Post-partum Depression
New mothers typically expect to feel overjoyed after giving birth. But because of the enormous hormonal changes of delivery and the challenges of dealing with an infant, some two-thirds of women feel transient sadness. About 10% to 15% become clinically depressed. And about one in 1000 become so severely depressed that they must be hospitalized for their own safety and the safety of their baby.
The first selective serotonin reuptake inhibitor, Prozac, was approved by the FDA in 1987. Zoloft followed in 1991 and Paxil in 1992.
SSRIs may cause sexual side effects. Depending on the study, 40% to 50% of SSRI users complain of one or more sexual side effects, mostly, inability to have an orgasm, but also decreased desire and arousal, erection impairment in men, and loss of lubrication in women.
SSRIs also disrupt sleep. They often cause “micro-awakenings.” Users usually remain unaware of these sleep disruptions, but they appear clearly in sleep studies of SSRI users, and contribute to the fatigue some users cite as a reason for dissatisfaction with these drugs. If SSRIs keep you awake, take the dose before noon each day. If they make you sleepy, take the dose at bedtime.
Generally, SSRIs can cause headache, excessive sweating, nausea, upset stomach, diarrhea, difficulty sleeping, drowsiness, and tremor. A decrease in weight tends to occur more often than weight gain.
Prozac. The recommended initial dose is 20 mg/day. Doses above 20 mg/day may be given in two doses, at morning and noon. If necessary, it may be increased up to a maximum of 80 mg/day. Seniors will require lower dosing, as will people with kidney or liver problems.
Zoloft. The recommended initial dose is 50 mg/day. If necessary, it may be increased up to a maximum of 200 mg/day. Seniors will require lower dosing, as will people with kidney or liver problems.
PHILADELPHIA, May 7, 1996 — Paxil (paroxetine hydrochloride) was cleared by the U.S. Food and Drug Administration today for the treatment of panic disorder, SmithKline Beecham announced. Panic disorder is a chronic, disabling condition that will affect 3 to 6 million Americans at some time in their lives.
Paxil is the first and only antidepressant indicated for treating panic disorder and the first new drug therapy to be cleared for panic disorder in nearly a decade. Paxil belongs to the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs
Paxil. The recommended initial dose is 20 mg/day. If necessary, it may be increased up to a maximum of 50 mg/day. Seniors will require lower dosing, as will people with kidney or liver problems.
The side effects: Stopping an SRI too quickly can bring on dizziness, insomnia, vivid dreams, headaches, nausea, fatigue, and/or chills, says panel member Jerrold F. Rosenbaum, MD, associate chief for clinical research in the department of psychiatry at Massachusetts General Hospital in Boston. You might also feel anxious, agitated, or irritable, or have uncharacteristic crying spells.
Why it happens: Your brain must adapt to lower levels of the neurotransmitter serotonin when you quit. “If the chemical makeup of your brain changes abruptly, side effects are more likely,” Dr. Rosenbaum says.
Paxil/Seroxat, up 18% to 1.06 billion ($1.76 billion); the first SSRI approved for panic and social anxiety disorder/social phobia.
SRIs with active ingredients that leave the body quickly — paroxetine (Paxil), sertraline (Zoloft), venlafaxine (Effexor), and fluvoxamine (Luvox) — seem to cause side effects more often than those with components that linger, such as fluoxetine (Prozac).
Alternatives
The research shows that for mild depression, non-drug therapies are as effective as antidepressant medications. For mild-to-moderate depression, non-drug therapies may be sufficient, but many people also need antidepressant medications. The two often work best together.
For moderate-to-severe or severe depression, medications are necessary. But the non-drug therapies can still play a valuable supportive role in treatment.
· Have more fun. In mild depression, this often helps. “Happiness requires action,” says psychologist Jennifer James, Ph.D., author of Women and the Blues. Try not to mope. Visit a friend. Have a massage. Get a pet. Redecorate. Take a class. Take a vacation. If nothing feels fun, do things you used to enjoy.
· Cognitive therapy. You can’t talk yourself out of depression, but you can stop talking yourself deeper into it. Cognitive therapy — also called cognitive restructuring — teaches people to recognize and correct depressive thinking. If you make a mistake at work, you might think, “I’m hopelessly incompetent,” and slide toward depression. That’s “awful-izing” — a thought distortion that magnifies minor upsets into catastrophes. With cognitive therapy, the reaction changes: “OK, I made a mistake. Everyone makes mistakes. Fortunately, my boss and co-workers know I don’t make many. And I can fix this one easily.” A National Institute of Mental Health (NIMH) study showed that after 16 weeks of cognitive restructuring training, 51 percent of those with mild to moderate depression reported significant improvement. “Cognitive therapy also lends itself to self-help,” Dr. Freeman says.
Psychotherapy. Long-term Freudian psychoanalysis has been largely replaced by shorter-term “talk therapies.” The NIMH study showed that after 16 weeks of psychotherapy, 55% of those with mild to moderate depression reported significant improvement. How long is long enough? “For most major depressive episodes,” Dr. Freeman says, “four to five months is usually about right.”
Support groups. Depression feels terribly isolating. Support groups show you that you’re not alone. They are particularly helpful for depressions associated with drug or alcohol abuse, which is why Alcoholics Anonymous and the other Anonymous organizations are so popular.
Herbal medicines. Several medicinal herbs have antidepressant effects. The most powerful is St. John’s wort, a natural SSRI and weak MAO inhibitor. In addition, kava-kava, ginkgo, and caffeine can also help.
Dietary supplements. Certain vitamin deficiencies — notably B-6, B-12, C, folic acid, thiamine, niacin, riboflavin, biotin, and pantothenic acid — can cause depression.
Exersize. Studies have shown that tremendous improvements have been made to decrease symptoms of depression through high cardio vascular exersize. Also, exersize enhances sexual drive as well as acting as an overall mood enhancer.
Acupuncture, aromatherapy, and other alternative treatments. The United Nations World Health Organization recognizes acupuncture as effective for mild-to-moderate depression. Other helpful treatments include aromatherapy, massage therapy, music therapy, and meditation.
Phototherapy. Seasonal affective disorder is caused by lack of sunlight in winter. Supplemental artificial light successfully treats it. A half-hour a day in front of a special bright-light appliance lifts the spirits of 60% to 80% of those with winter depression. Another appliance that simulates an earlier dawn may also be beneficial. Antidepressant medication can help as well. So can midwinter tropical vacations. The emotional benefits typically last a week or two after returning north.
5-hydroxytryptophan (5-HTP) is the less well known cousin of serotonin (5-HT), one of the most important brain neurotransmitters. Tryptophan is first converted to 5-HTP in nerve cells by a vitamin B3 dependant enzyme, and then 5-HTP is converted to 5-HT by a vitamin B6 dependant enzyme. Modern science has creted a way for 5-HTP to be dependantly created.
5-HTP passes through the blood brain barrier into the brain far more easily than tryptophan, and getting tryptophan through the blood brain barrier is the main bottleneck, which in many people leads to inadequate brain serotonin levels.
Tryptophan can be broken down in the liver by pyrrolase, an enzyme that converts tryptophan to kynurenine and its metabolites, which can be mildly liver toxic at high levels. 5-HTP is not metabolized through this pathway.
The work of HM van Praag, SN Young and others over the last 20 years, shows that serotonin is a key brain neurotransmitter involved in mood regulation (anti-anxiety and antidepressant), impulse control (inhibits aggression and obsessive compulsive disorders [OCD], pain control and sleep).
Serotonin is also the precursor for our pineal gland s production of melatonin. Human clinical studies show that 5-HTP is a far more efficient increaser of brain serotonin than tryptophan.
5-HTP has been shown to increase brain dopamine (DA) and noradrenaline (NA) activity. These are two key mood and alertness regulating neurotransmitters, and when tyrosine, the amino-acid precursor for brain DA/NA is given along with 5-HTP, the effect is even more powerful.
Van Praag s and Young s work suggests that 5-HTP is more likely to be effective for those suffering an anxious, agitated, aggressive, irritable depression and is rarely effective for those suffering from a severe, vegetative, total “blahs” type depression.
5-HTP may also be helpful in some cases of compulsive carbohydrate overeating, alcohol addiction and compulsive gambling (specific forms of OCD), as well as for insomnia.
Side effects of 5-HTP are occasional gastrointestinal upset, hypomania and euphoria. Even though 5-HTP is a natural substance normally made by the brain, without medical supervision prudence suggests limiting daily dosage to 100mg to 200mg, a dose shown to be effective in human clinical studies.
Research also shows that 5-HTP, increases the activity of MAO inhibitor drugs, tricyclic antidepressants and selective serotonin inhibitor (SSRI) drugs, such as Prozac, Paxil and Zoloft. Therefore tryptophan and especially 5-HTP, should only be used by anyone taking any of these drugs ONLY with their prescribing physician s consent and supervision.
The idea that prescribing Prozac was a sort of “cosmetic psychopharmacology” was promoted by psychiatrist Peter Kramer, author of the best-selling Listening to Prozac. In his book, Kramer expressed concern that this antidepressant alters personality as well as illness in a “substantial minority” of users. Actually, Kramer says he doesn’t prescribe Prozac that often and notes that it works for a wide variety of problems in addition to depression. His book was not so much for or against Prozac as it was a philosophical exploration of antidepressants and the human personality.
The main difference between Prozac and other SSRIs is that Prozac stays in the body much longer; this has both positive and negative implications. Prozac’s half-life (the time it takes for a drug in the blood to decrease by half of its original dose) is about a week, compared to about a day for Paxil and Zoloft. Up to six weeks after you stop taking the drug, traces of Prozac and its metabolites can still be found in your body. What this means is that if you have a bad reaction to Zoloft or Paxil, the unpleasant symptoms may linger for a week or two. But adverse effects from taking Prozac can last for up to six weeks after you’ve stopped taking the drug.
There’s a benefit to a long half-life, however. You’ll be less likely to experience relapse of depression if you forget a dose or two of Prozac, and you’ll be less likely to have withdrawal effects from suddenly discontinuing the drug.
Neither Prozac nor the other SSRIs cause the same side effects as older antidepressants — dry mouth, dizziness, blurred vision, constipation. Prozac just helps people feel less fearful, more outgoing, and more self-confident.
Serzone — not an SSRI, but a serotonin-related antidepressant — combines the benefits of Prozac with lower price and fewer instances of at least two side effects (insomnia and sexual dysfunction), according to its makers, Bristol-Myers Squibb. While the FDA cautions that no direct comparisons of Serzone have proven its superiority, it does not directly dispute the company’s claims. Bristol-Myers Squibb bases its figures on published reports of other drugs’ effects.
“Before I took Prozac, every day was difficult,” says Joan. “I didn’t get any joy out of anything; everything was futile. There seemed to be no hope. After being on Prozac for about a month, I suddenly felt that half my life had already gone by. I’d better get in gear!
“I used to compare myself with everyone,” she continues. “Now I don’t care. I’m more confident with other people, and I don’t freak out in groups. I wish,” she sighs, “I had the past 20 years back.”
Prozac Vs. Older Antidepressants
Not everyone who is depressed experiences the disorder in the same way, and not everyone responds to the same antidepressant.
The main advantage of Prozac, compared with the tricyclics and MAOIs, is that it produces relatively mild side effects.
“Elavil (amitriptyline, a tricyclic) made me tired and stupid, but not less depressed,” recalls Marie, who tried a number of antidepressants before responding well to Prozac. “The MAOI was fine, but I couldn’t take the diet, and it did weird things to my blood pressure; I kept passing out in inappropriate places. I was in a daze all the time. Of all the drugs I took, Prozac was clearly the best for me. It worked best for the longest period of time, and I didn’t have any side effects.”
Unlike older antidepressants and lithium, which can be quite toxic, Prozac is not very dangerous even in high doses. Faced with suicidal patients, many doctors feel more comfortable prescribing Prozac, since it’s unlikely a person could cause permanent damage by taking too much. (In one case, a patient who supposedly took more than 3,000 milligrams of Prozac did not have lasting physical damage.) Also unlike older antidepressants, it appears to be a good choice if you have heart problems or high blood pressure, since it doesn’t appear to affect cardiovascular function.
Prozac is also a pleasant change for people who just don’t like taking pills, since the total daily dose of Prozac can be taken as one capsule or in liquid form, compared with the three to six pills usually needed for MAOIs or tricyclics.
Finally, unlike the many older antidepressants that cause significant weight gain, Prozac doesn’t cause weight gain in most people and may even cause them to lose a few pounds. This is partly because of the mild nausea people feel during the first few days, but it’s also because Prozac affects the serotonin system and lessens carbohydrate craving. This benefit shouldn’t be downplayed, psychiatrists say, since the weight gain caused by the older anti-depressants — which could be 30 pounds or more — could be a real stumbling block to staying on the drug.
This does not mean that Prozac is some sort of diet pill. It’s more likely to prevent weight gain than to initiate weight loss. Not everybody who takes Prozac loses weight, and most only lose a pound or two. One study found that 25 percent of Prozac users did gain weight, although this ratio still compared favorably to the 65 percent of users who gained weight on tricyclics. Researchers note that the heaviest people are those who tend to lose a few pounds on Prozac, while the slimmest users are the ones most likely to gain.
Side Effects of Prozac
Most common (in order of frequency)
· sexual dysfunction (40 percent)
· nausea (21 percent)
· headache (20 percent)
· insomnia (14 percent)
· diarrhea or drowsiness (12 percent)
Less common (10 percent or fewer patients)
· anxiety
· dry mouth
· appetite loss
· tremor
· upper respiratory infection
· dizziness
Infrequent (fewer than 5 percent)
· fatigue
· constipation
· abdominal pain
· flulike symptoms
· vision problems
· congestion
· sinus infection
· cough
· mania
Prozac’s stimulatory properties also can cause sleep problems in some people, probably because Prozac (like other SSRIs) affects serotonin, responsible for regulating the sleep-wake cycle. Fortunately, only about 2 percent of patients find the insomnia so troubling that they are forced to stop taking Prozac. About the same percentage are equally disturbed by drowsiness with this drug. If you do experience insomnia, you can try taking your medicine earlier in the day, or ask your doctor about combining Prozac with Desyrel (trazodone).
About 9 percent of people taking Prozac report dry mouth, compared to about 65 percent of those taking tricyclics. A few people also notice sweating, tremors, or rash.
Most antidepressants (except for Wellbutrin) cause some degree of sexual problems, and Prozac isn’t any different. As many as 40 percent of people experience some negative sexual effects, including delayed ejaculation, impotence, decreased desire, or problems reaching orgasm. Patients cite loss of sexual interest as one of the biggest problems with Prozac. On the other hand, some people feel more interested in sex than before, possibly because depression had interfered with their libido.
More seriously, Prozac can induce a manic state (excess elation, hyperactivity, agitation, and speeded-up thinking and talking) in people who are inclined to be manic-depressive. This is a real problem, and it’s something your doctor will be watching out for, especially if there’s a history of manic depression in your family. Your doctor may want to cut back your dose or combine Prozac with lithium to manage the mania. Some people may have to stop the drug completely.