It started out a normal day in August 2002. Bolin went to class at Georgia State University, where she was majoring in marketing, taught a yoga class and visited with her sister. Things were routine, but she felt disconnected. Something had agitated her the whole day, 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 had 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.
More than 18 million people suffer from depression in the United States. 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."
The thorny disease has boggled physicians for decades, and various ways to treat the illness compound the dilemma. The diversity of treatments, ranging from psychotherapy to shock treatment, can make the healing process tricky; doctors must not only diagnose properly but must also experiment, making patients go 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 best solution for depression, but later became stigmatized as inhumane. In the 1960s, physicians found tricyclics, a type of antidepressant, to be the remedy of choice, even though they produced acute 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. The drug being tested unexpectedly lifted people's moods, so Eli Lilly tested it for several years, and in 1988, the US 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 inhibitors, and the substance is believed to relieve depression by boosting levels of serotonin, a "feel good" chemical in the brain. SSRIs quickly gained popularity; unlike tricyclics, they didn't generate the same side effects. Instead of weight gain and blurred vision, a user might experience dry mouth or a limited libido, effects patients more willingly endured.
By the early 1990s, Prozac was all the rage. Books such as 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 would end 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.
Sixteen-year-old Tess Robinette had made a habit of locking the door in her Marietta, Georgia home exactly six times every day. She wiped the inside of each shoe three times to make sure they didn't contain bugs before sliding her foot in. She counted the number of times -- nine on each side -- she 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 the 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. After her first visit, Robinette was diagnosed with obsessive-compulsive disorder. Her psychiatrist told her that antidepressants could help treat the disorder and prescribed 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, which is 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 [antidepressants] 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 at the University of Georgia, 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."
One psychiatrist we spoke to was so supportive of SSRIs, he told us, "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, too, might be rioting. In 2001 alone, drug manufacturer Pfizer raked in $2.1 billion from Zoloft sales, more than a quarter of the company's total revenue. The New York Times reported in September that in a yearlong period ending in March, the worldwide sales of antidepressants totaled almost $20 billion.
A majority of the revenue can be chalked up to the impact of antidepressant claims in television commercials. Such commercials had been highly restricted until 1997, when pharmaceutical companies' relentless lobbying ended with the FDA allowing consumer-directed ads to be aired.
Karen Barth Menzies, an attorney who specializes in antidepressant litigation and who is looking into Bolin's situation, calls the ensuing marketing blitz "one of the best promo jobs ever."
The ads typically begin with a narrator vaguely addressing what seem like mild issues: "Are you nervous in crowds?" "Do you lack energy?" "Do you find it hard to concentrate?" The commercials then introduce the drug and cut to people smiling in pastoral settings, barbecuing, holding hands on the beach or raking leaves in the front yard.
Psychotherapist Leslie MacKinnon says that in addition to being turned off by these commercials, she's bothered by the pervasiveness of drug company representatives' visits to doctors' offices, where the reps can try to influence physicians' drug choices. MacKinnon says the drug reps -- as many as four in a span of 30 minutes -- descend on clinics with offers of golf getaways and luxurious vacations as incentives to prescribe their particular antidepressant.
"It's perk city," MacKinnon says. "Doctors are inundated by this material with glowing statistics. The drugs seem like a shortcut -- a quick fix for most of their patients' problems."
"The manufacturers are not only marketing 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 at Federal Supply Services. In the commercial, the actors ripped off their nametags and replaced them with new ones, figuratively revealing their true identities -- as a result of trying Paxil. Bolin thought the drug might be her solution. She scheduled an appointment with her doctor, just like the commercial advised. Perhaps with Paxil, her hands wouldn't shake and her voice wouldn't quaver when she spoke with clients. Her doctor gave her a sample of the drug -- no questions asked -- and recommended she see a psychiatrist.
Bolin says she started noticing side effects just days after beginning the medication. She started disagreeing with people frequently, crying for no reason and clawing 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 psychiatrists that Bolin was finally told, not by a psychiatrist but by a psychotherapist, that Paxil itself might be the problem.
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 so that she could buy razors at Home Depot to cut herself with? It's hard to say with certainty. But Bolin's self-destructive behavior might be attributed to what psychiatrists call akathisia. A 2002 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 brain chemicals as they boost serotonin levels.
But even before the akathisia study was published, the gloss was starting to come off the SSRI revolution.
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 Zoloft -- became 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. In the medical field, studies surfaced worldwide purporting that SSRIs increased suicidal ideations. Last year, England banned most SSRI use in children, citing increased suicidal thoughts. In March, the FDA issued a public health advisory urging parents and doctors to closely monitor children on antidepressants, and the agency stood by its recommendation that Prozac was the only antidepressant suitable for children.
As early as 1993, critics were recommending that the FDA require SSRIs to carry a black box warning -- the most severe warning a drug can incur -- explicitly addressing suicide risk.
Two months ago, antidepressant complaints culminated during a US House committee hearing and an FDA hearing. During the House hearing, experts criticized the FDA for withholding studies that suggested antidepressants might spur suicidal thoughts in children. (Incidentally, that hearing had been scheduled for July but was postponed for 50 days while its chair considered a pharmaceutical lobbyist position.) During the two-day FDA hearing, committee members heard testimony evaluating the antidepressant-related suicide risk. In the end, the committee recommended that the FDA require drug companies to issue a black box warning, the same one proposed 11 years earlier. With the new warning, doctors are now supposed to take extra precaution when prescribing the drugs. In response, many psychiatrists have said they will limit antidepressant prescriptions.
What's more, dozens of lawsuits have been filed alleging that drug manufacturers didn't release all data on antidepressants -- and that positive antidepressant studies published in medical journals often were ghostwritten by the manufacturers themselves.
In September, Bolin's lawyer began compiling testimony for an upcoming lawsuit against Paxil's makers, GlaxoSmithKline, claiming the company didn't publicize all the drug's side effects. Lawyers have noted that other countries, such as the Netherlands and Spain, offer stern warnings to patients by clearly printing the word "withdrawal" on the drug information sheet, implying the drug is habit-forming. But in fear of losing revenue, American labels only offer the euphemistic warning that the drug poses "discontinuation syndrome."
In addition to investigating Bolin's case, Menzies is heading the first-ever nationwide class-action lawsuit alleging that Paxil's manufacturers fail to adequately warn patients of the risk of withdrawal symptoms and suicidal thoughts when coming off Paxil. The case is scheduled to go to trial in May 2005. Menzies says testimony from more than 30 plaintiffs will bolster claims that when users try to stop taking Paxil, they experience unexpected symptoms such as electric "zaps," vertigo and anorexia. Others will testify 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 focus on their adverse reactions when ceasing the drug.
Today, Bolin is left wondering what her life would have been like without Paxil. Would Bolin -- whose only prior complaint was social anxiety and who to this day has not been diagnosed with depression -- still 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?
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. She's been free of antidepressants for over a year. Her move to Florida in the summer of 2003 with her boyfriend, now her fiance, helped her escape the city where so much pain had occurred.
She's in the midst of planning her wedding, and she's trying to take classes -- she needs only four more -- to finish her education that was abruptly halted. Most importantly, Bolin is trying to reconnect with the person she was prior to her madness.
"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."