The Stress Doc Letter
Cybernotes from the Online Psychohumorist (tm)
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``````````` Last edition, based on reader inquiry and with it being National Depression
Awarness Month, I shared the first half of a six-part series on my experience with
depression and medication. Here are the concluding essays. If you missed Part I, email me.
Recently, a number of reader inquiries have surfaced about the nature of clinical
depression and the effectiveness of medication. Not being a physician, I can't provide
general information in psychopharmacology. What I can share is my personal depression path
-- from long-term denial to more recent discovery and recovery.
Also, scroll past the essays to find information on my speaking and training schedule,
the library of articles on my award-winning website -- www.stressdoc.com <A
HREF="www.stressdoc.com">STRESSDOC HOMEPAGE</A> - and any fastbreaking
developments. And here's my AOL/Online Psych Page <A
HREF="aol://4344:972.doc.1264535.556723207">The Stress Doc @ Online Psych
</A> and special AOL/Workplace Series <A
HREF="aol://4344:972.docwork.1255066.562088752">The Stress Doc Interview @
Click on these links if you'd like free subscriptions to Humor From the Edge <A
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and/or to The Death and Dying Newsletter <A
HREF="http://www.death-dying.com/"> Welcome To Death & Dying...Where Life
Surroun...</A> (See, this newsletter will make you die laughing ;-)
Trial By Prozac
Well folks, after several steps out of the depression closet, we're into the
homesketch. As outlined previously, five years ago, an acutely depressing period of my
life - intense pressure as a Postal Service stress consultant, loss of a major consulting
contract, the sudden death of a beloved uncle - finally compelled me to face my chronic
low (and, occasionally, not so low) grade depression. Recently, I noted contributing
factors for my resistance to an antidepressant meds trial - from psychiatric family
history and misguided, neurotic false pride to fear of a psychotic reaction along with the
loss of my primal pain and passion.
The Prozac Plunge
In my mid-40s, I had hit bottom; I couldn't willpower my way out of the latest black
hole. Maybe a lifetime of creating and combating stress really does take a toll. I stopped
fighting my resident psychiatrist's recommendation. Of course, this was also a sign of
therapeutic progress. I was less defensive about the issues of depression and medication.
Anyway, with prescription in hand, I then nervously passed it to a pharmacist, carried
home the mysterious green and beige capsules...and popped my first 20mgs of Prozac.
(Prozac enables serotonin to linger longer between brain cells, improving the chemical's
efficacy. Serotonin plays a role in sleep, apetite, self-control, aggression and anxiety,
in addition to effecting mood states. Prozac and its clinical chemical cousins - Zoloft,
Paxil - have been likened to anti- inflammatories for emotional pain.)
Twenty milligrams is the basic starting clinical dosage. Typically, one is told that it
can take two or three weeks before the antidepressant effects kick in. Within a couple of
hours I knew I had ingested something unprecedented. Sort of like Alice's "eat
me" encounters while falling down the hole in her early, madcap adventures through
Wonderland. Things were getting "curiouser and curiouser." First, there was kind
of a buzz. Then, after a day or two, I realized I was not having such pronounced
sleepiness after eating. I had always attributed this to low blood sugar. Hmm, maybe there
was a serotonin-related chemical deficiency after all?
Within a week, a couple of dramatic symptoms appeared. I was recalling very vivid,
violent dreams. One involved stabbing a father-like figure. (My father, as many readers
know, has his own history of clinical depression.) Yet, I didn't feel malevolent or
enraged. More like a psychic part needed to be killed off for me to explore fully new
possibilities and paths. As the artistic genius Pablo Picasso observed: "Every act of
creation is first of all an act of destruction."
Then, a couple of weeks later, on my yearly retreat to see the Fall colors in the
mountains of West Virginia, I had a momentary scare. My thoughts were flyng. I was
probably a bit hypomanic. In fact, a friend had commented around this time that he thought
I was more aggressive than usual. I knew I was feeling a bit more energetic. What was his
problem? Why was he uncomfortable with my more animated, dynamic self?
Fortunately, my retreat was in a remote bed and breakfast known for its mountain view
and clean, crisp air. Gum drop trees on sloping sides as far as the eye could see. Out my
window, ducks paddling in a babbling stream. Sheep enclosed in a pasture. A quaint wooden
bridge connecting the rooms to the smoke curling out of the chimney Beekeeper Inn. The
enclave in Helvetia certainly lived up to its mountain moniker -- "Little
Switzerland." Being embraced by this pastoral panorama, I realized racing thoughts
were likely jump started by the Prozac. I reassured myself that this was a mind-body
system adaptation to a biochemical changing of the guard. My little alpine- like
eco-cradle gently rocked away the mania while nurturing my newfound energy.
Lasting Side Effects Trinity
However, there were some ongoing side effects. Let me itemize:
1. Sleep. Many people when depressed have difficulty getting up in the morning.
Sometimes this is due to staying up late at night or an inability to sleep through the
night. (Do you know all the best buys at 3am on the QVC home shopping channel?) But for
someone like myself, with a long-standing "agitated depression," getting up in
the morning wasn't the problem. I would get up at six or seven am and be at my desk
writing two minutes later. I never understood why people needed coffee as a catalyst. Of
course, anxiety- propelled fuel would burn off pretty fast and I might feel sleepy or
exhausted before the morning was out. (Who would have imagined that this was an aspect of
a depressive cycle? I just thought the shutdown was a brainstrain by- product of creative
"sturm und drang" or aerobic brainstorming. Ah, once a narcissist...)
With the Prozac, however, my sleep cycle was turned upside down. No longer was I
sleeping through the night. I was waking, though just one time, usually in a REM cycle. So
that was a positive - greater access to my dreams. And getting back to sleep was pretty
effortless. I could live with these developments.
However, the most disorienting and disturbing change in sleep pattern was actually
related to my waking pattern. For the first time in years, I was having difficulty getting
up in the morning. Of course, I could recall years where high anxiety about school - from
grade school to grad school - had me cowering under the covers. Now it seemed I was doing
an Alfred E. Neuman, "what me worry" imitation: the Prozac had me feeling less
agitated and obsessed; I lingered in bed enveloped in a drowsy, languid,
"manana" haze. But once the haze lifted, I hated the fact that I was no longer
hitting the floor running. My Type A New Yorker survival instincts were being chemically
manipulated and suppressed. There was less depression but new frustration. This effect
could not just be pushed to the side.
2. Sex. It's true. Prozac does diminish one's libido. Even occasional masturbation was
losing it's attraction. However, this phenomenon evoked a meaningful insight. For years, I
had been compulsively engaged in aerobic exercise (for the endorphins), high risk-takig
career pursuits - the mass media, public speaking, violence prevention (for the adrenalin)
and the romantic chase and sexual fantasy (for the testosterone and dopamine). Shoot...if
I was working this hard to alter my body chemistry, was I unconsciously trying to
self-medicate? Maybe there was a message: perhaps I was starting with (or had evolved) an
abnormally low resting hormonal level, at least as it effected my mood state.
Returning to sex, I must say, even with medication, when engaged in the real thing,
everything was just fine, thank you. (If Viagra, the new male potency drug, had been
around back then, I wouldn't have been a candidate.) In fact, I remember saying to a
partner in regard to my anatomical functioning: "Stronger than Prozac!" And
while ejaculation time was a bit delayed during my 20mg phase, I don't recall any
I can't resist one final musing. What about a scenario where Prozac and Viagra, are on
the same playing field, as it were? Is this a case of an "immovable object" vs.
the "irrisistible urge," I mean "force." Or, is it an
"irrisistible object"? That male ego never rests! And will a reluctant, yet
opportunistic, spouse demand a pharmaceutical quid pro quo: "I'll let you take Viagra
if you finally get on the Prozac"?
3. Chocolate. Believe it or not, upon taking Prozac for the first time, I found myself
salivating over real chocolate. Previously, I was clueless regarding the existence of
"chocoholics" or why people would mail greeting cards, "Things are
desperate. Send chocolate." Though I had experienced faux chococolate cravings. About
a dozen years earlier, a girlfriend created a surprise birthday confection. She made white
chocolate truffles, with almond liqueur and bits of maraschino cherry....Wow! Turned on by
the impostor and not the real thing...I should have known my biochemistry was all screwed
In summary, while Prozac startup had it's challenging moments, anything that has some
liberating effects upon sleeping, sex and chocolate eating patterns can't be all bad. In
fact, it can be pretty miraculous. Nonetheless, the right chemical, psychological and
social balance may still need to be discovered. And next time, I will conclude with
personal and professional insights gleaned from my supervised, yet adventurous,
experimentation regarding the appropriate dosage, use and value of antidepressant
medication. Until then, of course...Practice Safe Stress!
The Prozac Paradigm Shift
In the last depression series column, I surveyed some startup side effects of my trial
on Prozac - from short-lived violently liberating dreams and manic moments to ongoing
effects related to sleeping, sex and chocolate eating patterns. The Prozac, by increasing
the shelf-life and functionality of that brain chemistry catalyst, serotonin, was sparking
a rejuvenation. The changes were provocative and mind opening. And then, at the three
month mark, I had a revelation.
The Crying Scene
The revelation occurred in a movie theatre watching, "Uncle Vanya On 42nd
Street," a film about the making and performing of the angst-ridden Checkov play. In
a closing soliloquy, one of the main characters, a young woman and daughter of the family,
makes an impassioned plea about the painful nature of life, loss and love. Intently
listening to the monologue, a profound awareness suddenly strikes: I'm not crying. I
always get tearful during poignant movie scenes...and this one is just about off the
Emotional Richter Scale! I'm moved, just not watery-eyed. How is this possible?
Let me place my capacity for copious tears in context. I have always been "the
sensitive one" in my family. At clan gatherings, while others were dry- eyed
listening to the trials and tribulations of immigrant relatives and the first generation,
my cheeks were invariably tear-stained from softly sobbing. And not just in my family. For
example, as a young adolescent my sensitivity and lack of integrity - meaning
significantly underdeveloped self-awareness, self-affirmation and assertive interpersonal
skills - made me an easy target. Attacking a wounded psyche was blood sport for piranha
peers. As I once penned in "The Poetic Scream":
The vacuum shrieks, the hours weeks The wail of solitaire. A wall leaks, piranha beaks
Affixed the meat of prayer.
The last line is a metaphor for desperate, mind numbing, adolescent masturbation.
Surely, overt and underlying issues of abandonment and rejection, raw fear and learned
helplessness absolutely reverberated in my psyche and soul...or so I thought.
Clearly, various stressors and traumas of childhood primed my sensitivity well. But my
capacity for emotional discrimination that night at the movies - being moved, not flooded
- could only mean one thing: the Prozac was impacting the deepest parts of my primal pool
of pain. Some of my sensitivity went beyond "personality" and family history and
surely sprung from my current biochemistry and, perhaps, a long-standing predisposition
Coming Clean, Getting Current
Five years ago, with the help of my resident psychiatrist and a friend who was already
taking Prozac, acknowledging my clinical depression and need for medication had finally
been possible...and a true relief. In addition to increased energy, now I could more
objectively survey and review jarring and eroding life experiences and memories without
feeling like such a wimp or a failure. There was a definite genetic and biochemical
component; my depressive adaptation was not simply a by-product of an intractably
deficient moral character and motivational nature. Ultimately, I was still personally
responsible for my life choices but, fortunately, not existentially culpable for my genes.
Especially when the depressive condition is not so blatant or when a pathological
process is slow building, it's hard to know what is normal. (Though with hindsight, the
psychological eruptions and tremors seem hard to miss. Denial can range wide as well as
run silent and deep.) Gradually, one begins to perceive and respond to life through a
depressive lens and dark filter. Sort of like wearing sunglasses all the time, indoors or
out, rain or shine. The depressed person can lose much of life's color and shading -
things are either black or gray. Equally sad, outer shades and inner shadows block access
to the windows of a melancholy soul.
Of course, a person laboring under a clinical depression rarely wants to get genuinely
close to others. He or she anticipates with dread (though sometimes, alas, with relief)
the possibility of being fatally swallowed in one's own emotional abyss. Then, again,
depending on the depth of despair and dysfunction, the depressive may want to cling for
sheer survival. Or he may need others for distraction if not as an addiction.
Not surprisingly, the chronic low grade depressive, having constructed a lifetime of
adaptation processes and compensations, some of which are "functional" if not
successful, finds letting go of and recalibrating one's coping patterns profoundly
disorienting. And it's not just in the person's head. The scenario is not unlike an
individual who has gradually and steadily lost his eyesight or has only limited tunnel
vision. And then, with successful surgery, he or she finds comprehensive sight and the
adjustment to this new perspective and forgotten world, initially disturbing. With
repetition, over time, our convincing take on "reality" is colored by
psychophysiological blindness, fearful tunnels and/or by those ever present,
indiscriminately shaded, if not jaded, sunglasses. The current challenge: how to unlearn
depressive, repressive and habitual perceptions and belief systems; how to modify and
transform self-defeating styles of thinking, feeling and reacting?
Reflecting and Reframing
Shortly after the three month revelation, my mind spun off vivid analogies illustrating
the burden and danger of chronic depression and why Prozac was a necessary, though not a
sufficient step, in recovery. (Maybe I should carry around a flashing yellow sign:
Paradigm Shift in the Making -- Approach with Caution.) Anyway...One analogy involves the
absence of a negative, the other the addition of a positive.
First, low grade (and not so low grade) depression is like having to run constantly
both short races and marathons with a heavy weight around your ankles. Granted, you've got
pretty impressive thigh muscles and a high capacity for empathy - you feel others' pain -
but it's damn demoralizing and exhausting so often feeling shackled and empty. A
constricted life is rarely a confident life or a life of emotional freedom and
exploration. Why shouldn't you be able to run full speed for a change?
The next analogy requires imagining yourself as an automobile with a slow leak in your
oil casing. You're also leaking power steering fluid. You can still drive yourself around
but, slowly, inexorably these compromised conditions will take a toll on the engine,
transmission and other operating systems. And the longer you put off fixing the leaks and
getting a full complement of oil and other vital fluids, the greater the likelihood of
secondary damage, major breakdown and lengthy, expensive repair. Why shouldn't you be able
to cruise around fully serviced?
Over forty years of challenging life stress was wearing down my psycho- biochemical
apparatus, especially with some of it's built in genetic vulnerability. Therapy had
enabled me to carry on, sometimes quite productively, but always straining mightily to do
so. With therapy and Prozac there was hope that I was out of the depression closet for
good. And in the next series column, I'll examine sharing my startup experience with a
family member, ongoing adaptations and experimentations with the medication and how I
began using my hard-earned wisdom with clients. Until then, of course...Practice Safe
In his closing segment, the Stress Doc steps outside and locks the door on his
depression closet. From sharing his Prozac trial with a family member to stabilizing on a
low dosage, the Doc documents why this has been, and continues to be, a life-changing,
affirming and ongoing experiment.
Out of the Depression Closet
In the last installment of this depression series, I shared a revelation experience:
after three months, I realized the Prozac was having a dramatic impact on my depression
and, even, my deep-seated sensitivity. I also likened the medication's effects to a runner
being freed of shackles or a car finally getting its full complement of oil and power
steering fluid after being chronically low. My concrete example: while touched
emotionally, on Prozac, tears did not automatically flow during a poignant movie scene.
Feeling better, I decided that Prozac had passed its three month probation period. Of
course, I didn't expect to take the stuff that long. My psychiatrist had suggested a six
to nine month trial before doing a thumb up or down on continuation. Ha! This Type A New
Yorker wanted proof of results in four to six weeks. Lasting three months on meds was not
just a clinical victory, but a triumph over cultural neurosis as well.
Confronting the Intimate FOE: Fear of Exposure
Flush with new found confidence and conviction in the experiment, I approached my
younger brother (by five years, and only sibling). The family's tradition of secretiveness
and shame around mental illness and my brother Larry's aversion to psychotherapy, despite
being trained as a clinical psychologist, evoked some anticipation anxiety. But Larry was
cool and basically understanding. A sometimes cutting or cover-up humor, especially when
feeling uncomfortable, only poked through one time: he wanted reassurance that I wasn't
going to be one of those, "Jews for Prozac." As much as it pains to admit it,
that was a funny line. I did a counterpunchline, though. I reassured him that I would not
proselytize Prozac over caffeine (his drug of choice).
Most important, being open with Larry helped reaffirm my identity as an individual who
has struggled long and hard with chronic, if not major, depression. That despite my
extensive training, personal therapy, my own practice, etc., even I had closed my mind to
many of the subtly powerful and pervasive dynamics of depression. And now, finally, I had
evolved a readiness to explore technological advances for treatment and recovery, to
complement years of traditional psychotherapy.
A Piece of the Prozac Puzzle
While progress was clear, a frustrating side effect remained: emerging from a hazy,
drowsy state was a daily morning chore. This was especially unnerving as pre-Prozac, two
minutes after awakening, I would hit the desk writing...without coffee! When still having
trouble awakening during a relaxing vacation, and exhaustion wasn't the issue, the culprit
became transparent -- overmedication. And so did the pass in the impasse. My psychiatrist
gave me the green light to halve the Prozac dosage. And within a couple of weeks, again,
the difference was noticeable. I still was not jumping out of bed and becoming superwriter
in response to anxious inner voices. However, now there was a dialogue about rising
instead of a stuporously mellow state.
Lately, I've instituted a little game to ease the transition from bed to writing desk.
I allow myself to read morning email for thirty minutes. Concentrating, first thing, on an
early easy task has become my rising sun. It burns away early haze or fog.
And nine months later I reduced the prozac dosage to 3 mgs/twice a day, taken at
breakfast and dinner. And with each decrease of dosage, getting up was easier, and not
just in the morning. My libido was also getting stronger!
At this point, the obvious question: why haven't I tried going off the Prozac? Here are
some of my thoughts:
1) I feel like my healthiest, strongest self these days, and like the feeling. 2) Have
heard too many stories of people eventually relapsing after stopping their antidepressant
meds. (Though some are making a successful transition from the newer generation of
antidepressants - Prozac, Zoloft, etc. - to St. Johns Wort, the natural herb which also
impacts serotonin efficacy. I still would talk to a doctor, preferably a psychiatrist,
about such a switch.) 3) Don't feel ashamed or less of a person taking my medications.
Prozac is not a crutch. If anything, it allows me to throw away the compulsive crutches
that I'd been using to compensate for depression - such as compulsive exercising and
codependent romantasizing. I'm finally breaking out of the biochemical and behavioral
shackles with which I've struggled for so many years. 4) There's a better balance between
energy and focus (without the pronounced or prolonged swings of moodiness and agitation)
while having access to my current emotions and past pain. I can still be a bit manic as an
extroverted performer and obsessed as a introverted writer. But now, the recovery time
from my psychophysiological peaks and valleys is much more manageable. There's a greater
likelihood I will live and return to tell the tale. 5) And finally, and most important, an
artist friend who knew me in my early days as a "Shrink Rapper" observed that
my, "rap singing (okay, I concede, it's an oxymoron) on the Prozac has never been
So I'm on medication for the long haul. Actually, I have come up with another
rationalizing reframe. With a 3 mgs/twice a day regimen, I'm not so much taking
antidepressant medication as a "Serotonin Supplement." (Isn't a mind a terrible
thing to waste?)
So this has been my story out of the depression closet. Some talk about the trinity of
mind-body-spirit. For me, I'll flesh out my m-b-s revelation: the
Prozac-Psychotherapy-Passion Connection. And as always...Practice Safe Stress!
(c) Mark Gorkin 1998 Shrink Rap Productions
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Mark Gorkin, "The Stress Doc," Licensed Clinical Social Worker, is a
nationally recognized speaker, workshop leader and author on stress, reorganizational
change, anger, team building, creativity and humor. He is also the internet's and the
nation's leading "Psychohumorist." The Stress Doc is a columnist for the popular
cyber-newsletter, Humor From The Edge . Mark is also the "Online Psychohumorist"
for the major AOL mental health resource network, Online Psych and Financial Services
Journal Online -- http://fsc.fsonline.com/fsj . And he is an offline writer for two mental
health/substance abuse publications -- Treatment Today and Paradigm Magazine. His motto:
Have Stress? Will Travel: A Smart Mouth for Hire! Reach "The Doc" at (202)
232-8662, email: Stress Doc@aol.com, or check out his "Hot Site" website:
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Site" and designated a four-star, top-rated site by Mental Health Net.)
(c) Mark Gorkin 1998 Shrink Rap Productions