Slipping into the darkness
March 20, 2010
The safety of anti-depressants is under the spotlight again, writes Kim Arlington.
The lights were off. The dressing room at Channel Ten's Sydney studios appeared empty. But when the head of the wardrobe department walked in, she found Charmaine Dragun sitting in the corner, eating lollies.
The network's Perth newsreader, Dragun was high-profile, polished and professional. Off screen, she was bright and cheerful. But not on this day – Dragun was alone, in the dark.
A few weeks later, on November 2, 2007, Dragun took her life at The Gap. She was 29. Her death was all the more shocking because only a handful of people had known of her decade-long battle with depression and anxiety.
What led her to take that final, tragic step is the focus of an inquest at the Coroner's Court in Glebe. Her medical management and changes to her medication – which put her at increased risk of suicide – have come under close scrutiny. Whether she was misdiagnosed, and had bipolar disorder that went untreated, is being considered by a Deputy State Coroner, Malcolm MacPherson.
Dragun could not stop the darkness closing in, but her family hopes her death will shine a light on the issue of patient care, and give hope to others suffering in the grip of depression.
Suicide claims more Australian lives each year than road accidents. For every suicide, there are 30 attempts. It is also a known risk of depression, and pharmaceutical companies acknowledge that antidepressants may contribute to worsening depression and the emergence of suicidal thoughts and behaviours.
What warnings patients are given, how closely they are monitored for danger signs, and who monitors them, are all under the spotlight.
Dragun had been on antidepressants throughout her adult life. She took Zoloft from 1996 as she recovered from anorexia, and switched to Efexor – prescribed to 240,000 Australians each month – in 2004.
Close friends and workmates never suspected that anxiety and negativity were gnawing at her constantly; everyone around her was struck by her intelligence, warmth and consideration. But her illness created an enormous gulf between her objective reality and how she perceived herself: ''as utterly incompetent in nearly all aspects of life''.
Not wanting to burden others, Dragun kept up a positive front – but also worried it would damage her career if people knew she was depressed and taking medication.
One friend who saw through her bubbly ''performance'' was an SBS journalist, Sarah Bamford. ''Everything in her life seemed so perfect, but she couldn't get well,'' Bamford told the inquest. ''It was her mind that was tormenting her.''
Dragun was debilitated by worry, guilt and indecision. Her perfectionism pushed her to maintain impossibly high standards and left no room for self-forgiveness. The way depression turned her mind into its own trap was vividly illustrated in her diary entries from July 2007.
''I have been submerged under a torrent of raging thoughts and feelings, unable to break through to the surface where reality and reason lives," she wrote. "I can't think straight … can't escape my own misery and self-absorption.''
She doubted her ability ''to live in this world and function as a normal person''. Her greatest fear was that she would ''remain like this for the rest of my days, unsure of every step … and so obsessed with this crazy shit that no one would want to know me any more''.
Dragun had moved to Sydney in 2005 to read Perth's nightly news bulletin – at that point, produced live from Ten's Pyrmont studios. Homesick for Perth and unsatisfied at work, her illness worsened.
Though severely depressed, she was not referred to a psychiatrist by two GPs she consulted in November 2006 and July 2007. Instead, both increased her dosage of Efexor. In February 2007 she began counselling with a psychologist, Belinda Khong. By July, she was recording her first suicidal thoughts in her diary. She spoke of them to Khong, who believed they were ''fleeting''.
But the thoughts persisted. Khong's notes record that on September 28, Dragun was feeling ''quite suicidal''. Though she had no plan, she was ''thinking of a way that is easy''.
Khong phoned a psychiatrist that day, Wai Mun Tang, about assessing Dragun. Questioned by David Hirsch, counsel assisting the coroner, Khong agreed Dragun required an urgent psychiatric review. But she knew it would be at least 18 days before Tang could see Dragun – and her notes of their conversation made no mention of the patient's suicidal thoughts.
Tang told the inquest that Khong said nothing to her about suicide in that call. Had she known of Dragun's state, Tang would have had her urgently assessed and possibly hospitalised.
When Dragun saw Tang on October 16, she was put on a new treatment plan – reducing Efexor, starting on a new drug, Lexapro, and taking fish oil tablets. Dragun was elated, telling her mother the treatment was "revolutionary". Recalling her daughter's excitement at the prospect of eventually living without drugs, of regaining control of her mind and her moods swings, Estelle Dragun said: ''There seemed to be a light at the end of the tunnel.''
By late October, however, Dragun was again despondent. On October 29, she told Bamford ''I expected I would feel better by now'' and told her mother she did not understand why the new medication was not working. Speaking to her mother on October 30, Dragun said Dr Tang ''wants me to give it a few more days to kick in''. Three days later, she jumped to her death.
STARTING a new antidepressant, or changing the dose, is a recognised danger period for suicidal thoughts and behaviour and intensifying depression. Dragun was doubly vulnerable, reducing her Efexor while introducing Lexapro. Combining the two drugs is not recommended by Lexapro's manufacturer, Lundbeck.
From October 27, the day she started taking Lexapro, friends noticed her showing signs of agitation, anxiety, confusion, nervousness and restlessness – all listed as side effects in pro
duct information from Lundbeck and Wyeth, which makes Efexor. Both note concerns that such symptoms ''may be precursors of emerging suicidality''.
The companies recommend that patients and their caregivers be alerted to the need to monitor for signs of suicidality and worsening depression. Dr Deborah Pelser, from Lundbeck, told the inquest that as patients may be too unwell to monitor themselves, it was a good idea for others to watch for these signs.
But those closest to Dragun were not advised to monitor any changes in her behaviour. Simon Struthers, her de facto partner, was not aware she had changed her medication until after she died.
A psychiatrist, Bill Lyndon, the director of the mood disorders unit at the Northside Clinic and a lecturer in psychiatry at Sydney University, told the Herald there should be regular monitoring of patients on antidepressants, especially early in their treatment. Patients who were prescribed antidepressants had an illness that was at least moderately severe and could be at risk, regardless of any side effects.
''It is important that the patient's welfare and well-being is monitored because of their illness, not just because of the medication they are taking,'' Dr Lyndon said.
Most GPs could competently diagnose and manage patients' depression, but ''good communication between all of the people who are involved in the patient's care'' was vital.
Estelle Dragun told the Herald that patients on antidepressants and their families should be ''given full understanding of the side effects and what might happen, so they are not put at risk'' or left in the dark. A patient's safety should be paramount, she said, and override any privacy concerns.
''If we were aware [of possible danger signs], then we could have supported her far better,'' she said. ''When [Charmaine] spoke to me, she didn't give any indication that she knew about any side effects. On the Monday before she died she said, 'Mum, I feel very unwell – I don't know what's going on.' She was desperate.''
It was a GP with 35 years' experience, Helena Berenson, who seriously questioned whether Dragun had bipolar disorder. The newsreader's history of anorexia and mood swings – feeling she could conquer the world, then crashing and feeling worthless – raised red flags during a consultation on September 29. Dr Berenson said Dragun's continued suffering, despite a decade on antidepressants, increased dosage and continuing psychotherapy, indicated the professionals ''hadn't got it right yet''.
Efexor, which Dragun had been taking for three years, is not recommended for bipolar patients.
Dragun, too, was searching for answers. ''She knew she shouldn't be as depressed as she was,'' Dr Berenson said. ''Things didn't add up for her, otherwise she wouldn't have been … asking for help.''
Estelle Dragun did not believe her daughter was consumed with suicidal thoughts when she went to The Gap, a notorious magnet for troubled souls. Impulsivity is another side effect of antidepressants, the inquest heard.
Woollahra Council has recently installed closed-circuit television cameras at The Gap, as well as telephones linked to emergency numbers and the 24-hour counselling service Lifeline. It has applied to the federal government for $2.5 million for further safety measures, including more security cameras, better lighting and new fences. Its campaign is supported by the Black Dog Institute, but the council is still waiting for funds.
The mayor of Woollahra, Andrew Petrie, said it was staggering that the government ''cannot find $2.5 million for something that is a national problem. If this was done years ago, it would have saved many lives.''
Anthony Sklavos saw Dragun in her last moments, pacing along a cliff ledge overlooking the sea. Although her torment was obvious, her body language convinced him she had not made a final decision, that a simple sign of love and concern could have saved her.
Calling triple-0, Sklavos was instructed, for safety reasons, not to approach Dragun. She cast one last look back at him; she jumped just as the police arrived. The call records his anguished lament: ''Oh, man, I could have done something …''
Sklavos is not the only one haunted by regret that Dragun was able to slip away.
Lifeline: 131 114