1 Boring Old Man

Last night we drove down to Atlanta for an event. Our Society went as a group to a Play, Freud’s Last Session – a fictionalized meeting between Freud and C.S. Lewis in London during Freud’s last days [with the added treat that the actor playing Freud was a personal acquaintance]. In the Play, they argued about science and religion while the crackling radio in the background interrupted their discussions with announcements of Hitler’s invasion of Poland and declarations of war from Neville Chamberlain and King George.

Like any good drama, the measure of its power comes in the feelings and thoughts that come later. By that standard, this was one fine Play. Freud, the 83 year old Victorian Darwinist escaping the religious mantle of nineteenth century Europe debating a forty year old C.S. Lewis, who with his friend J.R.R. Tolkein found solace in fantasy and Christianity after a traumatic youth in the trenches of World War I. C.S. Lewis, who lived with the mother of his good friend killed in that war until her death and Freud who was being cared for by devoted daughter Anna as they fled Hitler’s antisemitism in the terminal days of his cancer. The generational contrasts were equally represented in the audience – my own aging teachers being helped to their seats by the younger candidates, now my students training in an era very different from my own time; the older Analysts, all psychiatrists, contrasted with the younger ones, a mixture from widely diversified educational backgrounds. The contrast was internal as well – my own history as a psychiatrist and psychoanalyst in Atlanta and my current retired life in a very different locale – now thinking back about the changes and problems in psychiatry over my career. Then, when I got back late, this message was in my email Inbox.

Adding to the evening’s theme of personal history, the email was from the oldest of friends, my closest companion throughout our shared adolescence. The note felt a bit like a splash of cold water at first, an intrusion of the contemporary mishigas into the cloud of nostalgia that was in my mind on the long drive home – the kind of thoughts old men think. But I soon recalled that Paxil withdrawal was an opening parenthesis for me. By the time the SSRIs came out, I had left academia and was in practice, rarely prescribing. I’d heard the reports of Prozac and suicidal ideation – discounted at the time as the ravings of the antipsychiatrists. Then a good friend, a Social Worker who had taken Paxil soon after it came out with good results called and said that when she tried to stop it, she had a horrible time. That was in the days before the Internet, so I went to the Library and found nothing. But I could see the problem was very real and that it persisted in spite of a gradual reduction in dose. It was my first inkling of the difficulty with the modern drugs and the absence of literature about such things [the first PubMed entry for Paroxetine withdrawal is a case report in 1994, a year after my friend’s problem]. By 1995, the reports began to come out in the major clinical journals. Her experience had an impact on me though. I’ve never personally prescribed Paxil.

My reaction to that email was as always when similar things come up – a mixture of embarrassment and anger that my friend and his wife are having to figure out that it’s a withdrawal syndrome themselves rather than being told by their daughter’s psychiatrist. I talked to him today – ‘It seems to happen every time she tries to come off the Paxil. They try other drugs but she always ends up back on the Paxil. When it happens, she has frightening thoughts – death, suicide.’ I’ll not go on and on. If you’re reading this, you already know the story of the ups and downs of withdrawal.

Maybe it was being with my friends and colleagues last night, or the Play itself, or the fact that I’m teaching a course this month, but that email made me acutely aware of how isolated my life became after I left Emory in the late 1980s. I knew that psychiatry had changed radically, but I attributed it to the changes in insurance, or maybe some psychopharmacologic neurobiological fad. I knew that psychotherapists like me were out of favor in psychiatry, but it went the other way too. I stuck with people of my own kind and rarely went to psychiatric meetings, local or national. So it was a two way street. I felt abandoned, but I jumped ship myself. In all that time, I never realized that the pharmaceutical industry was frantically churning in the background. I didn’t really wake up to that until Senator Grassley rang a loud bell in 2008 by naming the chairman at Emory to his list of industry prostitutes. Maybe if I hadn’t withdrawn, I might have known sooner.

Today, my reaction was different. This is what I heard. ‘After my daughter told him she was having frightening suicidal thoughts, he told her that was good. It meant that she was afraid of the thoughts and wouldn’t act on them. It was her OCD. He increased the Wellbutrin.‘ I don’t think the psychiatrist knew she was having withdrawal symptoms! He thought it was OCD returning from being off of Paxil. He treated that with Wellbutrin? Since when was Wellbutrin a treatment for OCD anyway? Suicidal thoughts are good?! My initial reaction to all of this was that my once proud specialty had fallen into shambles. For a time, I think I equated this story with the crackling radio in the play last night. Freud and Lewis debating religion while the radio in the background announces that Europe is about to dissolve into a sea of hatred and carnage. That bit of drama-ville passed mercifully. I know it’s not as bad as that, though it’s bad enough for alarm. Some of my reaction was from the night before and the fact that it was my old pal’s daughter. I calmed down and will do what I’ve done before – refer them to someone who will help her gradually get off the Paxil, and manage whatever else needs taking care of.