by Jennifer Jacobs Syracuse Post-Standard March 28, 2004

A thump and screams in the middle of the night shook Valerie Kotyra from her sleep.

She found her daughter, Rebecca Caraway, 24, curled up on the floor in front of the refrigerator, fists clenched, face red. Kotyra remembers her daughter's tormented voice:

"Mommy, the spiders are coming," Caraway said.

"Becca," Kotyra asked, "did you have a bad dream? Did you see a spider?"

"No, I hear them coming. They're coming, Mommy."

Caraway, a Syracuse University junior, had abruptly quit taking Zoloft, a prescription drug for depression, a week earlier. She was still taking Xanax, an anti-anxiety medication, and she'd been chugging margaritas all week.

This mix spiked her into an agitated, paranoid, hallucinating mania.

It frightened her mother speechless. The police and paramedics came and left; they could not help, Kotyra said, recalling that night in 1999. Because Caraway was an unwilling patient who had not threatened to hurt herself or others, they couldn't transport her to the mental health emergency room in Syracuse.

"I didn't know what to do for her," Kotyra said, weeping softly at the memory.

Hours later, Caraway leapt to her death from a highway bridge. A girl in a passing car said Caraway never hesitated. She just left her car door open and the engine on, then jumped. A man walking on the street below said she never screamed.

After 4½ years of agonizing over her daughter’s last days and researching her medicines, Kotyra knows that antidepressants are powerful drugs not to be taken lightly — or quit abruptly.

Kotyra felt vindicated when the Food and Drug Administration last week issued warnings about antidepressants and a possible connection with suicidal thoughts. The FDA asked the makers of Zoloft and nine other popular antidepressants to add or strengthen suicide-related warnings on their labels.

Central New Yorkers last year consumed 6.3 million days’ worth of the most common anti- depressants — Prozac, Zoloft, Paxil and Celexa — at a cost of about $13.5 million, said Joel Owerbach, chief pharmacy officer for Excellus BlueCross BlueShield of the Central New York Region.

Anti-depressant users are most vulnerable to suicidal thoughts, the FDA said, when they first begin taking the drug or change the dose.

Quitting Zoloft cold turkey, as Caraway did, against medical advice, was a radical change of dose.

Yet suicide is almost never linked to any single event or factor, according to mental health experts, and more than 90 percent of suicide victims are suffering from an underlying psychiatric illness.

"We do know a main risk for suicide is being agitated and anxious and panicked. Going through withdrawal from an antidepressant can raise that risk," said Dr. Thomas Schwartz, a psychiatrist at Upstate Medical University in Syracuse.

"If you put the patient in more distress, could that tip them over the edge? Sure. But does an anti-depressant put suicidal thoughts in their mind? Absolutely not."

The FDA offered no research connecting the medications and suicide when it called for the consumer warnings last week. Critics asked the FDA at hearings last month to issue stronger warnings.

Caraway had battled depression since high school. She’d been assaulted. She’d had bulimia. She’d recently declared bankruptcy because of $6,500 in credit-card debt, and had ended a relationship with a married man.

Throughout these problems, she remained, for the most part, self-confident, her friends and relatives say. At Solvay High School, she scored 100 percent on a U.S. history regents exam and graduated 18th in her class of 116. She earned straight As her freshman year of college in 1997, and made the dean’s list sophomore year as well.

"Becca knew herself very well," her mother said. "She totally knew what she wanted out of life. She always worked her way through her little bouts of depression and came out of it with a very positive outlook and wrote about how she learned from them."

Kotyra said the antidepressants Caraway started taking at age 19 in 1995 turned her daughter’s behavior surly and zombie- like. Caraway wrote in her diary that the Zoloft often made her feel "nervous" and "anxious." Her blood sugar plummeted, a rare side effect of antidepressants, which landed her in the hospital twice, according to her medical records. Her doctor switched her to Paxil.

One of the nation’s leading critics of antidepressants, Dr. Peter Breggin, an Ithaca psychiatrist, said he thinks the drugs can induce abnormal behavior, violence and suicide by causing users to become agitated and to lose their customary ethical restraints and self-control.

The best solution, Breggin said, is to slowly stop taking the drugs — while under a doctor’s supervision — and seek treatment with psychotherapy instead.

Other experts say antidepressants help far more people than they hurt.

"We need to remind ourselves that depression is a severe and lethal illness," said Dr. Mantosh Dewan, chairman of the psychiatry department at Upstate. "It has a very high suicide rate. It’s not a skin rash you’re treating there’s an enormous amount of pain and suffering. No, you don’t throw an anti-depressant at everybody who walks through the door. But in severe cases when psychotherapy is not enough, I would use them relatively freely."

The FDA warnings, though, have "definitely raised the stakes again," said Dewan, who was among experts who analyzed a link between antidepressants and suicide when complaints were raised nationwide in the 1990s. At that time, the FDA concluded there was no link.

Syracuse psychiatrist Dr. Joyce Garber doesn’t buy the "Prozac made me do it" argument.

"These drugs are used for people that are already depressed and suicidal, so it’s very difficult to make a claim that they cause suicidal or homicidal behavior. In fact there are so many people taking these drugs that the streets would be running with blood if that were true," said Garber, former president of the Onondaga County Medical Society. There are a small number of people who cannot tolerate antidepressants without additional drugs, in particular people with bi-polar disorder or schizophrenia, Garber said.

Drugs a life saver for some

Experts said it takes time for patients to find the right antidepressant — or the right mix of two or three.

Kathleen Roberts, who works in hospital administration and lives in Syracuse, said she tried Wellbutrin for depression, but it made her anxiety level "10 times worse" and made thoughts of suicide more pronounced.

"It feels like you're going 100 mph hour inside and you just can't stop," said Roberts, 52.

Neither Zoloft nor Celexa worked either, so in May 2002 Roberts switched to a combination of Effexor and Risperdal, and is doing better, she said.

"I really wish people could understand that depression is such a debilitating thing. It makes it difficult for people to exist in society," Roberts said. "My family will say, Just get out of it.' I can't get out of it. It's not that I just don't want to get better. It's a chemical thing with my brain."

Gregg Phillips, 43, a married father of one, said he tried to kill himself five times before going on Prozac in 1998. When he quits taking it, he said, he plunges into that same black hole of depression, huddled on his bed with the blinds closed, not wanting to get up even to use the bathroom.

"Would my illness be worse off the drug?" said Phillips, a sales manager for a Syracuse area medical linens supply company. "Definitely."

No single case can be used as an example of how someone else will react to an antidepressant, said Dr. Jud Staller, a child psychiatrist at Upstate.

"What's puzzling and confusing about these drugs is that some people respond beautifully and dramatically to them and others respond poorly," Staller said. "It's such an individual thing."

The key is for patients and their loved ones to be on the lookout for side effects that might require their doctor to change the dose or switch drugs, he said.

Many drugs, many doctors

About 75 percent of patients obtain their prescriptions from primary care doctors, according to Excellus. That's because those doctors can often see the patient the soonest and the visit will be covered by insurance, said Dewan from Upstate. But those doctors may spend less time with each patient and know less about the complex pharmacology of drugs than specialists.

According to Caraway's medical records, which her mother obtained after her death, Caraway got her final prescriptions for Zoloft and Xanax from an urgent care center, whose staff had never met her before. It is not clear whether she told them she'd had bad reactions to Zoloft three years earlier.

She was first given antidepressants by her family doctor in June 1995. She was also seeing a psychologist. The Zoloft changed her personality, making her angry and tired, her family said. She gained 18 pounds and suffered from dizziness. When her psychologist died suddenly in 1998, she was deeply upset.

Over the years, Caraway switched from Zoloft to Paxil back to Zoloft then to Prozac (using a friend's stash of unused prescription pills) and back to Zoloft.

"It's time to start dealing with life again, as bad as it may be," she wrote Aug. 9, 1999 in her planner. The calendar pages were filled through Oct. 4, 1999 with class assignments and goals for exercise and healthy eating. "I have to fight this self-destructive streak."

But she wrote that the Zoloft was making her jittery and so sleepy that she had to take three- hour naps.

Caraway decided to quit Zoloft altogether and to drink alcohol, despite warnings on the drug labels and warnings from her doctors.

Family tried to get help

In mid-September 1999, she alarmed her co-workers at her telemarketing job with nonsensical rambling and sobbing. Her mother, brother Joe, then 13, and stepfather, Chet, were freaked out by her moodiness and extreme paranoia. She swore everyone in Syracuse was trying to kill her. Watching "Law & Order," she burst into inappropriate laughter. She closed herself in her bedroom, typing at the computer, playing classical music and growling, "Shhhhh. I need quiet. Quiet.'"

One day, she collapsed into bed.

"She raised her head off the pillow to talk to me and it was like I was looking at a monster — her eyes were all bloodshot," her mother said.

Caraway refused to go to the hospital, so on Sept. 18, Kotyra telephoned a mental health hot line, then St. Joseph's Hospital's mental health unit. She said she asked the Comprehensive Psychiatric Emergency Program to send their mobile unit to her home on Horan Road in Camillus. An appointment was set for Sept. 20.

The morning of Sunday, Sept. 19, Caraway asked her mother to take her to Wegmans to get sushi. She wouldn't change out of her pajamas and refused to enter the grocery store. She stood outside smoking a cigarette, her eyes nervous, her movements jerky.

Back in the car, she stared out the window, muttering to herself.

Kotyra leaned toward her. "Are you O.K., honey?"

Caraway, eyes wide, sprang at Kotyra and screamed in her face, "YOU ARE NOT REAL!" She slumped in her seat and moaned, "I want out. Let me out of here. I want out."

Kotyra, terrified for her daughter, silently wished for Sept. 20 to come quickly.

That night, Caraway, her feet half-shoved into Steve Madden tennis shoes, snatched her car keys off the kitchen counter. Kotyra tried to stop her. Caraway ignored her.

Caraway drove the short distance to the Interstate 690 bridge over State Fair Boulevard, climbed the railing and dropped out of sight.

About a half an hour later, the family had just finished supper when there was a knock at the door. There's been an accident, a Camillus police officer said, you need to come to the hospital.

In the squad car, the family shot past the scene on the bridge, red and blue lights from emergency vehicles flashing in the dark night.