The Liberating and Entangling Webs of Technology, Depression and Prozac by Mark Gorkin In the first of two essays the Stress Doc examines the potentially disruptive if not dangerous effects of a health care system casually prescribing and inadequately supervising the new, "clean" generation of antidepressant medications. Next, the Doc outlines how, with proper diagnosis and biochemical and psychotherapeutic intervention, Prozac, Zoloft et al. may fulfill their promise as "wonder drugs." Section 1. 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, the impact of these medications 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[TM]. (Published by AdviceZone.com in Spring 2000.)The sidebar, "Top Twelve Tips for Beating (Mostly) Moderate Chronic Clinical Depression," is the second essay 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...caveat 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 medications are contraindicated. And allegedly, there was no monitoring of side effects or 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 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 likely 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 lawsuit 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! Next Month Section 2 Mark Gorkin, LICSW, known as "The Stress Doc,"is the Internet's and America Online's "Online Psychohumorist" (TM). 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, 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 202-232-8662. Spring 2000, look for Practicing Safe Stress with the Stress Doc:Survival Skills from the Online Psychohumorist, published byAdviceZone.com.