November 9, 2010

Mark Foster, DO
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Bob–

Today, I saw a very friendly, highly intelligent (she has a PhD in economics) and overweight 34 year old woman for a refill of her Zoloft, which she had been on for the last twelve years, until about fifteen months ago when she asked if she could change to Cymbalta. Her mother is on Cymbalta and has done well, had advised her to try it, and so she asked for the change. Today, she came back saying that the Cymbalta was making her feel very fuzzy-headed, and so she wants to go back to Zoloft.

As I had prescribed these meds for her previously, I’m sure she was surprised when she found out she had walked into my new paradigm of psychiatric care. Unlike our initial visits, today I explored her psych history in depth, and I found out that she was first diagnosed with major depression as a teen, when her symptoms were sadness, frequent crying and fatigue. She says that she would cry all the time for no reason, such as combing her hair in the mirror. She was never suicidal. She also has a strong family history of depression. She was never offered counseling, and instead was started on a medication at age fifteen, eventually going through pretty much all the available meds until she stabilized on Zoloft while in college. She says that the Zoloft never elevated her mood, just kept her stable enough so that she was not crying all the time and could perform at school or in her job.

At the end of her successful college career, she cut her dose in half on her own, hoping to wean off of it completely. However, her emotionality returned, frequent crying, and so after three months she returned to her previous dose, and her mood stabilized again. She never really considered going off of it after that. She said, “I just learned that I’ll always need to be on something.” It was about that time that she started putting on weight, and now she is about seventy-five lbs overweight. I perceive that this obesity is a major emotional problem of its own for her, as it makes her feel unattractive. All that aside, she smiles and laughs easily, is a pleasant conversationalist, and does not appear depressed on the surface.

I did not want to rock her boat too much today, as she feels that her medications are working just fine. But as she is wanting to change again, I told her that I needed to share with her my new paradigm of psychiatric care, and how her experience with medications fits into that. I suggested that long term use of SSRIs could actually worsen her underlying problems, as well as cause unwanted side effects such as anxiety and weight gain. At this point, she became very emotional, crying, then apologizing for doing so. She has recently gone through a lot of turmoil at her work, and had her longtime pet dog die, and so this is a stressful time for her. For her, the medications have simply become a lifelong expectation, sort of a constant crutch, and I’m sure it seemed very threatening to have her doctor propose stopping them. Really, her entire adult experience has involved psychiatric medications, and her one trial of decreasing them was curtailed by a not-unexpected withdrawal response.

We talked for a good while, and after she went through half a tissue box, I decided to not pursue this much further today, other than to express that I felt it was my job to ask the question at least yearly of whether or not the medication is still warranted, and that stopping the medicine may help her lose weight, and in the end, feel better. I put her back on Zoloft, recommended your book, and will be seeing her again in one month.

It seemed to me as if I were visiting with someone who had been told their whole life that they were disabled, broken, and would never be able to walk, and so they’ve spent their entire life in a wheelchair, when in reality, all it would take for them would be the encouragement and self-confidence to rise up and walk. They might fall at first, and it may take some time, support and encouragement as they built up their strength. But if they could be empowered to believe in their capacity for wellness without turning to crutches or meds, then they might find that they can not only walk, but also run, especially when the chemical restraints were lifted from their brains.

The image that comes to mind here is that of Forrest Gump breaking out of his clunky leg braces and discovering that not only can he run without them, but that he can run very, very fast. “Run, Forrest, run!” Modern orthopedic doctors almost never prescribe those orthotic devices for kids anymore, except for the most severe cases, because they eventually learned that, in spite of how expensive and impressive these devices appeared, first of all, they didn’t work, and second of all, they actually did more harm than good. Turns out the body can self-correct gait and toeing abnormalities much better than science ever could.

If only modern psychiatry could admit to the same failure of their medical arsenal . . .

Mark