Avoid heavy foods

Be moderate in the drinking of wine

Take massage, baths, exercise and gymnastics

Fight insomnia with gentle rocking or

the sound of running water

Change surroundings and take long journeys

Strictly avoid frightening ideas

Indulge in cheerful conversation and amusements

Listen to music

advice to melancholics -A. Cornelius Celsus, 1ST century ad

It is typical for us humans to expect everything to fly into our mouths without work, art, effort, grief and suffering. But all of this is not God’s way; rather, it is His will that we should work hard for our food and that we should want to support both ourselves and those around us.

Paracelsus, I493-I54I

There is an old joke about a bookseller who is trying to sell a book to a student. ‘It will do half your work for you,’ he claims. ‘Great,’ says the student. ‘I’ll buy two copies.’ It is only human for us to want to have all our work done for us or all our problems solved by a simple remedy such as a pill. The bad news – and, of course, it is not really news at all – is that wondrous though a pill may be, St John’s Wort included, it will not cure all that ails you. The good news is that there are so many ways to help yourself, many of them quite painless and even pleasurable, as the advice of A. Cornelius Celsus above would suggest. Celsus was the doctor to the Emperor Tiberius, a cruel, powerful and frightening man, and the gentleness of Celsus’ advice was perhaps as much politic as it was wise. Paracelsus, an outspoken man, fearless and impolitic in the conduct of his own life, had no qualms about expressing himself frankly. If you want your life to be better, you need to exert some effort to make it so. In my own dealings with depressed people I have found many ways in which modifying elements of one’s life can contribute enormously to an anti-depressant lifestyle that works beautifully in conjunction with anti-depressant medications, including St John’s Wort. In this chapter we will consider some of the many ways that you can help take control of your life and conquer your own depression.

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What is the lowest dose shown to be effective, and when is this indicated? Anecdotal reports by individual psychiatrists suggest that the lowest dose that seems to have been effective is 2.5 to 5 mg a day. As noted above, this may be indicated in young children, some very elderly patients, and patients who develop side effects on a standard dose.

What is the highest safe dosage of Prozac, and when is this indicated? Individuals differ, both in their genetic tolerance for a given dose and in the side effects they experience, but in general, the maximum recommended dose is 80 mg a day. However, that dosage has been exceeded occasionally with very overweight patients. Some obese patients nave come out of depressive episodes after being given over 80 mg in select cases where safety has been maintained. Such a dosage is not advised in general because there are potential safety concerns in patients taking over 80 mg a day.

Will a stronger dose get the patient back to the previous level? Usually, what is going on in such an instance is that the patient, after coming out of depression on Prozac, forgets to take the medication or cuts down on the drug without the physician’s knowledge. Sometimes the doctor and not the patient is to blame: a frequent reason for slipping back into depression after an excellent response is that the physician, typically someone who has not had extensive training and experience with Prozac and other antidepressant drugs, takes the patient off the drug too soon. If these possibilities are eliminated and the patient is still losing ground, the dosage should be increased. The problem may be that although the dosage brought the patient out of the initial depression, the level of the drug in the blood did not remain high enough to prevent relapse.

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Although a number of studies have shown that the depressed mood may begin to lift in a week, it generally takes at least two to three weeks for the patient and family to notice a real difference. The low mood may continue to lift for five to eight weeks before leveling off. In 65% to 70% of cases, the depression recedes within four to eight weeks. A patient should take a full dose of Prozac, under the supervision of an expert physician, for at least six weeks before concluding that the drug has failed to act on the depressive illness.

Occasionally people may claim to experience immediate relief. Although psychiatrists generally say this is the placebo effect, no psychopharmacologist can rule out the possibility that a given patient’s metabolism may in rare instances react to the drug immediately, causing rapid changes in mood and behavior within one or two days.

Is it justified to give Prozac to patients who are not suffering from an identifiable psychiatric illness but who have one or two symptoms? Symptoms such as low self-esteem, sadness, sluggishness, or chronic discouragement may not add up to full-blown depression or dysthymia but can be considered symptoms of subclinical or subsyndromal depression, which is about to become a new diagnostic entity. In previous years, subclinical depression hadn’t been identified as a formal DSM disorder. Instead, psychiatrists and analysts diagnosed a personality or character disorder and concentrated in therapy on self-defeating personality traits and defense mechanisms rather than mood. (Cognitive therapy is the only exception.) Today, subclinical depression is recognized as a disorder that can be responsive to medication. Therefore, many psychiatrists treating these patients now use Prozac along with psychotherapy or instead of it if the therapy alone has not worked.

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Secondary depression can develop in the presence of a previously existing condition, whether it is medical, such as a hypothyroidism, stroke, Parkinson’s disease, or AIDS, or psychiatric, such as schizophrenia, panic disorder, or bulimia, among others. The key is which came first. When the depression clearly develops chronologically after the other primary medical or psychiatric condition, it is considered secondary.

Is Prozac an effective treatment for secondary depression? It can be. But the first step should always be to focus on bringing the primary disorder under control. If the depression persists even after the primary illness has been treated, Prozac can be added and is often effective, as are other antidepressants.

Antidepressants can also be effective in the presence of other psychiatric disorders and can be combined with other medications, so long as the primary treatment is not an MAOI antidepressant. In the case of schizophrenia, Prozac can be safely combined with major tranquilizers. When anxiety disorders are primary, Prozac can be given with minor tranquilizers, and when the diagnosis is bipolar manic depression, it can be taken along with lithium, Tegretol, or Depakote.

With obsessive-compulsive disorder, bulimia, and panic disorder, evidence is emerging that Prozac may alleviate the symptoms of both the primary illness and the secondary depression so often experienced in these disorders.

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Cyclothymic disorder can be diagnosed after two years (one for children and adolescents) in which a patient who usually continues to function quite reasonably has had several hypomanic episodes along with numerous periods of depression. These ups and downs do not meet the full criteria for major depression. Between the mood swings the symptoms never disappear for longer than two months at a time. Yet there is no clear evidence of a major depressive or manic disorder. The ups are energetic and productive, while the downs are simply tolerable, with the person becoming more pessimistic and withdrawn. Cyclothymics usually remain cyclothymics, and they appear to be afflicted by mild versions of manic-depressive disorder. In some instances, however, the episode may change into full-blown manic depression. Manic depression requires treatment with lithium, and, in some instances, cyclothymia requires lithium treatment as well.

The use of Prozac in cyclothymia has not been adequately studied, but the very nature of the illness makes this an area for caution. Presumably, from all we know about Prozac, it would alleviate the depression. The problem is that it could also accentuate the periods of hypomania. Thus, it could conceivably turn a cyclothymic disorder into full-blown manic depression. For this reason, Prozac should not be used on a long-term basis in cyclothymic patients, and if used in the depressive phase, it should be used very cautiously, and in smaller doses than usual. However, if Prozac is given in conjunction with lithium or one of its alternatives, it could theoretically provide safe, long-term protection against the ups and downs of cyclothymia.

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