'I wonder if he's on commission': A psychiatrist online prescribed me Prozac, punched the air in celebration - and suggested I have a beer. Is this normal?

By Quentin Fottrell

'I processed a $50 copay, and attended my appointment with the psychiatrist. It went fast, and every time I asked a question about antidepressants, he popped a medical study in the chat box'

Dear Quentin,

I recently went through a pretty bad breakup with my boyfriend, who cheated on me. I signed up for a telemedicine service. I looked through a lot of psychiatrists and psychologists online, and those who took insurance and were in-network had a long wait list. Hence, my choosing a Zoom (ZM) appointment with a psychiatric nurse on a Friday night. She then couldn't make it and rescheduled my appointment with an actual psychiatrist. I didn't mind the change so much, as long as it was not canceled.

I processed a $50 copay, and attended my appointment with the psychiatrist. It went fast, and every time I asked a question about antidepressants, he popped a medical study in the chat box. For every study that says Prozac (fluoxetine) or Celexa (citalopram) does not have a certain side effect, there is another to say that they do. It's confusing. When I told him I thought about taking fluoxetine, he threw his arms in the air in celebration. I wonder if he is getting a commission.

He prescribed the medication, and sent the prescription to my local pharmacy. Now I'm getting regular emails about future appointments with warnings that the price of the sessions could fluctuate. If I were asked to use a word to describe this therapist, it would definitely be "pushy." The way he tells it, SSRIs are the perfect antidote to my anxiety and depression, and have almost no side effects. He knew this after speaking to me for all of 10 minutes.

At the end of our last call, I said I was going out with friends, and he told me, "Have a beer for me!" Now I'm wondering, is it my anxiety that is making me second-guess everything he says? I had addiction issues in my 20s in New York, but they are in the past. Am I being extra sensitive to every little comment? Or was this whole experience too rushed and, frankly, inappropriate? (The cheering when I suggested Prozac and his hoping that I have a beer on him.)

My mental health is fragile, and I'm now being hounded by emails to pay for upcoming sessions.

What do you think?

Depressed & Disillusioned

Related: 'He's quit talking to me': My father, 83, suffers from hoarding disorder and dementia. How can I help him and protect his estate?

Dear Depressed & Disillusioned,

Finding a good boyfriend is hard, but finding a good doctor is sometimes even harder. Your first appointment, the psychiatric nurse, probably had plans herself that Friday night.

Telemedicine gives both the client and the professional flexibility, but it's tricky doing your due diligence on your psychiatrist or psychiatric nurse practitioner if you don't have their name in advance. Throwing his arms in the air when you suggested Prozac does not seem like a normal response. It certainly does not sound like a professional response to prescribing an SSRI. After all, he is prescribing medication and not handing out candy to a child for good behavior.

Taking antidepressants does not appear to deter people from also drinking alcohol, and doctors warn against mixing the booze and pills. Alcohol is a depressant, so drinking can counteract the benefits of taking an SSRI in the first place. The Mayo Clinic gives a litany of reasons why you should avoid doing both: They can worsen any side effects, and make you feel less alert and more sleepy, drowsy and foggy, which could impede your ability to work or even drive.

His attitude to prescribing antidepressants seems very cavalier. You told him you had a preference for a particular medicine - not that you (or he) won the lottery. Antidepressants can also lead to suicidal thoughts, a lower sexual drive, more sleep - the list goes on. The psychiatrist, whether you connected with him online or in person, should have explained the risks to you and made sure you would contact him if your feelings of anxiety and depression got worse.

Federal law strictly prohibits doctors from receiving a commission for prescribing a specific drug. However, pharmaceutical companies may offer other, legal incentives. "Travel and accommodation to conferences are permitted, which allows for pharma companies to create incentives for doctors to be invited to lavish conferences," says the Kaufman Law Group, which is based in Los Angeles. (You can report also your doctor to the state medical board. Read more here.)

Federal law on commissions

Some doctors may have financial incentives: The Physician Payments Sunshine Act, which was part of the Affordable Care Act, requires that pharmaceutical and/or medical-device companies should report any payments made to teaching hospitals and individual physicians, and quantified industry payments made to psychiatrists. Still, that's not always clear to patients; if in doubt, ask. You will hopefully get an honest response, but that's not a guarantee.

At the best of times, it's a gray area. At the worst, it's a pretty complex (or murky) business. "The law allows for pharmaceutical companies to give money to doctors in multiple ways, which means that a doctor might feel pressure or incentive toward prescribing certain drugs or medicines," Kaufman Law Group adds. "And even if there's no overt pressure, these kinds of benefits can prejudice a doctor in a certain direction when it comes to prescribing drugs"

Some background: Telemedicine services were expanded in the wake of the COVID-19 emergency, which allowed them to prescribe controlled substances (currently until Dec. 31, 2024). The U.S. Drug Enforcement Administration does not consider fluoxetine, citalopram and other SSRIs as at a high risk for misuse or addiction by patients - at least not like opioids, for instance. (But don't try coming off an SSRI overnight and/or without medical supervision.)

Psychologists usually provide cognitive/talk therapy, but they can only prescribe medication in a handful of states. Psychiatrists can prescribe medication in every state, but the law is more complex for psychiatric nurses, who typically have graduate and/or postgraduate degrees. "Each state has different requirements to prescribe medication from full practice authority to needing a supervising psychiatrist," according to the American Psychiatric Nurses Association.

The good, bad and unreliable

There are good, bad and unreliable actors in every industry. We expect a certain level of care from mental-health professionals, but trust needs to be earned. In the wake of the pandemic, telehealth was booming and companies faced stiff competition to boost profits. Some had to hire practitioners at an inordinately fast pace to meet the demand; in other egregious cases, companies shared sensitive data and made it overly complicated for clients to cancel.

The telehealth industry has spent millions of dollars on social-media advertisements and, in at least one case, a company was the subject of a Drug Enforcement Administration probe for allegedly overprescribing stimulants and for using misleading advertising practices. In the wake of the pandemic, some companies were using actors masquerading as patients in ads with zero mention of side effects. (Facebook parent Meta (META) has said it will remove ads that violate its policies.)

But the industry has also helped millions of Americans. This study published last year, in the peer-reviewed Journal of Affective Disorders, found that both in-person and telehealth patients with major depressive disorder "were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups also reported a significant improvement in positive mental health, general well-being, coping ability, and functioning."

Don't see a doctor if you don't like them and/or they make you feel uncomfortable, and don't allow one swaggering cowboy to deter you from seeking out mental-health services from trusted companies and psychiatrists online or in-person. Now that you have a prescription, you could make an in-person appointment first, and have follow-up sessions online. Never take such medications unless you are under medical supervision, and never come off them on your own either.

And today? Your ex-boyfriend has done you a favor. He has made it possible for others to get to know you - and experience all the great qualities you have to offer.

Other resources for people with family members with addiction issues: The Center for Motivation and Change published this book, "Beyond Addiction: How Science and Kindness Help People Change." by Robert Meyers, who has been working in the field for four decades.

The Moneyist regrets he cannot reply to questions individually.

Previous columns by Quentin Fottrell:

'He's holding all the cards': My mother, 86, has dementia. Her partner of 30 years is on the deed to her home. How can I gain control of her finances?

'I live in a slum': My ex-husband knocked down, then rebuilt my home and left it in foreclosure. Now he refuses to pay alimony.

'I see my greedy in-laws as misogynists': I was a stockbroker in the 1980s and always kept my money separate from my husband's. Is such self-protection justified?

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-Quentin Fottrell

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05-11-24 1738ET

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