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The Stress Doc Letter
Cybernotes from the Online Psychohumorist ™

January 2000, No. 1

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.  After an intervention, the next best thing would be to sign the patient up for North Carolina treatment programs (Footnote 1; see page bottom) or something similar in their specific states or cities

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!

Summarizing key issues raised in the popular series on depression and his own meds trial, the Stress Doc provides a glimpse into the future: a sidebar from the forthcoming book, Practice Safe Stress with the Stress Doc, published by AdviceZone.com.

Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression

1. Recognize the Reality of Depression. Your depressed phase has lasted too long, with too many disruptive or intense symptoms - erratic sleep and eating patterns, frequently on the verge of tears, chronic procrastination and difficulty completing projects. You "just want to disappear" (as a client recently expressed), and there's a generalized loss of interest, pessimism, distrust and disorganization. The problem is likely more than just extended grieving or having "a sad personality," as one therapist told her client. The client had asked for a second opinion when, despite nine months of therapy, good insight and vigorous daily exercise she still felt on the verge of exhaustion. This woman still had to strain continuously to just keep up.

2. Begin to Let Go. Normal ways of coping won’t work in this existentially and biochemically troubling period. You're not just grappling with depressive symptomatology, but also likely struggling with denial and shame; one must admit that will power is not sufficient. This can be particularly confusing with moderate chronic depression. In the past you were able to get yourself out of your depressive box or cave. Alas, as we age, ongoing stress can impair the effectiveness of our biochemical and hormonal systems. In fact, just using will power, thrashing about to break the depressive bonds will probably exhaust you further. You feel trapped in that black hole or have a heightened sense of whirlpooling madness.

3. Acknowledge Shame and Ignorance. Too many people associate depression with cocooning under covers for hours on end or covering up through various addictive tendencies – compulsive eating, drinking and sexing, TV watching, video game playing, out of control shopping, etc. And, in fact, these may be accurate warning signs. However, many Type A achievers also struggle with depression. (Don't let resume size blind you to the possibility of depression.) For such hard-driving folks, shame and inaccurate information often impede getting the needed psychological and medical help. Especially if there's family history of mental illness or mood disorders, acknowledging that one hasn't fully escaped a genetic legacy can be a difficult step. And if you were or are the family standard bearer, the one who exemplifies "improvement in the generations," then giving in to depression becomes a sign of failure, of letting others down.

4. Beware Drug Reaction. Despite the widespread use of SSRIs, many are still resistant to exploring the use of antidepressant medication. These include individuals who: a) erroneously see medication as a crutch or as a means of simply numbing or masking emotions, b) had a troubling trial with the older generation of antidepressant meds – tricyclics or MAO Inhibitors, c) had an unsuccessful brief trial with an SSRI, including troubling side effects and don’t understand that a meds trial is as much art as science; for some Zoloft works better than Prozac or Wellbutrin may interact differently than Serazone with other prescription drugs and d) have psychological if not medical scars from previous drug or alcohol history; folks with family members who've struggled with substance abuse also may be guarded.

Warning: If you are using alcohol in anything but very strict moderation, taking antidepressant medication is inviting trouble. In fact, alcohol is contraindicated. And remember, alcohol is a depressant drug.

5. Admit Dread of Losing Your Edge. For individuals with an agitated depression as well as cyclothymic (a cycle of mood swinging) or bipolar tendencies with pronounced highs and lows, especially where the agitation-mania fuels productive efforts or creative outbursts, there may be understandable resistance to a meds trial. There is a natural fear that ones existential and emotional range, post-Prozac, will extend from the mediocre to the tapioca, that is the blandly normal. While there is an adjustment period, with the proper medication and dosage, over time my bias supports the likelihood of more energy being freed for creative endeavor. Performance may take on a somewhat different hue, but will still have your distinctive quality. (Email stressdoc@aol.com for a provocative, counter-intuitive essay on "Van Gogh, Prozac and Creativity.")

6. Find a Psychiatrist. A common medical mistake, if not a professional abuse, is the numbers of GPs, internists, gynecologists, etc. who prescribe antidepressant medication for patients without psychotherapeutic follow-up and sufficient monitoring of side effects. The professionals best trained in the realm of mood medicine are medical doctors with degrees in psychiatry and psychopharmacology. Alas, even consulting with the latter specialists does not guarantee proper meds dosage or regular supervision. The medical field is still in the learning curve stages of understanding the bio-psycho-social dynamics for overcoming mood and mental disturbance. As mentioned, finding the right medication is as much art as science and must take into account individual difference.

7. Integrate Psychotherapy. Upon completion of a proper diagnostic and medication evaluation and the start of a supervised meds trial, if you can’t afford to see a psychiatrist on an ongoing basis, search for a mental health professional experienced in the depression field. For chronic depression, look for a therapist who is open to exploring the best biochemical and psychotherapeutic intervention mix as opposed to a clinician whose bias pits one approach against the other. The problem isn’t just hair-trigger prescriptions. Too many therapists still misdiagnose clinical depression as "deep sadness" which can be overcome by "intensive working through."

8. Assess Initial Symptomatology. Conventional medical wisdom says it often takes from two to six weeks for the therapeutic effects of antidepressant medication to kick in. If you are so predisposed, that is, you react sensitively to medication, be prepared to notice a mind-body difference in two-six hours. This is an "N of 1" experiment and you are the star subject. Early side effects may include sleep disturbance – restlessness or a slothful lying in bed, vivid dreams, having more energy, including aggressive energy and phases of hypomania (a rash of impulse shopping, for example) and diminished sex drive. Your mind-body system is adjusting to a biochemical sea change. As you adapt to the meds and your depressed mood begins to lift, these symptoms may diminish or your tolerance for them may increase. (Hey, with Prozac I had some unprecedented and not totally undesirable side effects: I started grooving on chocolate and my mildly diminished libido -- slowed ejaculation time yet without impeding erectile functioning -- certainly drew no complaints from the ladies. ;-)

Sometimes side effects may be double-edged, e.g., some restlessness during sleep opened wider the window to my dreams. Or even the drowsy morning haze (once meds dosage was properly adjusted) became more a maze for mentally meandering through dawning levels of consciousness.

Clearly, if the symptoms feel troublesome or confusing, do not suffer in silence; you don’t have to tough it out. Call your therapist and psychiatrist for a medication consultation.

9. Assemble the Cumulative Evidence. In two-three months, with effective medication and psychotherapy there should be noticeable improvement: more energy, better eating and sleeping patterns, sharper mental focus, crawling out from the barrel bottom, the return of laughter and a less generalized sense of emptiness and teariness. In fact, the lack of reflexive crying, despite feeling empathy at a traditional tear-jerker movie scene at the three month meds trial mark opened my mind to the correlation between biochemistry, overt emotionality and my inherent "sensitive nature." I could now be moved without necessarily being flooded.

Much past and present jarring life experiences and behavior patterns are open to reexamination and reinterpretation. From chronic procrastination and profound shyness to impulsive or addictive tendencies ("recreational" drug use as self-medication, for example), all may be influenced by a mood disorder or be depressive adaptations. Your existence and essence was and is not simply a byproduct of an intrinsically or intractably deficient moral character and demotivated nature.

10. Use Self-Accepting Analogies and Self-Energizing Rituals. An important part of integrating the depressive experience and being able to share it with others is having accessible and vivid analogies and illustrative examples at your command. For example, the feeling that one has been running with an invisible 30-pound weight tied to ones ankle. Another way of framing the problem: imagine yourself as a car that's slowly leaking oil and power steering fluid. You're a quart low on oil. Can you still get around? Sure, but increasingly, as the miles mount, there will be wear and tear on the engine, transmission, steering, etc. If you don't plug the leak, major damage lies ahead!

Also, integrate new rituals to aid your depression recovery-meds adjustment process. If a slow starter, try some morning exercise. Personally, thirty minutes of answering email after rolling (or crawling) out of bed is like a warm-up for the creative writing looming ahead. If self-employed, for example, find a coffeehouse that gets you out of the computer cave and that allows for work and some socializing. Learn to take a rejuvenating post-lunch or dinner, 10-20 minute nap. (And now you realize the effects of depression, not just "low blood sugar," may make this a necessity, not just a luxury.)

11. Confront Approach-Avoidance Conflict and Impatience. While mood uplift and enhanced role performance is likely to seem remarkable, the challenge now is not to shortchange longer-term growth for newfound chemical balance. In other words, there's a lifetime of depressive ways of perceiving, interpreting, relating, reacting and defending that need to be acknowledged. Old assumptions will be put to the test. Much unfreezing and new learning must occur for ongoing mind-body and interpersonal maturation. At the same time, all childhood emotional or perceptual sensitivities and sensibilities need not be thrown out with the darkened depressive waters. This process may be scary, though. Long-term survival (albeit, self-defeating) coping patterns must be gradually dismantled. Untreated depression is like being stuck with a 486 computer when the world keeps changing at a dizzying pace. You cant or, more likely, are afraid of or feel overwhelmed by upgrading.

The other concern, of course, is impatience, when your mood state and energy levels aren't improving fast enough. Again, proper supervision for medication and commitment to ongoing therapy strongly increase the chances of building over time a solid foundation for recovery. Medication is not a crutch. Neither are depression support groups, men’s or women’s groups, 12-step groups, etc. The latter are normative resting, retreating and refueling stations on the challenging journey of life.

12. Is It Forever Prozac? How long do you stay on Prozac or its chemical cousins? I'm not sure there is a definitive answer. Each meds trial is as distinct as the patient's genetic and life cycle history, along with current resources, sense of affiliations and accomplishments, strength of self-identity and future possibilities. Careful supervised experimentation is the password. Biochemical and emotional stability along with positive functioning over time, yet still accompanied by some moderately disconcerting side effects, may signal a window for trying a new antidepressant medication or for reducing your current dosage. Regarding the latter, with strengthened attitude and activity levels, less medication (thereby further attenuating side effects) without diminishing therapeutic benefits is possible.

Some may choose to be meds free. I recall a woman artist in her 40's, after a successful meds trial, announcing in a bar: "Prozac for the house!" Yet she decided to stop taking Prozac upon basically overcoming her dark period. She didn't mind feeling "a little blue on Sundays." Though I've encountered more people who regretted or had second thoughts about stopping their meds trial.

The combination of biochemical intervention and psychosocial maturation seems to make some lasting repairs in neurotransmitter functioning. While long-term research results for the SSRI meds family and its offspring are still in transit, until there's contrary scientific evidence, I'm taking that "serotonin supplement" (10mgs/day). This regimen is part of my natural path, one still filled with passion and pain. And it's a path for recovery, resiliency and rejuvenation. Amen!

Mark Gorkin, LICSW, known as "The Stress Doc," is the Internet's and America Online's "Online Psychohumorist"™. An experienced psychotherapist, The Doc is a nationally recognized speaker and training and OD consultant specializing in Stress, Anger Management, Reorganizational Change, Team Building and HUMOR! His writings are syndicated by iSyndicate.com and appear in a wide variety of online and offline forums and publications, including AOL's Online Psych and Business Know How, WorkforceOnline, Mental Health Net, Financial Services Journal Online, Paradigm Magazine and Counseling Today. Check out his USA Today Online "Hotsite" Website -- www.stressdoc.com . For info on his workshops or for his free newsletter, email stressdoc@aol.com or call 301-875-2567. Spring 2000, look for Practice Safe Stress with The Stress Doc™, published by AdviceZone.com.

(c) Mark Gorkin 1999 Shrink Rap™ Productions

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Footnotes

1.  North Carolina Drug Abuse Treatment Programs: Coalition against Drug Abuse