Other mood fluctuations occur over days and are less easy to recognize. For example, people may become depressed a few days after the clocks are turned back at the end of autumn, after returning from abroad or after a big party. In these three situations the deterioration in mood may be due to the hour’s decrease in afternoon daylight, jet lag, or the delayed effects of alcohol respectively. One useful strategy for those who experience unexplained dips in mood is to keep a daily mood log, which will help you to recognize the connection between mood fluctuations and external events. At times such logs can be crucial in convincing you that a clear pattern exists. For example, it was only after she had kept a log for several months that one of my patients was willing to concede that the alcohol she consumed on Saturday night was responsible for the dip in mood experienced two or three days later.

Finally, there are mood changes that have a longer period of duration, such as the monthly mood changes of premenstrual syndrome or the annual mood fluctuations that occur with the change of the seasons in people with SAD or the winter blues.

Mood may change with the environment – physical, climatic or human. One of my patients would feel depressed every time she went to her office. This seemed strange as she liked her colleagues and was passionate about the work itself. The clues to her depression lay in her associated symptoms – headache, dizziness, fatigue and difficulties with short-term memory. She worked in an air-tight office block full of office chemicals – printer cartridges, copiers, FAX machines and other sources of organic solvents. She was a victim of the so-called sick-building syndrome, and depression is one of the key symptoms that affect people suffering from this disorder. One patient with seasonal affective disorder experienced depression after she moved from a bright high-rise block of flats to a dim ground-floor studio. A third patient became depressed every time she visited her mother-in-law. The patient was very self-conscious about her looks and was constantly battling to lose weight. Somehow her mother-in-law always managed to direct the conversation to the patient’s figure, often in the guise of a compliment. ‘That dress really suits you,’ she would say, ‘it’s just right for your shape. Where did you find it?’ This would invariably make the patient self-conscious and depressed. In all of these cases, the first step in handling the problem was understanding it. An old medical adage is that you cannot treat before you diagnose. I therefore recommend that if you are of a moody disposition, become your own diagnostician, find out what is depressing you and then proceed to take remedial steps.

*66\75\2*

John P. Feighner and his International Clinical Research (ICR) team investigated Prozac’s effects on the elderly, using at least two methodologies: double blind studies, in which some patients were given Prozac and some patients received tricyclic antidepressants, but neither patients nor researchers knew who got what, and open studies, which lack a control group. Both types of studies indicate that Prozac relieves the symptoms of depression as effectively an other antidepressants in geriatric patients. But patients taking Prozac complained less frequently of dry mouth, constipation, and drowsiness. As a result, they were much less likely to stop taking the drug due to adverse effects. Some 35% to 36.8% of the patients on tricyclic antidepressants dropped out of various studies, whereas 43% to 47.1% of the Prozac patients discontinued.

Prozac lacks adverse cardiovascular effects, compared to the tricyclic drugs, and is much less dangerous in overdose. Thus, most psychopharmacologists prefer Prozac as an antidepressant in the elderly.

Prescribing physicians should consider giving elderly patients lower dosages, especially when the patient has physical problems or is on a variety of other medications.

*101\22\4*

CAN Prozac be used simultaneously with the tricyclic antidepressants (TCAs)? Although this has not been studied sufficiently, Prozac it frequently given in clincial practice with small dotes of TCAs. Adding Prozac to a TCA has occasionally led to an increase – even a doubling—of the previously stable blood level of the TCA. This requires more study.

Can Prozac be used with second generation antidepressants such as Desyrel (trazodone), Ludiomil (maprotiline), and Asendin (amoxapine)? Caution should be used if any of these drugs is taken with Prozac, and small doses should be given until further scientific evidence is forthcoming as the combined safety. Enough research just hasn’t been done, but to date I have used the combination and it appears safe.

Can Prozac be used safely in combination with Tegretol (carbamazepine) or Depakote (valproic acid) and under what conditions is it called for? Bipolar and schizoaffective patients often have psychotic features that lithium alone has failed to control. In these cases, Tegretol or Depakote may be substituted for lithium or added to it. An antipsychotic may also be needed. If the depression is still moderate to severe, an antidepressant such as Prozac must be added to stabilize the illness. Patients receiving Tegretol or Depakote may have Prozac added in combination with the usual concerns for idiosyncratic reactions.

Can Prozac be used in combination with major tranquilizers such as Thorazine, Mellaril, Trilafon, Steiazme, Haldol, Loxapine, Navane, and Prolixin? To date, there are no contraindications for using these major tranquilizers in combination with Prozac. However, doses of these drugs, when used in combination, should be started low and escalated slowly and cautiously. Usually an anti-Parkinson drug such as cogentin, artane, benadryl, or kemadrine should be added to counteract the side effects of these major tranquilizers.

Can Prozac be used in conjunction with habit-forming minor tranquilizers such as Valium

(diazepam), Xanax (alprazolam), Ativan (lorazepam) or Klonopin (clonazepam)? What about tranquilizers that are not habit-forming, such as Buspar (buspirone)? There are no known contraindications to using Prozac with these minor tranquilizers, both habit-forming and nonhabit-forming. However, all the data is not in. Habit-forming medications should be used sparingly. Caution is warranted in combining buspirone, a non-habit forming antianxiety drug, with Prozac due to a few reports of hypomanic reactions.

Can Prozac be used safely with hypnotics (sleeping pills) including Restorii, Dalmane, Halcion, chloral hydrate, and barbiturates? There are no known contraindications for using Prozac in combination with any of these sleeping pills. Remember, however, that all of them have habit-forming properties and cross-addictive tolerance with alcohol. Alcoholics should not be given these hypnotics, and nonalcoholics should be given low doses for short periods of time to avoid doctor-induced addicions to these substances.

What antidepressants are available for depressed patients in the United States and abroad?

The most important antidepressants can be divided into several main categories:

• tricyclic antidepressants (TCAs)

• monoamine oxidase inhibitors (MAOis)

• selective serotonin reuptake inhil

• lithium

• structurally unrelated compounds

*81\22\4*

Major depression is something else. It does not just blow away in the course of a week or ten days. It persists for at least two weeks, according to the DSM-IV criteria, and sometimes for years. On the average, a major depression lasts three to eight months. Because ft lasts longer and is more serious than temporary feelings of lethargy, gloominess, or sadness, it impairs functioning in a real way.

Since the word “depression” is sometimes used to mean anything from a passing mood to a clinical illness, the first thing any doctor must do when a pattern comes into the office and complains of feeling blue or depressed is to conduct a detailed psychiatric diagnostic evaluation, obtain a recent physical exam, and get a personal and family history. A patient who facto sufficient symptoms to make a DSM-IV diagnosis of one of the depressive disorders may simply be experiencing a temporary down – a normal depression. Or the patient may be experiencing a subclinical depression with only one to two deprive symptoms, in the latter case, many psychiatrists, and particularly psychotherapists, term the subclinical depression a personality disorder since it does not meet the full DSM-IV criteria for any of the main categories of depression.

Prozac should not be used for the transitory down or unhappy feelings that everyone at times experiences. These are part of our normal range of emotions.

On the other hand, if the depression lasts for more than a few weeks, and is accompanied by a sufficient number of DSM-IV symptoms, a diagnosis of major depression, dysthymic or bipolar depression is made and action in the form of medication needs to be taken by a trained expert. This is usually a psychiatrist specifically trained in giving medications (psychopharmacologist).

*61\22\4*

Nonetheless, although a number of patients do report some altered sexual functioning with Prozac, and also with the newer SSRIs, they seldom stop taking the drug for this reason. Although they’re not pleased to have sexual difficulties, they are so grateful to feel normal in other respects that usually they learn to cope.

Other people (including three elderly men who reportedly had sexual functioning restored after many years of dysfunction) experience no problems in sexual functioning and often find themselves more interested in sex than they had been. Since depression causes a decrease in libido, most patients who recover from depression can confidently expect an increase in sexual desire. By lifting the depression, Prozac increases the libido and makes it easier to find enjoyment in all kinds of activities, including sex. However, the price may be delayed orgasm in one third of both men and women.

According to at least one non-scientifically controlled study published on six men and women receiving SSRIs and experiencing the typical sexual side effects, most of these symptoms were improved with the administration of Yohimbine.

*39\22\4*

A certain number of depressed patients, year after year, come to the office in a depression, take an antidepressant, and then once the depression is alleviated, stop their office visits and go off the drug on their own. In these instances, after a relapse, the antidepressant usually has to be reintroduced at the previous therapeutic level or at an even higher level before the depression again disappears.

*19\22\4*