David's Inferno (41 page)

Phone: Started taking Celexa 20 mg again. Feels wired. Only change is Chinese herbs. He'll stop the herbs and see how he feels. Phone report
.

Phoned: Anxious. Valium helped. Crying jags
.

Seen with wife. Went off Celexa in summer and did fine. Started Celexa 20 mg ten days ago, and then to 40 mg. PCP gave Valium for business trip but just couldn't go, so cancelled. Each
A.M
. since Celexa has terrible feeling in pit of stomach. Vibration. Can't sit still. Lost 5+ pounds. Weighs less than in 10 years. Agitated, emotional, tearful. Not suicidal but could understand how it happens. Got off Celexa. Already getting better. 5 mg Valium until he feels like himself. Once he does, restart Wellbutrin but lower dose. SR 100. Then phone report. Will not go up on Wellbutrin or return to SSRIs until we speak
.

Prescription from primary-care physician: 40 5 mg Valium
.

Phone call for renewal of Valium 5 mg. Rarely needs it but wishes to have it available
.

Had two weeks fairly fine last November after discontinuing Celexa. Since then, he wakes restless, stomach restless/anxious. Crying jags every 3-4 days. Took Wellbutrin 150 mg March/April. No change. Assessment: Depression NOS. Anxiety NOS. Doubt bipolar (he's sleeping.) Try BuSpar 5 mg. 3x/day. Valium as needed up to 3x/day
.

Message from him on answering machine. Couldn't hear all of it but sounds like he's getting some relief at low dose of BuSpar but having trouble getting the dose up. Poor sleep if he takes it too close to bedtime.
Left message to take his time going up on the dose … to not go up if having side effects
.

May wake 1
A.M
. but back to sleep, then awake 4:30 with sudden jilt like adrenaline rush. Then has a sense of agitation and obsessiveness. Try going up to 10 mg BuSpar 3x/day
.

More anxious on 15 mg BuSpar so back to 10 mg again. He still wakes up 4
A.M
. wired—takes 10 mg Valium and can stay in bed 2 hours. Once up he'll have to be very active, take steam, sweat, before able to relax. Celexa triggered this in October ‘05. He's never felt really himself again since. Weight down 10-15 pounds. 135. His journal notes: “Essentially, there's nothing I want to do. Every time I think I hit bottom I'm out on a mountain bike sobbing or lying in bed panicked at 4
A.M
..” Hypomanic. Dysphoric mania. Will try Depakote
.

“Depakote really works.” Feels a little subdued but okay
.

First week on Depakote, the spells stopped. Second week dropped back into deep depression—now back to agitation. First week the explosion episodes stopped. Felt normal. When depressed in the past, wasn't agitated. But now wakes with sense of dread. Bipolar depression? Off BuSpar. Add Seroquel 25 mg to 50 mg to 100 mg to 200 mg. Continue Depakote and Valium. Contingency—DHMC
[i.e., Inpatient Psych Unit/Dartmouth-Hitchcock Medical Center].

Seroquel stopped the worst of the symptoms … the madness. At 200 mg he dreams again. Wakes once but back to sleep. Side effects: dry mouth, felt odd, eyes jittery and unsteady. “Don't feel like myself.” No more Valium. Can stay engaged when busy during the day. Depression's there but no
tears. Still 1250 mg Depakote and no side effects. Tired and can't sleep during the day
.

“I'm better—not amazingly so but better.”
A.M
.s still not great. He's tried going down on Seroquel. 200 mg works but 150 mg has fewer side effects. Seroquel “gets me through the night.” We'll go up to 1500 mg Depakote
.

On 1500 mg Depakote he got more shaky. Went down to 1250 mg. No change in shakiness. We'll back to 1000 mg Depakote and follow. Tremor may mean the agitated and manic state is continuing in which case would have to go up on Depakote/Seroquel again. He's down, blunted, sad today
.

Feels better on 1000 mg Depakote and 50 mg Seroquel. Then thought maybe go down further and start with an antidepressant. But still wakes up anxious. Used Wellbutrin and Celexa before. Lexapro didn't work for him. We'll use Seroquel as needed for sleep. Try Effexor for depression/anxiety. If doesn't work revisit 2-week Inpatient at DHMC
.

Phone: Really agitated on 37.5 mg Effexor. Lorazepam 1 mg 3x/day
.

[Full Review]
54y mwm w/ long history of confusing symptoms of mood vacillation, depression, seeming ADHD, etc., throughout life with never really having sustained remission of symptoms. Predominant symptoms is melancholic depression w/hypomanic episodes complicated by alcohol self medication. Feather away Depakote and benzodiazepams over time. Also address alcohol
.

Cymbalta: go 10 mg to 15 mg to 30 mg. as tolerated. Lamictal 25 mg. Continue Depakote ER 500 mg 2x/day
. [There's a “Starter Pack” for the transition from Lamictal to Depakote.]
Stop Seroquel and Lorazepam and Effexor. Switch to Clonazepam 1 mg
.

First
A.M
. after Lamictal w/Cymbalta was first time he felt good waking. Good eye contact, brighter affect, calmer, relaxed. Responded well and tolerated meds. Positive response to bipolar depression approach
.

The symptoms haven't really changed in terms of start of day. “I look forward to the end of the day … most of the day I'm sort of flat.” His journal notes: “No interest in getting up regardless of bedtime, exercise, whether I drink, food. If I get up and walk, I just cry on the walk. I'm driven and drowsy.” Hard exercise helps but can lead to dry heaves like last summer. Evening closest to “good mood.”

Good eye contact. Calmer still. Slowly stabilizing and accepting the gradual change offered by meds. Needing a lot of psych-ease and reassurance
.

“People really do notice improvement.” Told him it takes time to turn the Titanic around. Focus on best times, when noticeable. Had 4-5 pretty good days. Stopped drinking since last visit. Takes a little Clonazepam at night and once in a while a nibble during the day. Mornings are tough. Good eye contact and calmer. Very good response to cross-taper Depakote to Lamictal. Continue
.

A lot better. Significantly better. Two weeks ago it really kicked in. Went for bike ride and had experience of putting things in perspective. “It was such a relief, it was huge.” Working, writing, muse is back. Sleep is fine, just a little nibble of Clonazepam to sleep. Lamictal 100 mg just right. Very positive response to regime. Continue
.

He says things were blissful … then settled down … then he started to feel Cymbalta wasn't doing anything. Then he had one incident with low blood pressure. But only one classic attack; lasted a day … it was after he tried to do without Clonazepam. Didn't notice side effects
with Lamictal … Residual melancholy periodically. Slow incremental change
.

“Good, good … if I had any crying it was only ½ hour … writing is easier … able to sit still and read just regular stuff.” Still a little tentative about doing things where might not be in control. Side effect curling hair. Good eye contact. Calm, clear. More enthusiasm, relaxed. Humor. Try bumping up Lamictal to 200 mg/day. Try feathering away Clonazepam
.

Came with wife. “I went up to Cape Breton alone … big deal for me … a lot of that clearing away stuff.” Has some moderate dips that he manages. “I have my brain back.” Infrequent episodes vs. ongoing. “I have a lot of fun now.” Low key. Continue regime and monitor. Coach, support
.

“I'm like a poster child for Lamictal.” Side effects: a little word finding. “I'm throwing nouns around with abandon.” No problem … sleep is fine. Rarely takes Clonazepam. Doesn't oversleep as much. Much freer with writing. Happy and relieved. Looks incredibly relaxed and enthusiastic
.

I am not a Dante scholar. While I've probably read most every canto at one time or another, I've never done so sequentially. Still, I've thought about him a lot. More as a mythic character than a historical one; a kind of superhuman Scribe who—like Homer before him and Shakespeare after him—appears every once in a while to gather up all the human knowledge that can be held in one brain and write it down, in order to help humanity get its bearings … establish where we are in our evolution.

I'm as interested in how these writers might see the world now as I am in how they saw the world then. As if their understanding, rather than being static, has continued to evolve, following a kind of metaphysical trajectory up to and beyond our present day. To put it simply, the
living
Dante is not the same as the dead Dante.

At one point, I had a theory that
The Divine Comedy
was not the book that Dante had actually written. That rather, it was the “public” book, an expurgated version that he created for the contemporary church and state. Perhaps, I thought, there was a “secret text” of the book, hidden in some monastery or castle somewhere, that would, like an Egyptian papyrus, eventually see the light of day.

While that would make a great plot for a novel, I no longer think that's what happened. The book we read
was
the book he wrote, just not the book he really
wanted
to write. He didn't quite dare to reach as far as he had wanted to in terms of presenting a complete picture of human experience. It was not the church that had censored him … he had subconsciously censored himself. Or, rather, been inexorably censored by his time and place.

Fortunately, whether advertently or not, he left a clue that the journey wasn't complete: Beatrice told him he had to go back and tell all us temporal humans what he'd seen.

Think of what that means. He goes back. Tells people what he saw in Hell, and Purgatory, and Heaven. And then what? Well, if he sticks to his plot … he goes back again. To witness again and tell again. In the meantime, the people who were in Hell are still in Hell, those in Purgatory are still in Purgatory, and those in Paradise are still Paradise. If we follow this logic … we are
all
in the Hell of eternal repetition.

Say what you will about history repeating itself, when you finish writing a book you want to start a new one. I see Dante, looking at his elegant script on all those ancient sheaves of parchment shaking his head and smiling affectionately at that “young” Dante. Because by now he realizes that as long as he keeps leaving us in Hell, he's stuck there too. It's time for a new story.

Even though I've always had this almost metaphysical affinity for Dante's eternal journey, to invoke his name for a book like this seemed a bit contrived. While I could
feel
the parallels on multiple levels, on the surface our only resemblances are that we're both Gemini writers with aquiline noses.

At first I thought, well, I'll include some academic-type essays about Dante to try to obfuscate the apparent tenuousness of the connection. But as I began to immerse myself more deeply into both
The Divine Comedy
and my own writing, the parallels began to click into place in ways that felt increasingly seamless.