*68/129/5*

Once they are removed from their homes and put into a more loving environment their sleep improves and their growth becomes more rapid, as if they are catching up on lost ground. Of course, one cannot overlook other factors such as nutrition, exercise, and so on. We now know that children need much more sleep than adults. In fact, the older we are, the less sleep we need. Is this because we need less growth hormone as we become older and consequently less sleep?

*5\174\4*

The censure of the group, whether openly expressed or merely implied, causes tension; and this censure may arise from being too free, or from not being free enough, according to the prevailing morality of the particular group. With a certain amount of give and take the couple may be able to withstand these group pressures without tension. But the inner censor is more difficult to quiet. The idea of entering into sexual experience for the sake of one’s partner, seems so plausible at the time, but it does little to dispel subsequent tension and anxiety if it conflicts with the basic personality of the individual.

It is well to remember that the tension of those in this situation is often greatly increased by the glib but well-meaning advice of their fellows, “Go ahead and get it over, it will ease your tension just as it does mine,” is almost invariably bad advice. This is so because “going ahead” conflicts with the basic ideas of the individual. If this were not true, he obviously would have gone ahead before on his own initiative.

Some degree of anxiety from this type of situation is almost universal among young people. A medical student was so torn between the drive of his sexual urge and the dictates of his own inner conscience that he was on the verge of a serious breakdown. The situation was aggravated by his knowledge that most of his friends—real friends whom he respected—were promiscuous.

I talk to you merely as a physician whose concern is anxiety and tension—there may be others who would speak to you from a different point of view. Remember that different people have to find different solutions to the same problem. This is necessarily so because individual personalities differ. No problems are the same for everyone, and the real decision rests in each individual self. For many, these events are merely a necessary and commonplace experience in the process of growing up. They become something that helps to mature the personality, and as such may come to bring fullness to a future marriage. But with others the regret of past experience hangs heavily on the mind. If this be the case, remember we cannot undo the past. Let us accept it. As men and women we have all done wrong. But any experience, however bad it seems, almost always contains some element of good. Let us use this element to enrich our personality. Even an event which seems all bad—and I think this must be a rarity—may help us from the experience of coping with such a situation.

*31\57\2*

mild depression

short-term stress associated with depression and anxiety

moderate depression

depression in those who are very sensitive to, or concerned about, side-effects

winter depression (seasonal affective disorder or SAD)

depression in the elderly

dysthymia (chronic low-grade unhappiness)

St John’s wort should be considered, but probably not as a first-line treatment, for:

depression in children and adolescents

severe depression

St John’s wort should not be considered for:

depression in pregnancy

As I discussed in the chapter on research on St John’s Wort, the beneficial effects of the herb have been most convincingly demonstrated for mild and moderate depressions. There is one study in which it was used in more severely depressed individuals and proved as effective as a standard anti-depressant, imipramine. More research will be needed, however, before the herbal remedy can be recommended for more severe depressions.

A severely depressed man presented to me recently. He had legal actions pending against him and was in danger of being put in gaol. His business was in disarray and he was struggling to manage his day-to-day affairs. His desk was covered in papers that he was unable to muster the will or concentration to deal with. He could hardly sleep at all and it was an effort to fight his way through his exhaustion and get through each day. Yet it was critical that he be as functional as possible in order to co-operate with his solicitor in reaching the best possible deal with his creditors and the prosecutor’s office. He also needed to be alert and active in keeping his business afloat and avoiding bankruptcy if at all possible. He needed my help urgently. Given the seriousness of my patient’s depression, he was not someone in whom I wanted to try something that had not been fully researched for severe depression. I therefore chose a more established anti-depressant, nortriptyline, to which my patient responded well within a few weeks. Nortriptyline is one of a family of potent older antidepressants, which may have a number of undesirable side-effects, such as dry mouth, constipation and blurred vision. These side-effects seemed like reasonable trade-offs given the seriousness of this patient’s predicament. If the situation had been less urgent, however, I would have been more inclined to St John’s Wort with its much lower likelihood to produce unpleasant side-effects.

As more research studies are performed on the use of St John’s Wort for serious depression, clinical reasoning might change and the herbal anti-depressant might emerge as a first-line treatment even for severe depressions. In my experience, severely depressed people often end up on more than one anti-depressant, and there is no reason why St John’s Wort should not be used as one of a combination of anti-depressants if more than one is required.

There is at least one study suggesting that St John’s Wort might be useful in the treatment of SAD. Patients with SAD also benefit from light therapy and these treatments can be used together to good effect. St John’s Wort should also be considered as a prime anti-depressant candidate for treating depression in the elderly because of its mild side-effect profile. Depression in the elderly is becoming a particularly pervasive problem, given our ageing population.

It is only relatively recently that clinicians and the public at large have become aware of how common depression is in children and adolescents. There has been a rapid increase in the prescription of anti-depressants for young patients in recent years. Because there have not as yet been any studies on the use of St John’s Wort in young people, the herbal remedy should not be considered as a first-line treatment for these individuals. Nevertheless, I know of some cases where the herb has been used effectively in adolescents and have described one such case in an earlier chapter. In depressed children and adolescents, St John’s Wort should be regarded as a second-line treatment, to be used if conventional anti-depressants prove unsuitable for any reason.

Treating pregnant women with medications is something always undertaken with hesitancy and only after very careful deliberation, given the possibility that any medication may affect the growth and development of the baby. Yet some pregnant women are so depressed that it seems wrong not to provide them with relief of their symptoms because of some theoretical risk to the baby. In such cases I try to use medications with the longest track record, particularly if there is a published literature on their safe use in pregnancy. No such literature exists for the use of St John’s Wort in pregnant women, whereas there is some reassuring evidence that the older anti-depressants and Prozac might be relatively safe for the developing foetus. I would therefore prefer to use these drugs rather than St John’s Wort for the treatment of depression in pregnancy.

*83\75\2*

Will Prozac bring out my “true self”? If by your “true self” you mean your normal non-depressed, nonanxious, functioning self, which you feel is your baseline, the answer is yes, if you are currently depressed, since Prozac relieves the symptoms of depression and returns the person to baseline. Both scientific studies and anecdotal reports support the view that Prozac can in this sense return you to your former self.

Can Prozac make me more anxious or high-strung? Some patients complain mat they feel “revved up,” anxious, agitated, or “jittery” on Prozac, in which case the dose should be lowered.

*118\22\4*

The genetic link is particularly strong among manic-depressives, approximately 50% of whom have at least one parent afflicted with major depression or another mood disorder. Among children with one bipolar parent, 27% will have a mood disorder; when both parents are bipolar, the chances jump to 50% to 75%.

The importance of this cannot be underestimated for both the patients and their families. Thousands of parents are beginning to understand that it was not their faulty parenting that caused the sadly chaotic or wasted lives of their children with mood disorders. The cause is principally biological and genetic (although environment and events certainly can precipitate depression in those with the genetic tendency). As we gain more understanding about manic and depressive illness, both bipolar and unipolar, and as researchers find more effective treatments, guilt is being lifted from these families. While depression is for the most part an inherited disease, it is also easily treatable.

Over the past thirty years, enormous strides have been made in the diagnosis and treatment of mood disorders. New findings on the genetics of depression, a biological test for depression (the dexamethasone test), and precise blood measurements of lithium and antidepressant medications are now a reality. In my private practice, these tests and services are available on the premises.

Just as people in the past suffered and died from physical ailments now easily cured or prevented by medication, at least eleven million people in the United States today suffer from depressive disorders that are equally controllable. They wake up filled with dread, walk down the street wondering if they should step in front of a truck, and feel so unmotivated that sometimes they can’t even force themselves to take a shower or pick up the telephone. But these mood disorders don’t have to ruin people’s lives. With Prozac, lithium, and other drugs, new and old, they can be controlled.

*99\22\4*

their full dose of penicillin, they forget to bring their blood pressure pills on weekend trips, and they self-regulate, increasing or decreasing the dosage, often by at least 40%. Studies have shown that only 50% of the time do patients take their medications as prescribed. And in some surveys the number is as high as 93%.

Patients on Prozac are much more compliant than those on other antidepressants. In the combined data of all the Prozac clinical trials, patients taking tricyclic antidepressants stopped taking their medication at approximately twice the rate as those on Prozac. The main reasons for this difference are that Prozac has fewer side effects man other antidepressants and that patients on Prozac need to swallow only one or two pills a day on the average, while patients taking TCAs need to take between three and six pills daily.

An additional factor in the antidepressant equation is contact with the doctor. Studies have shown that the longer the period between visits to the physician, the poorer the compliance rate: patients who see the doctor on a weekly basis are more compliant than those who monthly appointments, who are more compliant than those who see the doctor every two to three months.

*78\22\4*

This increased public awareness has improved the climate for talking about and dealing with major depression. When imipramine, the first antidepressant, was discovered 1958 no one talked about depression. By the time Prozac was introduced in 1987, that taboo had largely evaporated.

In addition to its promised ability to alleviate depression. Prozac’s “mood enhancing” or “mood brightening” properties caught the attention of the public and the media. Its effects were presented as dramatic and miraculous—and let’s face it, a lot of people in our culture continue to look for a quick fix. Unfortunately, the newspaper and magazine articles and talk shows failed to delineate the myth from the reality and did not make the point that major transformations, when they did occur, took place in perhaps 10% of Prozac responders. The media instead implied that most everyone, depressed or not who even has a few personality quirks might take Prozac and have complete relief of all unpleasant symptoms as well as a personality change. It was heralded that slower going, somewhat introspective, chronically unhappy people, upon taking Prozac, could become upbeat, highly confident, energetic, extroverted people. They would essentially be able to change their personalities to what the American culture considers most desirable – the highly energised and charismatic personality with the competitive edge. Then, in the middle of all this media attention, came an all-out attack orchestrated by the Church of Scientology. It focused on a very small group of people, among the millions who have taken Prozac, who had suicidal or violent thoughts or in a few instances actually committed suicide or homicide. These rare cases led the press and the media to produce more coverage on the possibly negative effects of the drug, charges of which Prozac was later exonerated. All in all, Prozac has received more than its share of publicity, both good and bad.

*57\22\4*

Although the participants who received Prozac reported a higher incidence of insomnia, nausea, and other side effects, they did not drop out of the program at a greater rate than those on the placebo, suggesting once more that the side effects of Prozac are relatively tolerable.

*37\22\4*