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Jackson Free Press
by Alyssa Abkowitz, Photo by Josh Hailey
November 15, 2006
Angela Bolin was lying on her bathroom floor in a T-shirt and panties when she woke up in a pool of blood. Paramedics hovered over her. Her mother, father and sister stood there, sobbing. She didn’t know what was happening, but when she looked down at her inner thighs, she saw they were covered in razor-thin slices. There were 45 cuts on one thigh, 46 on the other. The air reeked of bandages and antiseptic cream. It took a second for it to register. Bolin looked around, dazed, and spotted the used razor next to the sink. Then she remembered.
It started out a normal day in August 2002. Bolin went to class at Georgia State, where she was majoring in marketing, taught a yoga class and visited with her sister. Things were routine, but she felt disconnected. The whole day something had agitated her, but she couldn’t pinpoint the problem. During dinner that night, her parents asked about the new medication she’d been taking for three weeks; she had started on it after watching a commercial touting its benefits. Bolin’s father said he didn’t believe she should be on the drug, that it caused mood swings. She got mad, finished dinner and marched upstairs. She took apart a disposable razor and started slicing. She did it methodically one cut to her left leg, one to the right, moving down toward her knee. She felt like she was watching a movie, felt she possessed no control over her actions. She kept slashing and got to number 91 before passing out.
It took about 20 stitches to mend her, but the nightmare didn’t end there. Bolin attempted suicide again, by cutting herself more than 200 times in a department store bathroom. In addition to self-mutilation, it took hospitalization in two mental institutes, dropping out of college during her final year, and endless hours of research before Bolin concluded what had triggered the unwarranted behavior that almost took her life: Paxil.
The Happy Bandwagon
More than 18 million Americans suffer from depression. That’s approximately 6 percent of the population, so chances are you know someone who’s dealt with the disease. Depression is complicated; doctors must make diagnoses that are personal yet subjective. Unlike those suffering from other ailments, victims of depression can’t exactly improve their condition with the same preventive measures say, a better diet or more exercise that stave off other illnesses.
Nor can patients control the life factors that contribute to extreme lows. A woman can’t turn off postpartum depression; a boy can’t change the fact that bipolar disorder runs in his family; a man can’t reverse the death of his wife of 60 years. Yet all these people, with their vastly different experiences, are lumped under a single common term: “depressed.”
This thorny disease has boggled physicians for decades, and methods for treating the illness compound the dilemma. The diversity of treatments, ranging from psychotherapy to shock treatment, can make recovery exacting; doctors must not only diagnose properly but also experiment, forcing patients through a trial-and-error process that sometimes does more harm than good.
“When we think about depression, we tend to think of it as one big field,” says William McDonald, director of the Fuqua Center for Late-Life Depression at Emory University, in Atlanta. “But everyone’s got it for a little different reason, and that’s why one treatment won’t work for everyone.”
The problem, critics of certain treatments say, is that doctors don’t always disclose all options to patients. The result is that antidepressants, which are now the primary remedy for depression, have polarized the medical field; pro-Prozac types are pitted against those who are anti-antidepressants. What’s more, two schools of thought have emerged among those who oppose antidepressants. On one side, critics claim that antidepressants can cause suicidal thoughts shortly after users begin taking the drug (like in Bolin’s case), while others say the real suicide risk occurs only after users discontinue its use.
In the end, the antidepressant feuds remain murky. The drugs have saved some lives and taken others, and have left the country confused as to what’s the best way to relieve depression and avoid drug dependence.
In the early 20th century, shock treatment prevailed as the preferred treatment for depression, but it later came to be regarded as inhumane, partly as a consequence of abuse. In the 1960s, physicians settled on a type of antidepressant known as tricyclics as the remedy of choice, even though the drugs produced severe side effects like 20-pound weight gain and blurred vision.
Then, in the 1980s, researchers at Eli Lilly & Co. stumbled upon a new relief while trying to find a treatment for tuberculosis. In trials, the drug unexpectedly lifted subject’s moods, says Michael Kuhar, a pharmacology professor at Emory. Eli Lilly tested it for several years, and in 1988, the U.S. Food and Drug Administration approved it as Prozac, the first of a new class of antidepressants known as SSRIs.
SSRI stands for selective serotonin reuptake inhibitor. These drugs work by reducing the brain’s ability to break down seratonin, a neurotransmitter that regulates mood. By boosting levels of seratonin in the brain, SSRIs mitigate the symptoms of depression in many people.
SSRIs quickly gained popularity. Unlike tricyclics, they didn’t cause weight gain or blurred vision. There were side effects, but they tended to be dry mouth or reduced libido, which more patients were willing to tolerate.
By the early 1990s, Prozac was all the rage. Books like “Prozac Nation,” which documented a woman’s bouts with depression, and “Listening to Prozac,” which hailed the SSRI as a wonder drug, quickly became best-sellers. Other drug manufacturers saw the success of Eli Lilly and jumped on the SSRI bandwagon. The result: the manufacture and release of six FDA-approved SSRIs in a matter of 12 years. The drugs saturated the psychiatric field; a 15-minute consultation often ended with a patient holding a prescription for Zoloft or Celexa, Luvox or Effexor, Paxil or Prozac.
It was an easy solution for the millions suffering from depression and other mental disorders. For some, it worked.
Thanks to The Pills
Sixteen-year-old Tess Robinette had made a habit of locking the door in her Marietta, Ga., home exactly six times every day. She wiped the inside of each shoe three times to make sure there were no hidden bugs before sliding her foot in. She counted the number of timesnine on each sideshe swiped deodorant across her armpits. If someone standing next to her accidentally brushed her shoulder, she made a point of re-brushing the person’s sleeve, thinking the second encounter would cancel any germs transferred during the first. Fearing t
he touch of another person, she’d never been on a date. Still, after she turned 17, she became convinced she had AIDS. Even though she was a virgin, she took an HIV test (it came out negative)and fainted during the procedure, prompting her parents to take her to a psychiatrist.
Robinette’s doctor diagnosed her with obsessive-compulsive disorder. He told her that antidepressants could help treat the disorder and prescribed her Zoloft. In the beginning, it didn’t seem to work. Robinette would inspect the bottle three times on each side before opening it to take her daily dose. After a few weeks, her condition improved, but she still experienced OCD tendencies.
Her doctor decided to switch her to Luvox, used specifically to treat obsession, though it produces more side effects than Zoloft. Within a month, almost all of Robinette’s obsessive urges disappeared. She no longer peered under the bed three times each night before resting her head on her pillow. And she no longer feared holding a boy’s hand.
“I’m able to live my life now,” Robinette says. “If I hadn’t taken (SSRIs), I wouldn’t be comfortable going to a concert or a bar.”
Because of various side effects ranging from fatigue to diarrhea, Robinette has tried three SSRIs. She is now on Prozac and says it’s helped her maintain a normal lifestyle. In fact, Robinette just entered pharmacy school, saying her ordeal spurred her interest. It’s taken time, patience and experimentation, but Robinette says the trial-and-error process has been worth it.
“I’m much happier now,” she says. “Thanks to these pills, I can be me.”
The Revolution Will Be Advertised
John Lochridge, a child and adolescent psychiatrist, has practiced medicine for two decades and now prescribes antidepressants to hundreds of children, the youngest being a 4-year-old who takes about a half-teaspoon of liquid Prozac to subside his separation anxiety. Lochridge says he can analyze a child’s serotonin level when he or she is still sitting in a high chair. He believes SSRIs work wonders and hasn’t altered his stance despite the FDA’s warning about the dangers of antidepressant use in children.
In October 2004, the FDA directed manufacturers of SSRIs to put a special black-box warning on the drugs. The warning would alert health care providers to an increased risk of suicidality in children and teens using the medications. In July 2005, the FDA issued a public health advisory raising the possibility that the risk of suicidality also applied to adults taking SSRIs, after several studies pointed that way.
“Prozac is one of the top 10 inventions of the 20th century,” Lochridge says. “When it’s prescribed right, it’s a miracle. I’ve got 200 kids on an antidepressant right now, and if people took them away, I’d have parents up in arms, rioting in the streets.”
The drug companies might riot, too. Eli Lilly, the sixth-largest American drug maker, reported last month that its third-quarter sales had risen 7 percent, to $3.9 billion, and its profits were up 10 percent, to $874 million, compared with 2005. Eli Lilly makes Zyprexa, which is used to treat schizophrenia and other severe mental illnesses. It is widely prescribed to Medicaid patients under the prescription drug benefit passed by Congress in 2003. Pharmaceutical companies have posted record profits under Part D, although GlaxoSmithKline has suffered a setback. This month, the company announced a $63.8 million legal settlement for claims that it promoted Paxil for use by children and adolescents while withholding negative information about the medication’s safety and effectiveness. GlaxoSmithKline admitted no wrong-doing.
The explosion in sales of SSRIs was driven by an explosion in advertising. Pharmaceutical commercials were highly restricted until 1997, when relentless lobbying ended with the FDA allowing the companies to air consumer-directed ads. Karen Barth Menzies, an attorney who specializes in antidepressant litigation, calls the ensuing marketing blitz “one of the best promo jobs ever.”
The ads typically begin with a narrator darkly but sympatheticallydescribing a host of torments: “Are you nervous in crowds?” “Do you lack energy?” “Do you find it hard to concentrate?” Then, there is a diaphanous wash of color, and the sun shines down on bright green yards, where smiling people barbecue. A couple runs hand in hand along a tropical beach. And it’s all thanks to Paxil, or Lexapro or Zoloft.
Psychotherapist Leslie MacKinnon says that in addition to being turned off by these commercials, she’s bothered by the steady press drug representatives make on doctors’ offices, where the reps can try to influence physicians’ drug choices. MacKinnon says the drug repsas many as four in a span of 30 minutesdescend on clinics with offers of golf getaways and luxurious vacations as incentives to prescribe their particular SSRI.
“It’s perk city,” MacKinnon says. “Doctors are inundated by this material with glowing statistics. The drugs seem like a shortcuta quick fix for most of their patients’ problems.”
“The manufacturers are not only mar-keting the drug, but also the depression disease,” Menzies claims. “They’ve permeated all aspects of society and have everyone thinking, ‘This drug might help me with my problems.’”
That’s how it worked for Bolin. She was watching television in July 2002 when she noticed one of those commercials showing people wearing nametags that read “Anxious,” “Depressed” and “Nervous.” (The commercial was pulled off the air a month later, after a federal court in Los Angeles deemed it misleading.) Bolin identified with the people in the commercial. Though she never thought of herself as depressed, she was exceptionally shy and grew jittery when interacting with co-workers at her marketing internship.
In the commercial, the actors ripped off their nametags and replaced them with new ones, figuratively revealing their true identitiesas a result of trying Paxil. Bolin accepted the invitation to fantasize about the changes the drug might make in her life. She scheduled an appointment with her doctor, just like the commercial advised. If she were on Paxil, maybe her hands wouldn’t shake and her voice wouldn’t quaver when she spoke with clients. Her doctor gave her a sample of the drugno questions askedand recommended she see a psychiatrist.
Bolin says that she started noticing side effects just days after beginning the medication. She started disagreeing with people frequently and crying for no reason. She began to claw at herself. One night, she had an argument with her parents and repeatedly banged her head into a wall. Her father had to restrain her. She says that when she told her psychiatrist about the incident, the doctor suggested doubling her dose.
It wasn’t until she visited six more specialists that Bolin was told that Paxil itself might be the problem. It was a psychotherapist, not a psychiatrist, who warned her that she might be having an adverse reaction to Paxil. This reflects the general split between mental health specialists. Psychiatrists, who have the power of prescription, tend to favor writing scrips. Psychotherapists and psychologists tend to be skeptics of treatment by prescription alone, stressing the need for talk therapy, though there are many psychiatrists who are skeptical toward SSRIs and many psychologists who embrace them.
Could it have been Paxil that caused Bolin to walk into a Bath & Body Works and buy nearly every product in the store, to stand motionless in fire ant beds, to leave school early to buy razors at Home Depot so she could cut herself when she got home?
It’s hard to say with certainty. But Bolin’s self-destructive behavior might be attributed to what psychiatrists call akathisia. An article in Food and Drug Law Journal describes the condition as “an inner sense of restlessness and inability to sit still, resulting in patients feeling like they are ‘jumping out of their skin.’” The article states that SSRIs like Paxil can spur agitation because they sometimes interfere with other neurotransmitters even as they boost serotonin levels.
But long before scientists described the risk of akathisia, blots had begun to stain the SSRI revolution.
The Coming Storm
By 2000, tales of the dark side of SSRIs had entered the mainstream. Stories of antidepressant use gone wrong a man who killed his wife and himself 11 days after beginning Prozac; a 12-year-old who killed his grandparents a few weeks after starting Zoloftbecame the banter of late-night talk shows. The Church of Scientology weighed in, holding up Tom Cruise as a spokesman willing to criticize SSRI use long before he went after Brooke Shields.
In the medical field, studies surfaced worldwide purporting that SSRIs increased suicidal ideations. In 2003, England banned most SSRI use in children, citing increased suicidal thoughts. The FDA urges parents and doctors to closely monitor children on antidepressants, and the agency has recommended that doctors stick to Prozac in prescribing SSRIs for children.
As early as 1993, critics were recommending that the FDA require SSRIs to carry a black box warningthe most severe warning a drug can incurexplicitly addressing suicide risk. But the FDA ruled that the current, less severe warnings were sufficient.
Then, in 1997, the American Law Institute published a rule stating it is primarily the doctors’ responsibilityand not the manufacturers’to inform patients of the drugs’ side effects. But drug manufacturers withheld data that doctors needed to make the most informed decisions, says Aaron Twerski, a products liability professor at Brooklyn Law School.
Dozens of lawsuits have been filed alleging that drug manufacturers didn’t release all data on antidepressantsand that positive antidepressant studies published in medical journals often were ghostwritten by the manufacturers themselves.
In the Paxil lawsuit, plaintiffs documented widespread of severe withdrawal symptoms, including electric “zaps,” vertigo and anorexia. Others testified that they tried to kill themselves while attempting to get off the drug. While Bolin’s claims center on her violent reaction when starting Paxil, the 30-plus plaintiffs’ complaints focused on their adverse reactions when ceasing the drug. Patients have reported similar adverse reactions for drugs like Zoloft and Wellbutrin.
It seems that there’s no end in sight for SSRI lawsuits as class-action attorneys continue to gather evidence from alledgedly damaged patients. In at least one suit settled in August of this year, which involved a 17-year-old Nebraska boy who committed suicide while taking both Zoloft and Effexor, Pfizer, Inc., and Wyeth Pharmaceuticals settled out of court for an undisclosed amount. And, in another new wrinkle, a lawsuit filed in October, 2006, alleges that Paxil caused severe birth defects to a Philadelphia baby born in 2004.
To further muddy the controversial SSRI waters, a 2006 study published by the American Journal of Psychiatry concluded that if no prescriptions for SSRIs were written, there would be 253 more child and adolescent suicides in the U.S. each year. This new study focused on county-by-county child and adolescent suicide data, cross-referenced by prescription information in the same counties. For the age groups studied, the highest suicide rates were in counties with the lowest SSRI prescription rates. Dr. Grant Mitchell, chief of psychiatry at Northern Westchester Hospital in Mt. Kisco, N.Y. stated that, “There is a much greater risk of suicide in patients who are depressed and untreated than there is from the use of SSRIs in terms of side effects.” None of this information makes the decision to treat depression any easier than it is today.
After her ordeal, Bolin was left wondering what her life would have been like without Paxil. Would Bolinwhose only prior complaint was social anxiety and who to this day has not been diagnosed with depressionstill have been admitted to a mental hospital? Would she still have been given tranquilizers and anti-psychotics to quiet her nerves? Would she still have had to visit eight doctors before determining what might have caused her to lose her mind?
The New Electroshock
On a Monday afternoon, a 53-year-old woman slides into a blue doctor’s chair in a small, stark office in the back of a hospital in Atlanta. She adjusts her feet on a footrest. Jane Gillespie, a research nurse at Emory’s Wesley Woods Hospital, straps a black plastic headband to the woman’s crown, pressing a five-pound magnet against her forehead. Gillespie positions cushions under the woman’s arms to make sure she’s comfortable. Then she clicks a button on a gray machine that sends four-second magnetic energy bursts, sounding like a woodpecker, into the woman’s brain every 26 seconds. The machine repeats the process 75 times.
The woman, a former schoolteacher, chats with Gillespie as she undergoes transcranial magnetic stimulation, an experimental but well established clinical depression treatment.
The method, called TMS, uses an electromagnetic coil to create pulses that stimulate nerves in the front of the brain, which is where depression is thought to occur, says McDonald, the Fuqua Center director. Unlike shock treatments, which also use electricity to treat depression, TMS allows the patient to stay awake and feel no discomfort during the session, which is administered five times a week for six weeks.
“TMS was born out of the desire to get effects like (shock treatment) but in a less risky manner,” Gillespie says. She points out that although shock treatment has a higher success rate85 percentit’s the study’s hope that TMS will achieve similar results “without the intensity.”
The woman in the chair drives 110 miles round-trip daily to receive the clinical treatment and says it’s worth it. For 15 years, she sampled almost every antidepressant available through her general practitionerto no avail, she claims. She says the drugs would work for a while but then plateau, which triggered her doctor to up her dose until she reached the point where she felt like a zombie.
“When I saw the ad in the paper for TMS, I thought, ‘I’ve got nothing to lose,’” the woman says. “I’ve never handled drugs well. When I saw that this treatment was drug-free, I thought maybe it would work.”
So far, she feels it has. After three weeks, she noticed a difference in her mood. She’s able to get through the day and still feels she possesses her personalitysomething she lost on anti-depressants.
McDonald says TMS produces a 60 percent to 70 percent response rate, though a 50 percent relapse rate. Few side effects have been reported, with mild headaches being the only complaint.
Treatments like TMS could ignite an uphill battle with drug companies. The new treatment could deter doctors from prescribing antidepressants as ubiquitously as they currently do, and drug manufacturers might have to bring out the cannons to protect their market share. But for now, that’s not the case.
When Bolin steps onto the beach, a five-minute walk from her new home in Panama City, Fla., she’s dressed like a snowbird lost in the tropics, clad in a long-sleeved shirt and pants despite the scorching sun and humidity. She takes her three dogs on the walk, working up a sweat pretty quickly. But she doesn’t mind. She’d rather be dripping than receive awkward stares from adults and hear little children whisper about what happened to her limbs.
“I won’t go out in public in shorts,” Bolin says. “I’m too self-conscious about it.”
That’s because Bolin has scars, numerous scars, from the summer of 2002. Luckily, that’s one of the few remnants of the past.
“I can never be the person I was before,” she says. “But I want to try to get back to where I was. I just want to be happy and be able to trust myself again.”
Additional reporting by Brian Johnson.