits with Monalisa, and struggling to get myself up and drive to pick up the boys after school, my stubbornness and complacency once again took hold and I missed appointments with Michelle multiple times. I blamed it on not wanting to drive to her office. I could have scheduled telehealth therapy visits with her just as easily as I did with Monalisa, but I felt myself sliding into depression, getting back to sleeping 18 to 20 hours a day again on my days off. When August 2024 came around, Marina finally gave me an ultimatum: call Michelle and schedule an appointment or else Marina would call on my behalf. I was mortified. I forbade her from doing so. I felt it was not her place to interfere. Probably the closest to having a real yelling fight we’ve ever been. Finally, though, I did it. I texted Michelle and got back on the schedule and back into the office. I drove myself, difficult as it was, and started seeing her regularly again, working on EMDR processing of everything that had happened, and working on releasing triggers and past events. Were it not for Marina stepping in and forcing my hand, I don’t know how long it would have taken me to get back into therapy.

On a particularly warm September 2024 Sunday afternoon, I was responding first to a scene as the supervisor to a trauma call, and I had applied a tourniquet to an injured leg. The medic crew arrived after me and I assisted with loading the patient onto the ambulance. While I was standing at the side door of the unit, checking to see if the crew needed anything else, I suddenly got nauseated, sweaty, shaky, and felt my vision closing in. Next thing I knew, I was on my back in the dirt next to the ambulance and the medic from the crew was standing over me on the radio calling for another unit and calling for a chief to respond. Well, shit. Thought I was making a lot of progress, now here I am, syncopized again. Only this time I don’t think it was a panic attack, at least I didn’t have all of those feelings leading up to it, just got a little stressed out on-scene being on my own on a trauma call for the first time since being back, maybe a little nervous, but not what I would call panic. Anyway, the second unit shows up (waste of resources), my Chief showed up (embarrassing), and they assist me in walking to the unit for evaluation (waste of time). Vitals and 12-lead all check out normal, I sign a refusal and Chief drives me back to station. He looks worried. We sit down in the conference room and he wants to know what’s going on. I tell him I think I’m just dehydrated, just got too hot. I don’t let on that I’m concerned that I still think this is some of the psychiatric symptoms still not abated, because then what option would he have but to send me home or dismiss me, declaring me unfit for duty? I hydrate with a couple of gatorades, call Marina and fill her in. She offers to come get me, and I refuse. Chief advises that I should try to take the rest of the shift as an “admin” day and only respond to calls if absolutely necessary. I was embarrassed but I agreed. Fortunately, I haven’t had another episode like that at work since then. About a week later I had a near-syncope episode while I was out at dinner with Marina, but it was transient and relieved with cold water. I’m partially convinced these were medication side effects from either the Prozac or the Abilify because of their sudden onset and seemingly random nature.

FINALLY

A few more months went by, I continued to press Monalisa with my frustration on the lack of results from the medication. I still didn’t feel like “ME” I would tell her, repeatedly. By the time we got to January 2025, I was on 40mg of Prozac and 10mg of Abilify, still without any appreciable change in my anxiety. The depression had somewhat improved, but I still had some lingering negative thoughts, a general feeling of MEH that I just couldn’t shake. It was never there before all of this, and I refused to accept that it was my new normal. Further, it made me angry every time I considered how unfair it was that stopping the Vraylar didn’t just reset the clock on my symptoms. At this point I felt like I had lost so much good engagement time with my family because of one stupid medication, it made me sick to my stomach. I felt the biggest improvement when we increased from 5mg to 10mg of Abilify, and although there are therapeutic levels above that, they’re not generally approved for depression/anxiety treatment, they’re more geared towards psychosis, according to my discussions with Monalisa. I didn’t feel I was getting any more positive results from the increases on Prozac, and I felt like every change was so incremental, and took so much time to evaluate and process, that it wasn’t worth it. I was ready to try something new. Finally, FINALLY, through so much trial and error with dosing and waiting-and-seeing, and therapy, and talking, and waiting some more, we concluded that the Prozac/Abilify combination wasn’t working and it was time to try something else. In February 2025, Monalisa suggested we try an SNRI called Effexor (venlafaxine). While tapering off the Prozac and the Abilify, we started on a low dose of the Effexor, and let me tell you, the effect was almost immediate. I felt clearer. I felt lighter. I had been pep-talking myself into driving for so long that it had become second nature so that all of a sudden when I recognized I was still doing it, and didn’t need it, it was a shock. There was just a day in February all of a sudden that I got in my car and didn’t need to do a mental checklist of turning everything on and plugging everything in and assuring myself that I could do it – I was able to just get in, click my seatbelt, and drive. We started at 37.5mg of Effexor with the plan to titrate up as needed, and soon after increased to 75mg. Every incremental bump in doseage saw an exponential improvement in my mood, my activity level, my engagement with friends and family. It was like a light switch turned on. Marina told me she felt like she “had her husband back” again. That was both elating, and felt like a punch in the gut, knowing the hell I’ve put her through over the past months.

By March 2025, you can see in pictures of us that I finally have a genuine smile. Hell, the fact that there are even pictures to look at from attending events is a testament to how much the Effexor was doing. I was finally starting to feel like “ME” again. I was completing my daily duties at work by muscle memory again. New protocols coming up didn’t frighten me. Driving the boys to school, while it still is nerve-wracking because I never know what kind of attitude I’m gonna get from a 7- and 4-year old, doesn’t scare me. I look forward to family events. I ask Marina about going out to lunch or dinner. I enjoy cooking meals again. I don’t mind planning ahead for dinner prep. I feel like I have actual GOOD news to share in therapy sessions. In April 2025 we increased my dose a couple more times, eventually ending up at 225mg per day. As far as side effects, I had a minor essential tremor in my hands that self-resolved after a couple weeks, and I’ve had some persistent tinnitus that seems to be related to the Effexor. If I have to live with a little static in my ears as a trade-off for good mental health for the rest of my life, I’ll take it. Even with the warnings about consuming with food, I’ve had no stomach upset. My crew has noticed, too. All of them have individually pulled me aside and mentioned that I seem happier, or told me that it’s good to “have the old Dave back.” My chiefs noticed, too, since I’m back to asking for projects and additional work once my duties are completed.

In May 2025, I asked my chiefs for an informal sit-down. It had been almost a year since my return-to-work, and I wanted to catch up with them about some of what had gone on, and what had largely been unsaid between us. I thanked them for their grace in not confronting me about my lack of competence and capacity when I returned from FMLA not wholly ready for work, not completely myself. I acknowledged to them that it was a very long, difficult journey to get all of the right medications ironed out, and that I only recently got on, what I feel, is the RIGHT medication for me. They said they could tell when the change happened, and they were happy for me, and of course they were glad to give me the space to heal and grow, and they would always be here for me. I am beyond blessed to have a command staff that stands behind me and supports me as a professional and as a human being. I know for a fact that at previous places of employment if I had suffered this type of debilitating illness, I would have been hung out to dry and left on my own, terminated, without health insurance, and without assistance. I owe a huge debt of gratitude to my agency and to my county for supporting me through my illness and my recovery.

Still reading? Consider me impressed. Don’t worry, we’re wrapping up.

So, you might be asking yourself, having read thus far, why did I write this post? Why share all of the details of the better part of a year and a half of mental illness and recovery? There are a number of reasons. First and foremost, I wanted to process it by writing it out. I needed a lot of help from Marina to fill in some of the blanks because a good portion of time between October 2023 and May 2024 is only present in my mind in bits and pieces. This may be traumatic scarring, a side effect of the Vraylar, a secondary effect of all of the sleeping, or a combination of any of those. If I’m going to take the time to process and write it all out, the logical place to do so is this blog. After all, this is my place to share my random-ass thoughts on the internet. Secondly, I am a supervisor in the EMS industry, and I feel that, as an industry, we do an awful lot of talking about mental health this and stigma that, “call me if you ever need me”, code green, the list goes on – but we still hear too many times about suicides from within our ranks. Brothers and sisters who lost their fight with their internal demons. I came pretty close to that. I was in a very dark place. If I had gone through this without Marina, and without a pre-established relationship with a licensed therapist, I don’t know that I would have survived. Those two saved my life, literally. Certainly there were other wins along the way; Monalisa, the psychiatrist I was referred to, turned out to be excellent, and if you have any experience at all in the mental health world, you know that finding a good match and succeeding with a psychiatrist on your first try is not very common. Monalisa demonstrated repeatedly that she was determined as I was to see this through and continues to be an ally in my fight back to better mental health. Even more wins; my chiefs at my EMS job supported me without question, my family kept a respectable distance and didn’t bother me with too many questions (although I later found out that they checked on me a lot through Marina), and as I mentioned before, a few friends never gave up on me – Tommy, Chris, and Mikey.

I would be remiss if I did not also point out some areas this journey could have gone better, though; access to my primary care physician was abysmal – I felt abandoned and shunned in my time of need. The lack of communication from peers in my industry, who were aware I was out on FMLA was disheartening. Even without knowing the type of medical reason, a simple “hey how’s it going” can go a long way when somebody is dealing with an injury or illness. I had to fight tooth and nail with my insurance for almost every medication change, they wanted to argue with me about every time we changed meds because it wasn’t their version of step therapy. Billing administrators at insurance companies should not be allowed to practice medicine. Full stop.

If you happen to find yourself in a position where a loved one, friend, or coworker is in the midst of a medical or mental health emergency, my advice is firstly, do not be alarmed. They are already doing enough of that for themself. In the blandest, most honest, open, generic possible way, just say hello. Offer a listening ear. You don’t have to start a meal train, or a gofundme, or circle the wagons or whatever else. Start small. Let them decide to engage or not engage with you, and it will organically grow from there. Any health situation, but especially a mental health emergency, can feel very isolating, and the smallest gestures can have a huge impact with very little effort.

So, What Now?

Without sounding too hyperbolic, I feel like I have been gifted a new lease on life. I take time to listen to my boys. I play with them as much as I can. I check in with Marina more often. I talk and joke with my crews more. I try not to sleep the day away when I have days off and actually do something with myself, even if it’s just reading or relaxing, rather than spend the day in bed. I know that for years and years I was lucky with all of the medications I took being successful at meeting their intended function without side effects, never having to play roulette with the wheel-o-medications and figure out the next, best option until this series of events. Hopefully with the room to expand on the dose range in Effexor, I have some time before we have to explore anything else new, and when that time comes, I’ll have good luck again. For now, I’m going to focus my energy on being positive and present with my family and my work, and on breaking the silence and the stigma around mental health illness and emergencies, so that if somebody I know and care about experiences something like this, they know that they are not alone in the process. At the risk of sounding like a broken record, I have to thank Marina again. My wife, my partner, at times my champion, my chauffeur, my scheduler, my healer, my everything. I quite literally would not be here writing this if you were not here for me. I love you.

---

If you or someone you know are experiencing a mental health emergency,
call or text the national suicide hotline at 988.
There is help available 24/7. You matter.

With some help from ChatGPT, I developed this Mental Health Resource Guide. I hope it helps you answer some questions or plan ahead. I am happy to answer any questions about it or help you develop your own resource guide – reach out any time at dave@ventricularescape.com.

---

I could not have written this post without the patience and assistance of my incredible wife, Marina. She lovingly and patiently filled in all of the blanks in my memory over the past 18 months and helped me edit my rambling and incoherent thoughts. Thanks also to my Uncle Dave who was willing to be my first rough draft reader and provided some very valuable feedback (and a way too complimentary first review).