Tuesday, August 26, 2008

Therapy: what's with the stigma?

I was having a conversation with someone who we'll refer to as a "friend of a friend" whose child (a middle schooler) was a sort-of-witness to a sexual assault. I say sort-of-witness because the child didn't see the assault; she was approached after the fact by the victim who told her all about the incident--in all its grisly details. The child of this "friend of a friend" was smart and reported the assault, but because the assault happened between some of the child's friends things have gotten ugly. Anyway, my "friend of a friend's" child was deeply disturbed by what happened and has been having nightmares that are intense enough to keep her awake and never seems to feel safe. In the course of events it was suggested that this child should see a therapist to help her process the whole sordid event. The "friend of a friend" was not happy with that suggestion. The "friend of a friend" believes that if word got out the child was in therapy there would be a lot of negative consequences. Basically this friend believes that sending her child to therapy would be worse for her than the fear and nightmares that have been bothering the child for more than a month.

Now, I want to be clear: I'm NOT criticizing this person for choosing to avoid therapy. Everyone has to make choices for their own families as they see fit. All my information is second hand, so I'm NOT judging.

What I am wondering is this: does therapy still have that kind of stigma for most people? I thought that as a culture Americans were over therapists as modern incarnation of snake oil sellers and therapy as something only for weirdos. Am I wrong about that?

And another question: is it different among LDS? In our cultural subset are we NOT over it?

Saturday, August 23, 2008

CSA Update: can you name this mystery veggie?

Friday was a crazy day but the craziest moment was when I opened up my CSA box and found three rolly-polly somethings that looked like, well, like alien eggs. It didn't have any real smell and it was plain white when I chopped it open. After tasting it (surprisingly yummy!) and doing some awesome internetting, I know what it is! Do you? I'll post the answer in the comments :)

Thursday, August 21, 2008

Depression Profile: It IS Okay

This is the story of Miss S (the "S" stands for surviving and smiling) an LDS woman living in California and dealing with depression. I am so grateful to her for sharing her story here.

Looking back, I've probably always suffered from some kind of mild depression. I was raised in a home (not LDS)with a lot of yelling and name-calling. I had my son when I was 17 and never married his dad. I went through two divorces before 25. (Sounds really crazy when I say that out loud!)

The first time I thought I had depression was in my second marriage. I was always angry at the man I married (although, later I found out my anger was misdirected. I was actually angry at myself for marrying him). I'd have anger episodes that felt borderline psychotic: breaking down, screaming, shaking, so much fury. I got a quick prescription for Prozac, took it 3 days and threw it out because I figured I wasn't depressed chemically, it was just my situation. So, "we" started marriage counseling together and I kept going by myself after the separation. I started learning about myself and what I needed in my life--how to be happy by myself and those kinds of things.

I met my current husband shortly after that, joined the church at 26, married him at 27, had baby #2 at 28 and baby #3 at 30. My youngest is now 8 months old. I noticed depression kicking in around my seventh month of pregnancy. I didn't realize that's what it was until later. In retrospect, I think I probably suffered from PPD with my previous pregnancy also. My depression was hard to admit to, and to realize that it was depression, b/c for me, I become angry when I'm down. Also, to admit to depression is taboo in my family; "nobody" has it, but looking at my mom, I'm sure she does too. Anyway, I thought it was just PPD and that it would wear off.

My oldest child's father committed suicide 6 years ago. He suffered from bipolar disorder and was suicidal from the time I met him at 13 years of age. Growing up with him, I thought he was faking it, trying to get attention, that he could control it, that it was all "in his head." I tried to get him to focus on other things to distract him from depression. I didn't realize it was a REAL illness until after he died at 24. It was a long road. He turned to street drugs to self-medicate and by the time he got professional help, the meds counteracted and did more damage than good. He died within a year from that time.

I've been on Prozac for about 5 months now and I've tried to wean off twice. I noticed the first time that the depression signs came back right away. The second time, not so much, but a little here and there. I'm nervous that I will need meds the rest of my life. I really don't want to "need" medication, but so far I've noticed that I'm a much better person, wife, mother, etc. with it. I feel better on the medication, but I don't like being dependent on it. I'm only on 10 mg, at one point I thought I'd need more, but I'm taking it every other day now and doing fairly well. Maybe I'm getting better?

But then the other day I was so tired all day, got absolutely NOTHING done at home and had to drag myself to the scout court of honor at church. I've been very tired lately and thought I might be prego again (not to my excitement), but found out that it was PMS (Yay!). I need my energy back.

I like Prozac for the simple fact that there aren't many side effects. I do have night sweats, but not too badly and I get tired off and on. I have some really good, energetic days and other times sleepless nights and dragged out days. My appetite is normal and I've succeeded in losing some weight that I've been working on--but I hear Prozac suppresses your appetite so that might be part of it too.

Spiritually, my depression has affected me a great deal. When I'm not on meds, I'm a monster and want to be left alone; I'm angry and ungrateful. When I'm on meds, I'm indifferent to emotion. I've only cried three times in the last 6 months: once was at church when the Spirit hit me and I couldn't stop crying. I was a mess! Another time I was talking to my good friend and told her I couldn't figure out why I was emotionless. Then the flood gates opened. Either way, I continue to go to church even when I don't feel like it. My husband has helped us stay on track there. I love being active in the church, but many times I feel like I'm going through the motions. I don't set aside the time I should to pray and read scriptures. I think if I did, it would help more. We haven't been to the temple as much as we should b/c of small babies, but my husband just heard a great talk about how we should make the time to go no matter what. He is going with our 13 year old on Saturday to do baptisms with the youth. I might go and do a session on my own if I can find a babysitter.

I wish other people knew (I'm still learning this myself) is that IT IS OKAY. It's okay to be depressed. It's okay to ask for help. It's okay to be on meds. It's not your fault for being depressed; you didn't do anything wrong, it's just a trial in life. I still have trouble going to the clinic b/c I feel weird. I feel uncomfortable, like a freak, like I don't belong and I'm always nervous there. But just because I'm depressed doesn't mean I'm crazy. I'm still learning this. I haven't told my mom or my sister or my son for fear that they will think I'm nuts and should be doing this on my own, without a shrink or meds. I'm so grateful to have a supportive husband. Without him, I probably would go nuts!

We (my readers and I) send you our support and prayers, Miss S! Good for you for building a support system and making an effort to include the Lord in your life and trials. Even if you can't make it to the temple, all the small and simple things you do make a difference. Thanks again for sharing your story.

If anyone else would like to share their story here please email me at lolapalooza AT hotmail DOT com. Put "depression profile" in the subject line so I know you are not a spammer!

Monday, August 18, 2008

Postpartum Depression or I still have a hard time talking about it

My totally awesome blogger sister linked to me today. (Hi, Charlotte!) At the end of her post on the new fad of "pregorexia" she said, "We need less articles about post-partum flab and more about post-partum depression. Less about how to be a hot mommy and more about how to be a good mommy. Less about which star lost the weight the fastest and more about the stars in our eyes when we love our babies."

So here are a few words about PPD that I am glad others said to me and that I think more people need to hear:

*From my doctor, "PPD is an illness. It's not your fault. It is chemical. It's not your fault."

*From a nurse at the hospital when I asked her to hand me my pills, "Oh! I take those too. Sometimes we all need a little help."

*From my husband after I finally got treatment, "It's nice to see the woman I married. You weren't yourself before."

*From God, through the scriptures, "For God has not given us the spirit of fear, but of power, and of love, and of a sound mind." (i.e. Through the atonement of our Savior Jesus Christ there's hope!)

And here are the things I would say:

*This is not you. You are not bad and you do love your child, despite what your brain is telling you.

*You and your child are both in the loving care of our Father in Heaven, even though you can't feel it.

*Get help. Take medicine. Talk to a doctor, a therapist, a friend. Ask for support because you will find it.

*You are not alone in this. So many of us have been there and have survived.

Tuesday, August 12, 2008

Cymbalta Update

Here's the way my new depression medication was explained to me:

Imagine your depressed brain is the side of barn. On that barn there are three targets. These three targets are the neurotransmitter receptors for seratonin, norepinephrine, and dopamine. Antidepressants are like arrows being shot at the targets. Taking Lexapro, an SSRI, was like firing an arrow at the same spot on the seratonin target over and over. It works for awhile, but eventually you've shot arrows at the one spot for so long there's nothing left to hit. That part of the target is just a hole. If you switch to a different SSRI it aims at another part of the seratonin target and can help alleviate depression symptoms. That still leaves the other two targets untouched. What you do with those target depends on your symptoms. For me, my depression involves a lot of anxiety and intrusive thoughts so I needed the SSRI to take the edge off the anxiety but I needed something more for the intrusive thoughts. The psychiatrist I met with recommended Cymbalta because it is a SNRI (seratonin-norepinephrine reuptakte inhibitor). It works on two targets at once.

I started taking the Cymbalta on the 15th of July and the intrusive thoughts stopped after about a week. After about two weeks I noticed that I was hvaing more fun with my kids. I didn't mind playing on the floor with them or horsing around as much. I seemed to have more patience. Also at around two weeks I began feeling motivated to do housework (much to my husband's delight!). I'd never given up completely on the housework but I always found it overwhelming and it took a lot energy to work up to doing it. I could never figure out where to start and I spent a lot of time feeling distracted and forgetting what I was working on. After the Cymbalta had begun to kick in I was able to focus better and keep the house cleaner. (Notice I didn't say it was clean, just cleaner. If I could only get my kids to put their toys away!) I also started sleeping a lot deeper and would actually wake up refreshed on occasion. I've had a few crazy dreams. My favorite one was when I dreamed that my husband had to take all my friends as plural wives. It quickly turned into some sort of bizarre, pioneer-era Bachelorette show with me constantly protesting, "I get to be the first wife because I already had his children!" Like I said, CRAZY dreams. Anyway, Over the last week I've noticed an uptick in my energy level. I've even started working on my book again.

So that's all the good. Now here's the bad. The list of side effects for Cymbalta includes: nausea, increased sleepiness, and increased sweating. I have all those. So much so that I took a pregnancy test just to make sure I didn't have an accidental bun in the oven. (I don't. Thank goodness! I'm just not ready for more kids yet . . .) The nausea has been manageable but it still surprises me. The sleepiness has been almost comical. For the first week or so I HAD to nap every afternoon. One day I sat down to rewind a movie for the kids and just konked out. When I woke up two hours later my 2 1/2 year old was buck naked and snuggled up next to me eating candy while watching the credits roll. My five year old was just relaxing on the couch and my one year old was still napping, but I could tell I'd missed something. I'm still pretty sleepy but if I keep working I can get through it. It's odd to me that I'm sleepy but I have the motivation (and sometimes the energy) to do so much more housework and stuff. The sweatiness is, um, really kind of gross. I have to keep a towel nearby when I work out and I'm betting our electric bill will go up since I've been using the air conditioner a lot more. Oh, and I'm thirsty all the time.

When all is said and done I'm glad that I started the new medicine. It's been good to feel more functional and I just feel more relaxed since I'm not constantly combatting images of knives and blood (those are the intrusive thoughts). But the side effects are enough to make me want to wean off this as soon as possible. Which I think means at least six months. Maybe a year. The psychiatrist I meant with says maybe never. For now, I'm just taking it one day at a time.

Saturday, August 9, 2008

Depression profile: Doc

Thanks to Doc for sending me his story. I found it quite moving. He is one courageous guy! I had to really cut it down to fit here so be sure to check out his blog to get the whole story.

Part I—The Pretender
I have always been painfully, exceptionally, extraordinarily shy. The technical term is social phobia. This has haunted and hamstrung me most of my life, but never at anytime more than when I decided I might have the ability, the drive, and the heart to be a physician.

After surviving the brutal application process, my medical career was born. In my mind though, I had fooled them. I slipped by the gatekeepers whose job was to sift out “losers” like myself.

I did quite well with the first two years of medical school which were all academic. I was a miserable third year for the most part. Surgery in particular was a meltdown month. Otherwise, I learned to keep a low profile and slide along. What I did not learn to do was to become comfortable in my own skin, put patients at ease, and feel like I had a clue doing a physical exam.

There was only one exception: kids. The intimidation factor was not there and I let my goofy self out. I had the patience to get farther with them than other students. My first exposure to them was in Neurology, where I had the luck of being assigned to the Children’s Hospital. I fell in love with it, was fascinated by it and, best of all, there was a massive shortage of pediatric neurologists. I found my calling in medicine.

Unfortunately, I was still compromised by my phobia: pacing around the hospital for 20 minutes to work up the nerve to talk to a nurse; avoiding waking up patients; being terrified of phone calls.

Then it was time to find a residency. I interviewed at every pediatric residency I applied to. Pediatric neurology is the red-headed step child of pediatric subspecialties. It’s claimed by neither Neurology or Pediatrics in training. It requires a partial residency in both which causes political problems.
The fate of the interns is determined by a computer—the infamous “match” system. It works by residencies interviewing great swaths of medical students and medical students interviewing with many residencies. Then the two parties form wish lists and the computer optimizes the list so both students and programs get the places they indicated they prefer to be. In pediatrics, 93% of medical students get one of their top three choices. In my case, due to politics I got into my fifth choice, my failsafe. It was a large program with all the clinical exposure I could want and a bunch of strangely unhappy pediatric residents. I had a deep sense of foreboding.

Part II—Meltdown
Life stressors #1 (the new addition) and #2 (the move): We learned early in my last year of medical school that we were expecting a new baby boy. He was due right about the time we would move, the month after graduation. In order to have him covered by insurance we had to have him before we moved. My residency began orientation mid-June. Thanks to an understanding OB, labor was induced June 6th. We packed up the moving van and my wife was discharged from the hospital 2 hours later. We moved to a computer matched assigned city which, like medical school, was hundreds of miles from any family. I also realized I felt strangely detached from my son, thinking of him more in clinical terms than fatherly terms. It disturbed me.

Life stressor #3 (the heart): In preparing for the move I went into the doctor for a checkup. He thought he heard a murmur (never identified by anyone since) and sent me for an echocardiogram. It turned out I have a rare condition where the pericardial sack that my heart sits in did not form completely. While often not discovered or the cause of any problems, on rare occasion, part of the heart can get caught in the opening, strangulate, and rupture, causing sudden death. I had an MRI done the day before my son was born. I received a call that my cardiologist was discussing it with a heart surgeon (yikes!). In the end, this was all much ado about nothing and I never needed the surgery, but that was up in the air for several months. Death became a consuming theme in my thoughts.

Life stressor #4 (the job): I began the first year of my residency on what was the most difficult rotation for the year, the Neonatal ICU. We had overnight call every third night and put in about 100 hours per week. My head was absolutely swimming. I had to learn emergency care for some sick infants completely on the fly. We dealt regularly with distraught parents in a variety of intense situations. I had to make the dreaded phone calls. I had to learn to speak to the nurses.
I performed miserably, telling myself that all interns perform miserably their first month. To some extent this is true, the learning curve is indeed steep, but I faltered more than most. I walked around like a zombie, constantly exhausted. Some of the nurse practioners became so concerned they had the residency call me one day and tell me to sleep. People were always asking if I was okay.

I moved from this to the general inpatient pediatrics service. It should have been a relief, but I didn’t feel it. I couldn’t concentrate. I would sit on call with the other resident telling me about the patients I would be covering and what I needed to do and I wouldn’t hear anything past the first sentence. My mind was spinning out of control, imagining disastrous scenarios one after another. (This feeling, I later learned, is a hallmark of generalized anxiety disorder.)
Too often, when asking for help the answer was, “Figure it out for yourself. I had to when I was an intern.” I felt incredibly alone. The many critiques and suggestions brought to me a new round of self-flagellation. I was miserable. I began having strange worries. I wondered what it was that made people into child abusers. I started having intrusive, unwelcome thoughts about hurting children. I somehow convinced myself that I was really a monster, hiding beneath a facade. This kind of fear is also a part of generalized anxiety. There was no danger of me acting on these feelings, but they seemed real and distressing. My life was enveloped in guilt.

My wife, desparate for help with the children, left to stay for an extended period with family. I came home to an empty house every night. I began watching the same depressing movie over and over and over. I was living on donuts, boxes of cookies, anything that came in a box really.

The low point came when I was presenting a patient whose mother had Munchhausen’s syndrome. In typical, cynical, burntout MD fashion, we got to laughing about some of the nonmedical complaints the mother brought. I began laughing hysterically. My laughs turned into tears that would not stop. All the pain, all the anxiety, all the insecurity, and all the misery of my training just burst out of me. The tears were unsatisfying and bitter.

My attending was shaken; she quietly and concernedly gave me the number of the medical school counselor and encouraged me to go. I resisted. My senior resident came and told me to go. I resisted. Finally, she went to the chief residents who told me to go. I agreed. But put it off. Then our evaluations came in, my program director became involved and I was dragged into the counselor’s office, immediately suspended from clinical duty.

Part III—Acceptance
Here’s the funny thing: They told me I was depressed and I didn’t believe it. I took a kazillion question test, scored 98/100 on the depression scale, and I didn’t think I was depressed. I mean, aren’t all residents tired? Don’t all residents do nothing but eat work and sleep? I was not suicidal, hadn’t even had the thoughts.

I only knew this because I had had those thoughts before. My medical education alerted me to the fact that I had been in the throes of major depression previously. Junior high was not kind to me. I was an outcast, I was lonely, I was miserable. Young and unequipped to recognize and sort out what was going on with me, I struggled. I am likely the only Mormon kid who ever used to sneak into the chapel when the building was empty and just pour my heart out to God, begging, pleading for him stop the pain. I used to sit, staring at the bottle of Tylenol, wishing, just wishing I could get up the guts to down it all.

I never could. I always came back to the thought, “How could I do that to my family?” I knew they cared.

I moved past it on my own. I maintained high function in high school, having some happy moments and involving myself in extracurriculars and a small group of friends. I graduated fifth in my class. I received a 4 year tuition scholarship to Somewhere Else University.

I served a mission which was no small achievement for a social phobic.I took verbal abuse on what I believed and still presented what I had to offer in a spirit of love. I grew and matured. There was a period at the end where it was hard to do anything. I didn’t enjoy missionary activity or our liesure day anymore. It was a relapse, but I recovered.

Of course, when I returned to college I had my rough patches: periods of melancholy, lack of enjoyment, excessive tiredness. But, hey, I still kept my grades and married my soulmate. I made it to medical school. Sure, I was really disappointed by the general peds rotation, because I was doing something I loved got no joy out of it, but still, I wasn’t tempted to knock myself off.

Well, it turns out you don’t have to be suicidal to be depressed. I was referred to a psychiatrist, started on anti-depressants, and felt totally defeated. I wanted to be mentally strong. I didn’t want my secrets out. I didn’t want the prejudice. I felt like my medical career was slipping away, now that the pretender was caught.
On medication, disaster scenarios raced through my mind and thoughts of ending my life returned, again rebutted by the quandary of how my wife and kids would fare. While this kept me from giving in to suicidal thoughts, it sure didn’t help my guilt.

It took several weeks, but one day I found enjoyment in my old hobbies, in music, in joking around, in my children. I suddenly felt alive again, even though I had no idea previously how dead I felt for so long. I eased back into clinical duty, with a couple of rotations and with supportive attendings my abilities grew. The workload was less intense, but I was moving and thinking a thousand times better. I began to see how counter-productive my fear of weakness had been. I felt like Moroni, a prophet in the Book of Mormon, whom God told “And because thou hast seen thy weakness thou shalt be made strong” (Ether 12:37).

This was so foreign to my previous mindset. I thought I knew all about the wonders of God’s love, and what it meant to be born of God. I thought I had witnessed the transformative power of the atonement. I had read the Book of Mormon; the power of the story of Alma was burnt into my soul. Yet, somehow, I didn’t really understand these doctrines. I wanted to be great on my own, to achieve on my own. I was proud (paradoxically in light of my poor self image) and I wanted to face down my shortcomings on my own.

Part IV—Fight the Power
As I recovered from depression it brought to light my anxiety. One of the first side effects the medication gave me was panic attacks. I worried incessantly about the future, about my patients, about the rumor mill, about the stigma.
My residency program had a reputation for regularly dropping people, but I slowly gained confidence as my performance quickly improved on lighter rotations. Still, as a resident, I was shuffled into new hospitals so quickly it was hard to adjust, which in most medical situations was dangerous. I reluctantly started a low dose benzodiazepine.

As my anxiety became more apparent, my counseling adjusted. I learned relaxation techniques, and learned to stop and evaluate my fears to see if they were founded in reason. I tried to learn to live in the now. While the consequences of failure were real, the doomsday scenarios in my head were excessive. It was more helpful to see what I needed to do right here and now. My anxiety was mitigated but still took a lot of energy to manage.

By the end of that rotation, I could see where my knowledge, comfort level and ability had skyrocketed. I felt competent, especially compared to other interns I performed alongside with. I was climbing out of a huge hole. I realized for the first time that medicine, even intensive care, was something I was capable of.

Unfortunately, the program began to feel maybe I just wouldn’t survive with my fragile mental state. Ironically, as the help they had me get started working and kicking in, the program’s willingness to let it work decreased.
In accordance with my career plans, I moved ahead with a child neurology interview. I was open about my issues. The interview went well. I felt my career was going to be salvaged. I was accepted to a program near my wife’s family. My local program director was not happy, but since I kept passing my rotations he couldn’t actually do anything to stop me.

That changed two months later, when I did the pediatric ER rotation. I wanted to really prove something here so without consulting anyone I stopped taking my benzos. In my mind, I was better now and needed to learn to perform without the drug. This was a horrible, stupid mistake. Things kept getting tougher and without the medicine the only coping mechanism I had was anger. I offended a lot of people and ended up losing my residency contract. I took some bogus limbo rotations and came up with a new plan. It had just one problem: I needed all the people who I offended to come to bat for me. It was awkward. But I knew I needed to reach a peace with them. I needed to forgive. I needed to let go of anger, which was eating at my soul.

Eventually, with a wealth of experience in the school of hard knocks, a dogged determination, a newly developed, hard fought self confidence, and a little luck, I pulled it off. I was accepted into a new child neurology residency and scrambled into a transition year. It was absolutely astounding.

I love what I am doing now. One deciding factor in making the plunge into medicine was the desire to force myself to overcome weakness. I don’t know if I could ever have comprehended what that really would entail. I really don’t know that I would choose to experience it all again if I had the choice, but I have undoubtedly grown.
I know not all bouts of depression end this way. Mental illness and its stigma destroy lives. I know of more than one doctor or medical student who have taken their life. I just hope that telling this story can in some way help others with either the stigma or the healing.

As always if you would like to share your depression story e-mail me at lolapalooza AT hotmail DOT com. Put "depression profile" in the subject line so I know you're not a spammer:)

Thursday, August 7, 2008

Breaking Dawn: A Review but Not a Spoiler! (hopefully)

Before I get into this post I want to say thanks. Thanks for all your considerate words about my aunt. And especially to those of you, Jessica and Myssie, who have children with RTS--thank you. I can't imagine the things you deal with everyday but I also know I can't imagine the blessings you receive because of your sacrifices and love. I consider the people who loved and took care of Barbara as heroes and you definitely are too. Again, thank you all for being a part of her passing.

And then there was Stephenie Meyer. When I recently blogged about the first three books in the Twilight saga I didn't know the fourth one was coming out so soon. I also didn't know I'd be getting my hands on it so soon. I know a lot you are interested in it and haven't read it yet so I will do my best not to spoil it for you. If anyone is looking for plot synopsis I'm not doing that here. These are just my thoughts about how it felt to read the book.

My opinion of the first three books was mixed. I enjoyed reading them but was a little disturbed by some of the more erotic moments and some of the violence and the mixture of the two--especially in the third book. I had also been bothered by the lack of character development and what I refer to as the "theme mallet". (The theme mallet is employed when an author relies on the frequent repetition of key facts and ideas rather than artistic skill or the reader's ability to convey meaning in a book.) A friend of mine who is pretty much a superfan of the Twilight saga said she had read one interview (sorry I don't have a better source for this quote) in which Stephenie Meyer basically said, "I'm not a good writer, per se. I'm a good storyteller." That is how I felt about the books. They weren't particularly well written (from an arty/literary point of view) but they were great stories, even if they were a bit disturbing. After all was said and done, I did want to find out what happened.

The fourth book fell into my hands rather serendipitously. Our ward had a quarterly Enrichment activity Tuesday evening and a sister and I had gotten into a heated debate about whether or not Bella and Edward "made out". (For a fleeting moment I was pretty sure I was fourteen years old again!) After a few glances from our perplexed Relief Society president the other sister asked me if I had read the fourth book. "No," I snorted. "I don't even know anyone who owns it. Short of buying it, I have no idea how to get my hands on it." The other sister offered me her copy so long as I promised not to harm it in any way.

So it was that I picked up Breaking Dawn with trepidation. As I read the first few pages Bella was her usual self-deprecating yet competent self. Edward was the same, old, mercurial Ken doll. I sighed and settled in for what felt like the vampire novel version of a sitcom. But then something surprising happened. What is normally the denouement for a sitcom season finale, the wedding, happened in the first hundred pages. With 600 plus pages left to fill I was absolutely lost as to what Ms. Meyer planned on talking about. And she continued to surprise me until the final page, although the ending was not quite as satisfying as I'd hoped.

I finished it quickly and with a relatively light heart--a lot of the things that had bothered me about the first three books weren't problems in the fourth. Since Edward and Bella get married the teenage eroticism is toned down quite a bit. Don't get me wrong, there are plenty details about how their intimate affairs are going but the tension is gone. Once they are married it just doesn't feel as dirty. Instead of Bella trying to be a sexpot and seduce Edward it becomes more of an exploration of female sexuality and how it works in a marital relationship, which isn't necessarily inappropriate.

Anyway, Edward and Bella's sex lives aside, the book was just better written. Meyer takes a few narrative risks and changes point of view in different sections of the book. Those sections are a like opening the curtains in a stereotypical vampire's crypt: such a welcome change! She'd tried it for a few paragraphs at a time in the other books, but here other narrative voices are firmly fleshed out. (Jacob fans, get excited!) The theme mallet was still in operation but I let it go since these books are aimed at teenagers. Bella also becomes more nuanced. In the fourth book I start to appreciate her as a character and not just as a plot device. Edward and Jacob don't grow as much but they have their good moments too. Oh, and Meyer finally trusts the reader to remember how much Bella likes Edward's eyes and chiseled chest. She refrains from mentioning them every other sentence. (Thank goodness!)

The other thing that struck me about the first three books was how "nonmormon" they felt--besides the fact that Bella and Edward hadn't, shall we say, consummated their relationship (which is the main subject of book three), there was nothing there that made them intrinsically Mormon. Which I guess was a little disappointing. I guess some small part of me was hoping that the success of these books pointed to a little bit more opportunity for LDS writers to go mainstream and that just wasn't so. However, the fourth book is very LDS in its overtones and values. It turns out that signature LDS doctrines (like forever families and agency, to name a couple)were driving the books all along. Who knew?

Anyway, to sum up the review: these still aren't my favorite books but they were fun to read. And while I am still uncomfortable with the combination of violence and eroticism in the books I can see why so many readers are pleading that us literary types just let these books be.