Many of the suggestions of A. Cornelius Celsus mentioned above are healthy pleasures – music, soothing sounds like that of running water, cheerful conversations, massage and travel. Whatever it is that is a source of pleasure should be sought out and developed by the depressed person because the essence of depression is the lack of capacity for enjoyment, also known as anhedonia. But even when a certain degree of anhedonia is present, some activities might still provide pleasure.

Pets, for example, can be a great source of comfort and delight even to depressed people. Many years ago I decided that it would be a useful exercise to put several of my depressed patients together in a group. I reasoned that they might be able to help one another cope with depression. In truth it was not a good idea. The group was suffused by a sense of communal gloom and despair. But I remember on one occasion when someone mentioned her dog or cat, there was an immediate change in atmosphere as each of the group members pulled out a picture of his or her pet – animals that until that moment I had not even known to exist. For some time they pored over one another’s photos, admiring the animals and discussing their various special qualities and foibles. It was a vivid demonstration to me of the power of animals to cheer people up and how even depressed people are capable of spells of happiness if they are presented with the right stimuli.

Only you know what it is that delights you most when you are feeling well and how best to seek such activities out. Ask yourself what it is that still appeals even though you may be depressed. Is it painting watercolours, growing orchids or taking long walks in the countryside? The possibilities are limited only by the imagination. Consider the question, make a list of such sources of joy and then devise strategies for how you can bring them back into your life again.

I specify healthy pleasures because some pleasures are quite unhealthy, even if they are capable of bringing you out of depression for brief periods. Such pleasures may include alcohol and addictive drugs and compulsive behaviours, such as excessive shopping, spending, gambling or sexual activity. One of my patients, for example, would regularly go and shop for clothes that she could ill afford, did not need and in fact hardly ever wore. Her cupboards were full of expensive dresses that she had never even tried on after leaving the shop. For her, all the reward came from the act of shopping itself. There was something about the process of going to an expensive shop, trying on the garment, and having the saleslady pay attention to her and compliment her that proved irresistible. Of course, the comfort was very short-lived and the cost of the habit, both financially and in the form of marital conflict, severely exacerbated her depression. There are many different varieties of this habit and they can be very difficult to break. Addictive sexual behaviour is another costly way that some people use to medicate their depressed feelings. At times I have recommended specific recovery groups for these types of problems, with fairly good results.

And how do you tell the difference between a healthy pleasure and an unhealthy one? Usually it is fairly obvious. The one leaves you feeling good afterwards; the other leaves you feeling bad. The one feels like a wise investment that continues to yield dividends over time; the other like a foolish expenditure of time, money and energy, which ends up costing more than it’s worth. And finally, the one is a source of pride that you might be pleased to share with friends and family, whereas the other is often a source of shame, cloaked in secrecy.

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There is a continuous quest in all areas of medicine to develop new drugs with more specific mechanisms that those that are currently available. Psychotropic drugs presently available for treatment of mood disorders, although safe and effective, pose certain problems to many individuals in the form of adverse effects or poor response. Scientists make it their goal to improve upon medication by developing and testing new compounds with the hope of producing a marketable compound far superior to those that have been available to the general public. Prozac which was not marketed for a full fifteen years after it was developed in 1972, is a successful example of this lengthy process.

How can yon justify the gigantic costs of developing a new antidepressant drug? Depression is epidemic, affecting more people than virtually any other illness and costing the nation $43.7 billion annually. Only one third of depressed patients seek treatment, yet the reality is that not all of these people are .finding the treatment they need—in part because some patients are unresponsive to available medications. The right treatments for them do not exist and are awaiting development. Every time a new drug is developed, hundreds of thousands of people can be successfully treated. Their lives improve. They work more efficiently. (A depressed patient who has received adequate treatment loses half as much time from work as a depressed patient who has not been treated.) A new antidepressant drug can benefit the individual (and the nation) in ways that can be incalculable. As an example, look at Prozac.

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Can Prozac be prescribed for low self-esteem? Although not approved by die FDA for low self-esteem only, Prozac has been approved for major depression. It and minor depression (dysthymia) usually include a common symptom of low self-esteem. Thus, a detailed history should probe for other symptoms of depression or subclinical depression. If either is detected, I would try Prozac or another antidepressant drug.

Has Prozac been successfully used to treat social phobia? Social phobia is an anxiety disorder marked by a strong, persistent fear of certain social situations— especially those involving strangers or those in which the person expects scrutiny (such as public speaking). The apprehension and the fear of embarrassment or humiliation are so great that people who suffer from social phobia typically avoid the dreaded situations completely. Although in all other aspects of living they may function quite normally, they often have excuses for not participating in social situations and they may deny that their fear exists. They have been treated successfully with TCAs as well as MAOIs in the past. Recent reports indicate that Prozac has also been used successfully to treat social phobia.

Can Prozac take away the feeling that I am ugly? This sensation, also known by its official name, dysmorphic somatoform disorder, affects more people than one might imagine. Little research has been done on it, but one study reported ten cases in which patients who had a pathological feeling of ugliness I were treated successfully with Prozac.

It is also a common element of depression— especially among women. “When you’re depressed, you don’t think you’re pretty. None of your good attributes seem to be real,” comments a young bipolar patient of mine. After she made an impressive turnaround on a combination of lithium and Prozac, that feeling disappeared. “To me, it’s a remarkable thing now just to be able to look at myself, just to say. Gee, I’m really attractive,” she says. “It’s a very strange thing, because that good feeling could have been there before; I just don’t feel it when I’m depressed. The depression robs me of any objectivity or any belief that I am good or that there is anything good about me. Depression was like a smokescreen in front of me or a veil that lifted after I took Prozac with lithium.”

Can Prozac decrease suspiciousness in otherwise normal people? Considerable evidence suggests that it can. Although the family (and even the psychiatrist) may see the suspicious character trait as the only bothersome symptom, the suspiciousness may be masking an unrecognized depression. In these cases, Prozac alleviates the underlying clinical or subclinical depression, which in turn causes the patient to feel less suspicious or paranoid. Phobias and feelings of panic that accompany depression usually clear up as well, once the depressive symptoms are alleviated.

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There are some differences, however. Miltown, Librium, Valium, and Xanax are all classed as minor tranquilizing drugs with habituating properties. They have been and are being prescribed for anxiety disorders and, in some cases, panic attacks.

Prozac belongs to air entirely different group of drugs classified as antidepressants, with an entirely different mechanism of action and without die habit-forming properties that proved so troublesome with the antianxiety drugs listed above.

But even aside from these differences, there has never before been a fad for an antidepressant drug like the one that has accompanied Prozac. Other drug fads have promised that you’ll feel better and more relaxed. Prozac’s reputation promises not just that you’ll feel better but that you’ll feel, seem, and be different. It has been touted not only as a useful treatment for depression but as an aid for nondepressed people who want a “personality change” or just want to be happier.

The major reason for this reputation is that the blown up the usefulness of Prozac and d promises for it that extend far beyond tic conditions of major depressive disorder and obsessive-compulsive disorder, for which it roved. Clinical trials to date simply do t the exaggerated claims for this new compound as a panacea for all psychiatric and personality problems of the “worried well.”

Just because the claims are exaggerated doesn’t mean that they are completely false. Although many patients feel improved with Prozac, approximately 10% feel rapidly and distinctly better than their usual selves. This latter group—and it’s possible to predict who they will be with a reasonable degree of certainty—sometimes claim to feel better than they’ve ever felt before. Prozac is not a cure-all, but it is likely that the claims that Prozac can make a person more outgoing, less fearful, and more self-confident are indeed true. These claims are in fact true for all antidepressant drugs, pear, uncertainty and a lack of self-confidence are standard symptoms of depression. When the depression lifts for any reason, these symptoms disappear.

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Despite its wonder drug label, Prozac is not the first successful antidepressant. Many psychiatrists, patients, and families have remarked upon Prozac’s ability to enhance the patient’s outlook, energy level, and mood, but the truth is that many other medications work just as well as Prozac in countering the effects of depression. For instance, in clinical scientific studies. Prozac and other antidepressants have a similar rate of success and a similar onset of action (one to two weeks for most people, although in many cases up to six weeks may need to pass before symptoms are relieved). Although carefully controlled studies of more than one or two years have not been completed, early reports suggest that Prozac, the other SSRIs, and Effexor are as effective is preventing depressive relapses in recurrent or unipolar depression as are the classic tricyclic antidepressants used over the last thirty years, such as amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramine) and nortriptyline (Pamelor). It is also my impression that, when combined with lithium, Prozac appears to be effective in preventing relapses in patients with unipolar recurrent depression or bipolar manic depression.

The major difference between Prozac and other antidepressants is that Prozac is the first of a completely new category of antidepressant compounds, the SSRIs, all of which have minimal side effects. In

addition, most patients receiving Prozac have to take only one capsule a day compared to previous antidepressants that require between three and six a day.

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After numerous clinical trials, it is apparent that, compared with other older antidepressants, Prozac has an exceptionally low incidence of side effects. Nevertheless, there are some side effects. In clinical trials of about three thousand patients, the following reactions were seen:

• Nausea. Some 21% of the patients in clinical trials complained about nausea, making it the most frequent side effect associated with Prozac. However, only 2% of the patients actually vomited. Complaints of nausea were most frequent during the first few days to two weeks, after which the number of complaints dropped precipitously. After a few weeks, almost all of the nausea subsided. Nausea is Prozac’s most notable side effect, so it is worth pointing out that in clinical studies comparing Prozac with tricyclic antidepressants and a placebo,. 15% of those taking the TCAs also complained of nausea, and so did 10% of those receiving a placebo.

• Headaches. About 20% of the Prozac patients experienced this side effect, but it caused only 2% to stop taking the drug. Again, approximately equal numbers of those taking the TCA imipramine or placebo also complained about headache.

• Nervousness and anxiety. Between 10% and 15% of the Prozac patients registered these complaints. For the most part, these side effects were relatively mild, causing only 5% of the patients actually to discontinue treatment

Insomnia. About 14% of the patients had difficulty sleeping, and 2% discontinued the drug as a result.

• Drowsiness. About 12% of the patients were bothered by drowsiness.

• Anorexia. This affected 9% of the patients. Some investigators (but not most) have concluded that this could explain why most Prozac patients fail to gain weight, in contrast to patients who take most of the tricyclic and MAOl antidepressants. This is one incredibly important aspect of Prozac that makes it particularly desirable among patients who are obese or tend to gain weight easily, especially with other antidepressant drugs.

• Diarrhea. About 12% of the patients experienced diarrhea.

• Dry mouth. Only 9.5% of Prozac patients experienced dry mouth—a stunning improvement over the 64.3% of patients taking tricyclic antidepressants who complained about this irritating (for some) symptom. Sucking hard candy helps.

• Sweating and tremor. These symptoms affected about 8% of the patients taking Prozac.

• Rash. Rashes showed up in about 3% of the patients, a figure not so different from the 4% who break out in rashes after taking tricyclic antidepressants (and the 2% of patients taking a placebo who develop a rash). Typically, the rash appeared during the first few weeks and usually disappeared within a week, whether or not the patient stopped taking Prozac. Occasionally, hives, pains in the joints, or other systemic problems occurred simultaneously with the rash. For this reason, most physician recommend that, if a rash appears, the patient should immediately stop taking the medication.

Laboratory data have shown no evidence of damage to the liver, kidneys, bone marrow, or heart associated with Prozac.

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