Depression: Out of the Blue
When Eli Lilly & Co. introduced Prozac in the late '80s, antidepressants became part of our pop culture. Now movie characters refer to Prozac. Greeting cards make light of our affection for it. But for those who've been to the depths of darkness, who've felt their voices thin to a sad whisper and for whom suicide has become a real, seemingly rational option, depression is no joke. It's as real as utter despair can be, complete with total, hopeless misery.Major depression is the single most widespread mental disorder, according to the National Comorbidity Survey, affecting 10.3 percent of Americans annually. For them, a new group of antidepressants -- particularly Prozac, Paxil and Zoloft -- are a hopeful Holy Grail. By elevating serotonin levels in the brain, SSRIs (selective serotonin reuptake inhibitors) transform one's mood from blue to neutral, making life worth living for many. "How lucky I am to live in these times when there's a little blue pill I can take to feel better," says one investment banker who's been there. Now, five years into a major antidepressant prescription boom, some patients are feeling better and want to quit forking over an average of $60 per month for drugs. Some come off without a hitch. Others wrestle with a nightmare.Go on Prozac for a while, your mental health profession told you. You'll train your brain to make that chemical connection. You'll go off Prozac and live happily ever after. But it may not be that easy. How do you know you're ready to come off? Or if you should go back on?The key to going off is close physician supervision, doctors say. But, determining the wellness of a patient who's been on antidepressants may be difficult. As Dr. Lawrence Gernon, a Richmond internist, says, "There is no test to quantitate serotonin levels." All the information in the world from clinical trials and drug companies still won't give complete definition to a drug's impact on the human body, much less the many varieties of human bodies, each with their own chemistry set. "That's what makes it an art," says Gernon of the practice of medicine. So, once over the stigma of going on medication, once spirits are lifted and thoughts of suicide are forgotten, then what? Definitive answers are hard to come by. Different physicians say conflicting things. One might say that depression is like diabetes; once on Prozac, always on. Another might tell a patient it's OK to terminate medication cold turkey. Confusion and conflicting information abounds regarding the half-life (lasting effect) of antidepressants, side effects and dosage. Frustrated with the lack of hard facts and with conflicting information, some patients turn to each other via the Internet. They share their experiences and questions and search for empathy and answers through newsgroup postings.Meanwhile, researchers continue to study the effects of long-term use of antidepressants and the nuances of their impact on our lives, as we begin taking them and as we discontinue. The shocking is like hitting the funny bone except it is felt throughout the body -- like a whole body reflex brought on by a doctor tapping your knee. Only here someone taps your head and you feel it in the soles of your feet. The way that I described it to people around me was "Blender Head" -- as if my head was a blender that was suddenly turned on high speed for 30 seconds or so. I found a very unpleasant sensation -- one of being in a runaway elevator, a slight fever and being disconnnected from my peripheral senses. Whenever I try to get off Paxil I feel like my brains are being scrambled. Does anyone have any suggestions? Has anyone gotten off and still felt good? -- Excerpts from Internet newsgroup sci.med.pharmacy, Zoloft withdrawal threadA mother in her late 30s, Helen* was having trouble with intense anger, anxiety and depression. "I went to my doctor in tears," Helen says. "He said `you need to be medicated.'" He referred her to another doctor who recommended an antidepressant. Helen resisted because of the horror stories about people on Prozac doing crazy things. "I said, `I don't like what I've heard, and I don't want to do it.'" Her husband agreed. He felt that if she just learned life skills to cope with her problems then medication would not be needed, "but I just couldn't do it," she says. Taking the dose her doctor prescribed, 20 milligrams of Paxil daily, Helen says, "immediately I felt a difference. But as it progressed I felt sicker and sicker. I went back to my doctor and told him that I was nauseous and dizzy. It was like being bombed -- I had the spins." Her doctor lowered the dose to 10 mg. and, Helen says, "it was perfect. It changed my life. I could deal; I was calm."Trouble started again for Helen when she experienced a pregnancy scare. She called her obstetrician to ask what to do about the Paxil and he told her to go off -- cold turkey. Here's what happened in the days that followed: Day 1: she felt OK, Day 2: felt dizzy by the end of the day, Day 3: ill, nauseous, weepy, symptoms slightly alleviated by alcohol. A friend recommended Helen take half a pill and taper off from there.Still uncertain about being on the drug at all, even in smaller doses, she called her psychiatrist's office and the on-call doctor assured her it was safe to taper, even in a possibly pregnant condition. "I took half a pill every other day for a week," she says, still wondering if she was pregnant and, if so, what Paxil in her system might be doing to her baby. Torn between the psychiatrist recommending a tapering and an OB saying to get off immediately, she ultimately followed her OB's orders. "It's frightening when you think about what doctors don't know about these drugs, especially being at a childbearing age."Two months later, not pregnant and back at square one with her anxiety and depression, Helen tried another antidepressant, Luvox, which was ineffective. Now she's off all medication and feeling OK, she says.Depression and obsessive thought patterns were a way of life for 19-year-old Kim. She'd endured a youth of fragmented family and fearful events that kept her turned inward. When she sought counseling, antidepressants were recommended. "The depression, the obsessive thinking -- everything turned around," she says. "I had more energy and I felt smarter, had more self-confidence. It gave me a jump-start so I could actually function. I was on Zoloft for slightly less than a year and then my insurance ran out and I went off."The effects of Zoloft did not last, Kim says. "I was told that my body would produce more of whatever, but it's definitely not true. It did seem to last a couple of months." While on Zoloft, she followed doctor's orders and abstained from alcohol, but when she went off she figured it was OK to celebrate her birthday with a beer or two. "I guess I should have realized that alcohol is a depressant. It counteracted all that Zoloft did."Off of antidepressants since spring of '95, Kim says she's wondering about going back on as the obsessive thought patterns are creeping back into her behavior.The good news is that 80 to 90 percent of depression cases can be effectively treated, says Dr.Susan G. Kornstein, assistant professor of psychiatry and obstetrics/gynecology at MCV and clinical assistant professor of psychology at VCU. "I know for a fact that this drug saved my life," says Eleanor P., a Richmond lawyer who became depressed after the birth of her first child. "I had hit bottom and felt hopeless. The change was dramatic." In fact, millions of people have, through antidepressants, found a new life of feeling "normal" and productive. And that helps us all: Depression costs us $43 billion a year as it affects work performance and family life.So how long should patients be on antidepressants? "That question has not yet been clearly answered," says Kornstein. But increasingly, Kornstein says, psychiatrists are keeping patients on antidepressants longer. "We are doing research on it now. Clinically, the way I treat it is if the patient has been symptom-free for six to 12 months, we try to discontinue. I taper them off it slowly and carefully and I monitor them. Many do fine. If there's a relapse, we re-start. If a patient is tapered off correctly, there are usually not any withdrawal complications."Physicians say that withdrawal trouble often arises when patients try to take themselves off the medication too quickly without supervision. Regarding the shock symptoms some patients describe, Kornstein says, "I can vouch for what you're saying. I've had several patients describe electrical sensations and whooshing sounds in the ears, particularly with a rapid tapering off. But generally they subside within days to weeks."Kornstein says that six months on antidepressants may not be enough for some patients; it could be that two years is appropriate for some. "It may take a certain duration of treatment," she explains, "in order to re-set the neurotransmitters at their proper levels. Many will have a recurrence. You always have a vulnerability to become depressed again. More and more we're learning that depression is often a chronic or recurrent illness. It used to be said that 50 percent [of depression cases] recurred, but it's now thought to be as high as 70 percent." Like people with high blood pressure or diabetes who require lifelong drug maintenance, Kornstein says, "For especially chronic or recurrent cases of depression, a lifetime course of medication may well be indicated."Numbers show that without therapy, concurrent with medication, once the drugs are discontinued patients may find themselves right back where they started pre-drugs -- depressed. Through therapy, a patient can learn other coping styles to help them over rough spots. If, that is, they can get to a therapist. Kornstein laments that insurance companies often cover only limited psychotherapy, and, at $75 and up per hour, many patients can't afford to pay their own way. As talk therapy becomes less accessible, doctors lean more heavily on drug therapy. It's quick and easy. Health professionals from family doctors to obstetricians prescribe antidepressants for a variety of ailments (weight loss, migraines, back pain, etc.) other than obsessive-compulsive disorder and depression, the drugs' FDA-approved uses. And many psychiatrists do not approve of this trend, as some doctors may not be fully informed on how to monitor a patient's progress. "What I do think is not legitimate," says Kornstein, "is when they're using an antidepressant as a happy pill. I do not believe in prescribing them for anything other than a diagnosable disorder."Later this month, Kornstein and Dr. James P. McCullough, professor of psychology and psychiatry at VCU, will launch a multisite chronic depression study comparing cognitive behavioral therapy, drug therapy and a combination of the two. Twelve academic medical centers in the U.S. will participate. The type of cognitive behavioral therapy to be used in the study is a model developed by McCullough specifically for treatment of chronic depression. The study is expected to provide an answer to the question of which treatment is best for chronic depression. "I think that for moderate to severe depression, medication is usually indicated," Kornstein says, "but the best treatment is a combination of drug therapy and psychotherapy. That's how I treat patients in my practice."VCU's Unipolar Mood Disorders Institute is one of 10 sites in a four-year, 635-patient study. Stanford, Brown, Pittsburgh, Arizona, Chicago, Texas -- Galveston and Dallas, SUNY-Stonybrook and Cornell Universities are the other study sites. The study is evaluating the efficacy of two different antidepressant medications, Zoloft and imipramine, for the treatment and prevention of chronic depression. Is it not a conflict of interest that Pfizer, the pharmaceutical company that makes Zoloft, is funding this study? "The scientists involved in this study are too big" to compromise their integrity by swaying results in favor of Pfizer, says Kornstein. "They are the top researchers in depression in the country." Antidepressants are a huge dollar industry in the U.S., and "yes, Pfizer is taking some risk in letting them do this." When that study is complete within the next year, "we'll have more data on long-term use of antidepressants in the management of chronic depression," says Kornstein. "What we'll have in the end is a comparison of people who maintained a dosage for two years versus people who came off the drug after a seven-month course."SIDEBAR #1: An Alternate RouteTen years ago, Dr. Vernon Sylvest, a pathologist, was wracked with arthritis and depression. He ached from head to toe, plagued with pain and guilt from a failed marriage. He bottomed out and began to pray, something he hadn't done in years. He developed his own method of healing, soon to be published in his first book, called "The Formula: Who Gets Sick, Who Gets Well, Who is Unhappy, Who is Happy and Why." With prayer, meditation and internal vigilance -- banishing worries and judgmental thoughts -- Sylvest healed himself in nine months. He hasn't had a trace of arthritis since.Sylvest, a pathologist at LabCorp of America, a reference lab for physicians, is an interesting combination of the unconventional and the old school. Antidepressants are acceptable if administered "carefully with supervision of a very good psychiatrist who is willing to help," he says. "They can be very useful but they're not an end in itself. You've got to help [patients] learn to see the world differently and develop a different pattern of thinking." Depression is a physical phenomena, he believes. "It is a chemical by-product of our perception of situations. Those chemical changes don't cause depression; they are caused by depression. We can temporarily alleviate the symptoms of depression with drugs. I do believe that drugs are useful. I think they allow individuals to function better." But, Sylvest agrees with other physicians who have noted the overuse of drugs: "It's easy to write a prescription because it's not cost effective to spend an hour talking to the patient," he says, illustrating the effect managed care has had.The key to mental health, says Sylvest, is to focus on the emotions you want to experience. "Embrace the others, but say to yourself, `I prefer to feel love.' Because if you're happy, you're invulnerable to others." This process helps stop the process of fear leading to guilt, anger, depression and grief -- the loss of self. Praying out loud, he says, is a way of "activating that connection of love and healing thoughts." He encourages patients to send worry thoughts away with a prayer. "You can train the mind not to worry. When we are willing to let go of anger, guilt and fear and let go of worry thoughts, we can achieve a state of bliss." SIDEBAR #2: Q & A with Dr. Peter KramerIn 1993 Dr. Peter Kramer published his bestselling book "Listening to Prozac." The San Francisco Chronicle hailed it as "a provocative and insightful exploration of Prozac's dramatic and unforeseen impact on the human psyche, as well as on the practice of psychotherapy." It was one of the first definitive texts on the subject of depression since the advent of the new SSRIs, Prozac and Zoloft. Reached at his office in Providence, R.I., where he teaches at Brown University and sees patients, Kramer addressed the question of withdrawal.Question: What withdrawal experiences have you seen in your patients?Kramer: With all the antidepressants there are some withdrawal syndromes. They're not as dramatic as what you see with acute addictions like alcohol or heroin. In the past, these drugs were given to more seriously ill patients. They were experiencing so many other symptoms that withdrawal symptoms seemed minor. Now it's given to healthier people and the withdrawal effects may be more pronounced in the absence of other ailments.The problem with [withdrawal effects from] psychotherapeutic drugs is that you've got several possiblities: Is it recurrence of the illness? Is it withdrawal? Is it a rebound effect of some sort that eventually washes away? And there's a fourth possiblity -- has the ailment gotten worse under the cover of the medication?Q: How do you work with patients who want to go off antidepressants?K: I withdraw people very slowly from these medications -- maybe 20 mg. Prozac seven times a week, to six times a week, five times, then maybe 10 mg. five times and so on. The way I look at it is, why should their brains notice this? Technically, it's not a very big problem. There's rarely an urgent need to take a patient off. Many, many people come off without noticing anything. Percentage-wise very few experience problems coming off.Q: What about the withdrawal symptoms that some people describe?You've got to remember that this is a population of people that includes people who are hyper-aware of body changes, particulary hypochondriacs. Hypochondriasis is a known form of depression.Q: What about longterm use?K: There's some belief that people can start to metabolize these drugs faster over time. The longer-acting drugs may act like the shorter-acting ones when a patient discontinues use.Q: Should anyone stay on?K: Some people should stay on indefinitely because they have such a dangerous history of suicidal depression. Going off too soon could cause an immediate relapse or a recurrence later. A patient who has been on 6-12 months doing well steadily may be ready to come off. Feeling better and going off is a bad strategy.Q: Do you recommend therapy and drugs?K: All of my patients are doing both.Q: What about those who say that depression is not a disease, that it's just trouble coping with problems in living?K: To say that is not a legitimate point of view in 1996 -- it's a complex disorder.QUOTES FLOAT THESE QUOTES THROUGHOUT:"I think, I should be going off this drug. I've been on it for two years and I'm feeling really good. But every time I discontinue, within a day or two I'm sinking. And I'm angry and agitated, more so than I ever remember being pre-Prozac. So I give in and go back to it. What I don't know is this: is the crazy me off-Prozac the real me or is it the result of going off, like a withdrawal me?" -- Eleanor N., Richmond lawyerAfter that weird sensation subsided, I was fine physically, and just had the emotional stuff to deal with. I was tempted to go back on the meds a number of times but made myself hang in there, and now it's been 3 months. Within a month after going off the meds, I started therapy for the first time. I think it's a good support because I feel like I might get somewhere if I work on underlying things. If the depression gets bad again, though, for an extended period of time, I would start taking the Zoloft again. -- Nicole E., Internet newsgroupThis is not a cure for depression, but it certainly is an aid: My doctor advised me not to sleep late and get out of bed and walk around the block regardless of weather. It helped greatly. I hate this miserable disorder that no one but us understands. A "second-class" is how it is regarded by most. They should only experience it and try to convey what it is like to others. You can't. I'd rather be back in Vietnam than be depressed. -- America On-line message board postingPyschological dependence on a pill is something that I dread nearly as much as living in depression for the rest of my life. Who you are as a person is a process of your mental function; you can take away a person's legs and hair and even sight, but if you take his mind the person is no longer the same one that you knew. That's why I am leery of antidepressants. Yes, I am depressed. But the depressed person is me; trying to change that "factor" seems like a farce. Anyone see what I'm getting at? But if it seems to work for some people, it's time to try. So I am interested in hearing from people who have taken this kind of drug and no longer do. -- Tim L., Internet newsgroup*Some names have been changed for privacy.