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The Stress Doc Letter
Cybernotes from the Online Psychohumorist ™

January 2000, No. 1, Sect. 1

Fight when you can 
Take flight when you must 
Flow like a dream 
In the Phoenix we trust!

Table of Contents

News Flash: HealthAtoZ.com, Career Magazine and WorldWide Singles.com Announcements: AOL Chat Group and Q & A Links/Archives 
Q & A: Keeping the Stress Monkey In Place and In Perspective 
Shrink Rap: Double-Edged Webs of Technology, Depression and Prozac 
Readers' Submissions: What Is Normal Size??? and Skinnyland Express 
Sect 2: 
Main Essay: Twelve Tips for Beating Moderate, Chronic Clinical Depression

News Flash: Alas, only for AOL members, stop by my online "Shrink Rap (TM) and Group Chat," Tuesdays, 9-10:45pm EST.  Chat with the Stress Doc: It's a dynamic, lively, at times witty and always warm, thoughtful and supportive problem-solving group. We raise questions and share our ideas, hopes and experiences with each other.

News Flash:

Subj: Your site has won! Date: 12/15/99 12:27:55 PM Eastern Standard Time From: admin@healthatoz.com (admin) To: stressdoc@aol.com

Dear Webmaster,

Congratulations! Your website has received an award from HealthAtoZ.com, the premiere site for authoritative health information on the Internet. You and your organization have been chosen above hundreds of others for superior content, ease of use, layout and/or overall appeal.

Be on the lookout for our next email - the award will be attached, signifying that our seasoned team of medical catalogers has reviewed and chosen yours as a featured (starred) site on http://www.healthatoz.com.

By this time next week you'll have an opportunity to tell the world (and the people you report to) that you're a winner! You can proudly post the electronic award on your site. [Eds. Note: It's now attached; check out www. stressdoc.com, top part of home page.]

In the meantime, we invite you to visit the newly re-designed http://www.healthatoz.com, if you haven't done so recently. Our database of health information continues to grow daily, and we've added many enhancements including a medical spell checker. Tell your friends to visit, too - they'll be impressed.

Best wishes, and enjoy the benefits!

Raj Lakhanpal, MD, FRCS, FACEP President & CEO HealthAtoZ 

Subj: Check out Career Magazine: News and Articles About Career, Jobs and Employment Date: 1/3/00 8:52:16 PM Eastern Standard Time From: Maryk425 To: Stress Doc

Click here: Career Magazine: News and Articles About Career, Jobs and Employment</A>

Hi Mark,

Thought you might like to see this article [tips for dealing with stress] which is the featured piece in Career Magazine this week. I hope you hear from some folks as a result . . . (See end of the article for your stuff.)

Thanks :)

Kathy

And finally, check out my monthly column appearing in worldwidesingles.com -- http://worldwidesingles.relianthosting.com/WWS/mag/jan/articles2.htm

A lot of good stuff for singles.

Announcements: 1) For all cyberspace travelers, there's the new Ask the Stress Doc Q & A -- Work Stress Digital City - Washington, DC - Ask the Stres... and Love and Relationships Digital City - Washington, DC - Relations . Also, check the Doc's Q & A Archives: Stress Doc's Q&A and Q&A: Love and Relationships .

Ask the Stress Doc: AOL/Digital City--Washington, DC Work Stress/Love & Relationships

1) Keeping the Stress Monkey In Place and In Perspective

Q. Hello, I'm doing an extremely important project on stress. Could you please clearly define stress for me and back it up with statistics? What causes it, how to treat it and how do you prevent it?

A. Stress is having someone out of the blue wanting me to help them on, "an extremely important project," without asking me what my time and work schedule look like. ;-) A stress carrier is one who wants me to: "Clearly define stress…back it up with statistics (including) what causes it, how to treat it and how do you prevent it." (Yes, I could; now the issue is will I. Getting a little feisty, aren't you Stress Doc? Fortunately, the generic formula for a stressful situation is one in which there is high demand with little control or autonomy.) And chafing at the bit stress is not yet being able to retort: go to www.stressdoc.com to purchase Practice Safe Stress with "The Stress Doc." (But soon, soon.)

I did send this emailer some relevant information on file. (Perhaps the old squeaky wheel axiom wins out once again. I did receive a prompt "thank you" and yet another request for me to further refine the info I sent. Keep dreaming.) However, this Q & A will reflect upon ways others try to take the stress monkey off their own backs and place it on susceptible others. (Btw, do you think this query was sent at the eleventh hour? ;-) Who is vulnerable? Certainly, the person who is blind to the difference between caring about and caretaking for; the person who hasn't learned "The Basic Law of Safe Stress": Do Know Your Limits and Don't Limit Your "No"s.

Case in Point: I

This "giving of yourself/giving to yourself" issue was further heightened by a recent online encounter with a courageous and dedicated woman who created and heads her own national volunteer support organization. Her members are often in rather difficult if not dangerous life situations. I can imagine how great their needs are for social connection, vital information and virtual morale and ego massaging. Wisely, this leader recognized that she, herself, was approaching the burnout wall. And like most dynamic and passionate professionals who are organized, high performing, high energy (okay maybe a tad Type A perfectionist, too)…she (and we) don't really believe the "b"-word can happen to us. We are too aware. Ha!

Especially when growing up in a family with one or more dysfunctional players - critical or volatile alcoholics, withdrawn depressives, anxious controllers, etc. - the pressure can be great to fill the nurturing and self-esteem void. You lose your own individuality and voice. Or with the breakup of a marriage, as the responsible child, you must prop up a mother who is unraveling emotionally. Or you stifle your anger and your perception of reality by accepting a significant other's definition of you as "weak," "needy," "demanding," "unworthy" or just plain "bad." (Or tenaciously push yourself to prove otherwise.) Or you idolize a dominant parent - identification with the aggressor syndrome - which disguises a deep-seated fear of being humiliated, ignored or abandoned by the same.

A real albatross is being too concerned that people like or approve of you. When this is the case, one avoids healthy conflict at all cost - by passive retreat or, even, by hostile or rageful attack. Too many still believe anger is a bad or mad emotion (not so surprising if raised in a silently or openly destructive-aggressive household). So you stew…and procrastinate, hide out, smolder away, have anxiety attacks or develop compulsive rituals and maybe succumb to isolation and despair. You don't learn to challenge these old critical voices, you resist discovering that family members today are often not as frightening or fragile as they once were, in actuality and/or in memory.

You don't express feelings with conviction and clarity. To paraphrase the author of Creative Aggression (I believe it's Richard Bach): Healthy anger says, "This is who I am. This is what (I believe) is happening to me in relation to you. I have these feelings I need to express."

Case in Point: II

When anger or passion ("Passion" being one of my "Four Faces of Anger") is directed in a non-attacking mode, in a manner that affirms self-other limits and boundaries rather than assigning blame, the stage is set for dialogue and creative conflict resolution. I'm reminded of a friend who recently grappled with an existential decision. She's a mid-late 30s singer and actress and is at a career crossroads. Her Washington, DC path is definitely withered, especially for her talent and ambition. She's decided to move to LA.

The first words out of the mouths of most friends and acquaintances: "What about your husband?" I like her five-word reply: "It's not about my husband!" Of course it isn't. It's about her compelling need to pursue her essence, her passion, her talent; she speculates on fulfilling her "destiny."

And once my friend and her husband started grappling with this unshakable reality, not hampered by guilt or misguided notions of loyalty, options open up for self-other, win-win possibilities.

So how do you fight this stress monster, especially if you don't have an open and risk-taking partner? Well, I'll be glad to email, "The Stress Doc's Stress Tips," to interested parties. But I will close on this note: connect with a group of people grappling with issues you can relate to. Find a safe haven where you can bring up real emotion -- a church or 12-step group, a depression or grief support group, a men's group or even the Stress Doc's online "Shrink Rap and Group Chat." Actually, we have a small cadre of truly wonderful folks, individuals who both share and can be shy, who may laugh or cry; people who caringly challenge and comfort each other. For AOL folks, try dropping by some Tuesday evening, 9-10:45pm, EST <A HREF="aol://4344:363.gorkin.5732839.568857121">Dig City Promo - Stress Doc</A> and discover how we…Practice Safe Stress!

P.S. And for non-AOL folks, I'll be running a monthly chat for WebMD.com starting January 19th at 2 pm PST or 5 pm EST.

Shrink Rap™: The Liberating and Entangling Webs of Technology, Depression and Prozac

Sitting in the tea house, pondering my Y2000 future, I can't help but reflect on two technological developments that penetrated both mass consciousness and my consciousness this past decade. Engaging with these two innovations has dramatically increased "Stress Doc" productivity and visibility: experimenting with a new generation of antidepressant medications and exploring cyberspace as the New Frontier for pushing the writing, personal-professional connecting and marketing envelopes. My Internet battle cry: "Go Web Young Cyberite!"

Personally, these two breakthrough designs have achieved a powerful interaction effect. The series about my depression and "Trial By Prozac" has garnered much online feedback; perhaps, surpassed only by "The Four Stages of Burnout." (Email stressdoc@aol.com for these articles.) Readers of this newsletter know I strongly advocate integrating biochemical and psychotherapeutic interventions for managing clinical depression. This position is based both on personal experience and the overwhelming therapeutic impact for clients of the new generation of antidepressant medications - SSRIs or Selective Serotonin Reuptake Inhibitors.

Now this pro-Prozac stance at times has generated some adverse reaction, including being accused of "killing people." Acknowledging misuse if not abuse in the meds arena, however, doesn't make SSRI use a rigidly righteous, good vs. evil issue. Prozac and its chemical cousins -- like Paxil, Zoloft, Welbutrin, etc. -- can be "wonder drugs." That is, their impact can appear miraculous to someone who has struggled for years with an unrecognized mood disorder. Yet, these drugs are powerful substances with the potential for harm if not properly diagnosed and dispensed. Just because the side effects are usually much more tolerable than older generation antidepressants doesn't make Prozac or Paxil "feel good candy." (SSRIs more precisely target neurotransmitter firing and biochemical functioning impacting fewer organ systems, thereby having fewer side effects.)

Perhaps the Prozac glass is half full and half empty. As American author, F. Scott Fitzgerald, pronounced: "The test of a first rate intellect is the capacity to hold two opposed ideas in the mind at the same time and still retain the ability to function." So, does this mean such an intellectual aspirant must see SSRIs as potentially miraculous and murderous? But I get ahead of the story.

Grappling with the Double-Edged Prozac Web

The confluence of three recent events has created a mental maelstrom, challenging me to reconsider the context of Prozac advocacy and, perhaps, be more comprehending of the above-mentioned, fundamentalist-like "killer" mentality.

1. Depression Sidebar. The first factor was having depression and Prozac on the brain. I've been working on a sidebar for my upcoming book, Practice Safe Stress with the Stress Doc™. (Published by AdviceZone.com in Spring 2000.) The sidebar, "Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression," is the "Main Article" for today's newsletter. (See Sect. 2.) Actually, this piece extracts strategic points from the aforementioned six-part series. Also, I've been helping a new client overcome shame and misperceptions about her own depression and need for medication. The week began with the Prozac glass strongly half full.

2. FDA Report. A front-page article in The Washington Post began to shake the glass. Apparently, many of the online pharmacies are not licensed or do not meet the requisite state licensing standards. Not only is there concern about people obtaining prescription drugs illegally through the Internet but…c aveat emptor: Does prescription sent equal medicine received? Quality and legality controls are difficult when there's, "a Web site operator in one state, the pharmacist in another and a patient in the third."

The article also referred to a cautionary tale provided by the Food and Drug Administration. A 53 year-old Chicago man died after taking the impotence pill Viagra, a pill he had ordered from the Internet. (And there was no mention of him dying happy.) The critical point: This consumer never saw a doctor who, hopefully, would have advised him of his heart disease risks that made Viagra use dangerous.

This leads to an issue that is not just virtual but, alas, all too real: the disconnection in the medical system between patient, doctor and medication administration. A daily stream of email has me aware of the increasing numbers of people using mood medication under questionable, if not precarious, circumstances, even when prescribed by a physician. (I will limit the scope to SSRI antidepressants though, clearly, this is a much broader issue.) First, I strongly believe that before antidepressant medication is dispensed a psychiatrist should make a diagnosis. Internists, GPs, family physicians, gynecologists, etc., are not trained as psychiatric diagnosticians. Second, too often when patients get medication from non-psychiatric physicians (and, alas, as well from some psychiatric facilities) there is not appropriate or sufficient monitoring of the meds trial. "Call me in a month" (or three months) borders on malpractice when dealing with depression, even of a "minor" variety.

To what extent is this the fault of a Managed Care system that so tightly embraces time pressures and efficiency constraints often making adversaries of patient care and money? I'm not looking for easy scapegoats. But as I've recently learned, the consequences may be more than abstract words such as "mismanagement" and, even, "malpractice." Real lives are at stake!

3. An Agitated Caller. The final catalyst for this essay was a call last week from a distraught yet thoughtful gentleman. He had read some of my Web site writings on depression and Prozac and posed an evocative question: "Was there any connection between using Prozac and an increase of violent behavior?" After acknowledging not knowing hard research data, the reason for the call surfaced. His brother was in jail facing a life sentence for murder. He stressed that his brother had a family, was an electrician making $60,000/year and was not particularly aggressive by nature. The brother had fairly recently started taking Prozac. Had the medication somehow transformed him from a civil Dr. Jekyll into a primitive Mr. Hyde? (Startled by the call, I don't recall the details of the murder.)

The caller did acknowledge a serious confounding – his brother had an ongoing alcohol problem. (And, of course, alcohol tends to break down our inhibitions and civilities.) He also raised the troubling issue posited in the previous section: according to the caller, a non-psychiatrist physician prescribed Prozac without doing a sufficient patient history, that is, the doctor never asked about the brother's alcohol intake. Alcohol and mood medication are contraindicated. And allegedly, there was no monitoring of side effects nor of the brother’s overall adjustment on the Prozac. (Not surprisingly, the defendant’s lawyer is looking into a malpractice suit against the doctor.)

The caller does not deny that his sibling is a culpable party; he just doesn’t feel sole responsibility should be shouldered by his brother. I do recall three other observations: a) the thought of taking on Eli Lilly, manufacturer and distributor of Prozac, with its inexhaustible funds, seemed overwhelming, b) the notion being perpetuated by drug companies that Prozac and its kind are wonder drugs with no side effects to be concerned about and c) that so many people, the respective families of both victim and perpetrator, have been devastatingly scarred for life.

Recommendations for Insuring Professional-Personal Responsibility

So is Prozac miraculous or murderous? Clearly, a key dynamic is the quality of the medical-professional context. Sound from unsafe practice is distinguished by the degree of accuracy of the diagnosis and careful selection and supervision of medication in conjunction with psychotherapeutic support. With this in mind, some strong recommendations for four key players in the life and death issues of depression and mood medication.

1. Physicians Heal Thy Ways. Clearly, my bias is that psychiatrists, psychopharmacologists and other allied mental health professionals trained in treating depression need to be actively involved in an ongoing intervention process. Non-psychiatric physicians need to confer if not actively refer to psychiatrists for diagnostic assessment and meds trials. Physicians not clear if mood medication is indicated but sensing psychosocial dysfunction need to use licensed social workers, psychologists, counselors and psychiatric nurses as allied resources.

And, of course, all physicians prescribing antidepressant medication must carefully supervise their patients during the startup phase of a medication trial. (Based on my clinical and anecdotal experience, some increased aggressive and manic-like behavior, for example, agitated talking or out of control shopping, is not so uncommon in the early phases of meds adjustment.) Close monitoring is critical, obviously, because depression is potentially a fatal disease. In addition, proper medication and dosage is still as much art as science. To find the optimal balance between symptom relief and side effects may take more than one trial.

2. Corporate Responsibility, Not Just Profitability. While the pharmaceuticals producing the various SSRIs are right to champion these wonder drugs, they also have a responsibility to stress the proper administration of the same. Would Lilly or Pfizer encourage more of the collaboration as outlined above? Or would these conglomerates see such psychiatric quality control as slowing down the distribution of their product and, thus, an "unnecessary expense?"

Pharmaceuticals are now advertising directly to lay consumers. How about some highly visible warning labels: "Alcohol and Antidepressants Are as Safe as Alcohol and Automobiles." Or, "Antidepressant Medication without Active Monitoring = Medical Malpractice."

3. Medical Association Advocacy. The American Medical Association and the American Psychiatric Association need to be institutional role models and change agents for prevention coordination between various disciplines and departments of medicine. Seminars, even mandatory training, Continuing Education Units or CEUs, etc. are required to ensure that non-psychiatrist physicians realize that prescribing new generation mood medication is not the same as prescribing a slightly higher than over the counter dosage of Ibuprofen. These associations and state medical licensing bodies must emphasize the criticality of the initial meds evaluation and supervision process. Hopefully, these institutions won’t wait until their members increasingly play a negligent role and get caught in a tangled if not tragic and, as we’ve seen, potentially deadly web.

4. Patients/Families Get Real and Involved. Finally, the consumers of medical service must take more responsibility for the quality of their care, or lack thereof. Obviously, not seeking help for an existing alcohol problem, along with a doctor’s inappropriately prescribing Prozac by not recognizing the dual diagnosis – alcoholism and depression – are possible contributing factors to the aforementioned murderous act. And even family members of the alcoholic and/or depressed patient have options to intervene by joining Al Anon or a hospital-sponsored depression support group. A family intervention -- a meeting with the abuser or depressed individual and concerned family and friends -- led by a trained mental health/substance abuse professional is one of the most effective ways of motivating a person in denial to seek treatment.

This is not the first time hearing about a possible murderous effect of SSRI mood medications. One of the larger pharmaceuticals will be facing a law suit from a family whose adult child is accused of murdering several people (by stabbing I believe). Once again, there’s a confounding: the family is attempting to discount the son’s or daughter’s cocaine habit and place the ultimate blame for the irrational act on the SSRI. (One can’t help but ask for some examples of people engaging in dangerously aggressive or violent behavior on SSRIs who are strictly tea lovers, that is, who are not abusing alcohol or other illegal substances. Seriously, I would be interested in anecdotal evidence linking Prozac et al. with violent behavior.)

A closing personal example illustrates the need for consumer awareness in light of managed care realities. A few months back, during my yearly checkup, I asked my Primary Care Physician about the rising cost of my Prozac prescription – from $5 to $25/month. He explained that Prozac was not the formulary; Zoloft was the reduced price drug. He gladly offered to write me a prescription for Zoloft. I could gradually go off the former and build up the latter. He stated, "They are basically the same." When I expressed concerns about adjustment, he said call him with any problem.

I declined the offer. First, because Prozac and I have had a successful five year partnership. (Who says I can’t sustain a long-term relationship or that I’m a commitment-phobe? ;-) And the second concern was based on my psychotherapy work with clients who had switched SSRIs -- from Prozac to Zoloft or Zoloft to Paxil, etc. -- because of disruptive or disconcerting side effects. There was often small but subtly important, if not significant, differences in side effects and symptom relief among these antidepressant medications. Without this first hand knowledge, I likely would have opted for the formulary drug money. But the key points: a non-psychiatric physician innocently claims more expertise in psychopharmacology than in fact he likely has. And he’s willing to have a patient start a new meds trial without a scheduled follow-up appointment. Alas, we reap what (and how) we prescribe!

Conclusion

While "Murder By Prozac" may yet replace "Trial By Prozac," and start capturing the headlines, more commonplace yet pernicious practices are abounding: a) people obtaining antidepressant medications through unregulated online pharmacies, b) patients getting prescriptions for antidepressant meds too casually from a variety of physicians without an appropriate psychiatric evaluation and c) patients not having careful medical monitoring of their meds trials.

Both patients' lives and the objective reputation of potentially life-enhancing to lifesaving medications are inextricably intertwined. If physicians, medical institutions, pharmaceutical corporations and patients don’t confront and advocate against the misuse and abuse of the medical-biochemical-psychotherapeutic treatment and marketing processes then all players are inviting tragic consequences and a groundswell of irrational and rational censure. This can only augur ill; backward steps into the "good vs. evil," biochemical vs. psychotherapeutic dark shadows from which our hard-earned understanding of depression has been valiantly struggling to emerge.

As former Surgeon General, Dr. Koop observed: "The most important prescription is knowledge." So to greater enlightenment in the New Millennium and, of course…Practice Safe Stress!

Reader's "Higher Power of Humor" Section

What Is Normal Size????????????? Bizzybuni@aol.com

(Eds. Note. Some New year's Inspiration. These two pieces -- alternately poignant, provocative and playful -- are from a good friend and colleague who helped start an online weight loss support group. Email her if you have questions.)

Normal size is being able to fit into a booth at a restaurant, a seat on the plane, buy clothes in the "regular" department instead of being sent to the department behind housewares, purchase clothing without an "X" on it, get your blood pressure taken with a "regular" size cuff instead of oversized, fit into a hammock without touching the ground, go to the gym - take a class - and not be the biggest one in the class including the guys, walk down the street without huffing and puffing, make love in all kinds of wonderful positions, feel sexy, be able to look in a mirror at your entire self instead of just the neck up, walk up a flight of stairs without thinking you're going to die, go dancing and dance the whole night, sit on a barstool size chair without worrying it will topple over, stop outweighing football players, buy bras at Victoria's Secret, (that's the secret), get pregnant without risking your life, put on a two-piece bathing suit, have a regular period, do without high blood pressure pills, hemmorids, allergies due to obesity, stop having heartburn or gas because of constant overeating, feeling more comfortable to socialize, see your toes without looking around your stomach, get your boobs off your waist, have your knees stop hurting because too much weight is on them, lessen the chance of uterine cancer, breast cancer, colon cancer, diabetes, heart attack or stroke, curb your arthritis because your joints are carrying too much weight, cure your constant depression, have a guy look at you and want you because you're attractive, crawl over people in a movie theatre to get to your seat without making everyone stand up, get a massage without being embarrassed, go to the hairdressers for a hair cut and have the robe around you fit, stop having your friends and family around you "wince" when they're with you, stop thinking a new haircut, makeup earrings or shoes will make us prettier as we fail to look at what's going on between our necks and our ankles, lessening the chance people will taunt you because of your size, go to the spa and have the robe and towels fit around you, stop abnormal sweating because your body can't carry the weight around, stop the daily obsession, stop kidding ourselves that all of this doesn't affect us, and most of all, being "normal size weight" means no matter what - we don't have to carry the shame around any more (no matter what people try to tell us about self-confidence, we still face shame). Now, I'll step off my soap box. Thank you very much............Chere ----------------------------------------------

Attention!!! Attention all Skinnyland passengers!!!! This is Henry, your ticket taker speaking to you over the PA system!!!! Now, I'd like all of you to check your bags.....if you do not have some of these items, please return home and get them and promptly come back to the airport. We leave on Wednesday....Now, be sure you have:

1. An eating plan......... 2. An exercise plan....... 3. Plenty of water..... 4. A reasonable expectation or better yet, none at all 5. A good attitude...... 6. A commitment to check your e-mail..... 7. A buddy you can commiserate with.... 8. An idea how you want to participate in your plan..... 9. Loose fitting exercise clothes....... 10. A reasonable goal.....one short-term and one long-term......

Be prepared to check all excess baggage! You will only be allowed two carry-on bags on the plane.....and two bags to check....so be sure you leave everything you don't need behind............Because this is a fat-free flight, you will have to go through the food-detector prior to boarding the plane, so make sure that all unnecessary food is either eaten or left behind in the bins behind you. If necessary, give it away to those folks at Gate 98 who are boarding for Fatsville. As you know, we're leaving late because of one passenger who insisted on hiding a sugar booster in the form of buttercream frosting causing a complete de-icing of the plane..... And remember, we are still looking for some flight attendants to volunteer for the flight......OK, that's it for now.................Over and out!!!!

Seek the Higher Power of Humor: May the Farce Be with You!

 (c) Mark Gorkin 1999 Shrink Rap™ Productions