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There are many ways of tackling or managing stress, and mastering these techniques inevitably pays off by promoting an antidepressant lifestyle. Improving interpersonal skills, for example, is one way of reducing the feeling that others are a constant source of unavoidable and uncontrollable stress. When I first began to supervise research assistants, I would observe that they often seemed harried and anxious. On one occasion, as a result of a shuffling of government personnel, a senior manager was temporarily assigned to me as a research assistant. I delegated several tasks to him and, after the first week of working under my direction, he asked to meet with me. He explained that the number of tasks I had assigned him were more than he was able to manage competently in the course of his working hours. Would I be good enough, he asked, to indicate to him my priorities so that if he was unable to complete all the tasks by the week’s end, only the least important task would remain undone. This research assistant taught me two invaluable lessons: Not only did I learn to become a better manager, to set priorities and be more realistic about what could be accomplished in the time available, but I learned how someone who is subordinate in an organization can politely set limits and manage his or her level of daily stress. If you are feeling under pressure at work, take some time to analyse the situation. Make a list of all the sources of stress and then try to figure out solutions to each of them. It is in the interest of the other parties involved to have these stresses resolved as well. Consider ways of presenting the problem to your boss, co-workers or even those working for you in such a way as to point out how it would be mutually beneficial if the stresses could be alleviated. For example, the final product might be superior, production might be more efficient, or the working environment more conducive to creativity or productivity. All of these goals can be legitimately presented as being in the interests of both workers and management.

Exactly the same principles apply in a marriage or other type of relationship, only more so. In these situations all parties involved usually have major investments at multiple, different levels. For example, in a marriage or relationship it is in both parties’ interests to get along, not only because it is more pleasant to do so, but also for the sake of mutual investments in the form of children and other common goals. Once again sources of stress can be identified and communicated to your partner, and if this is done in the right way the outcome can diminish levels of stress, relieve the tension in the relationship and promote an anti-depressant lifestyle. The key is always to present the situation as a shared issue which it would benefit both individuals to solve together. Let us say, for example, that a husband comes home from work and goes straight to the fridge for a can of lager, ignoring his wife in the process. She is bound to feel neglected, angry and perhaps depressed. At this point she has a choice. She can attack her husband for his callous and brutish behaviour or she can take a more collaborative approach. Attacking him may make her feel better in the short run but is bound to make the problem worse. A collaborative approach may have a better chance of working in the long run. This could involve: (1) empathy – ‘I understand that you are stressed and tired at the end of a hard day’; (2) communication of her feelings – T feel the same way after running after the kids all day’; (3) involving him in solving the problem – ‘Can you think of some way that we can unwind together?’; and (4) demonstration of what’s in it for him to do so – ‘so that we can support each other at difficult times and maybe even figure out a way of having some fun in the process.’ Obviously the way in which she chooses to handle the communication is likely to influence the outcome of the evening and either exacerbate or ameliorate her depression.

Part of the skill involved in such communications is picking the right time. A perceptive husband might recognize, for example, that the three days before his wife’s period are not the best time to discuss the large charges they have run up on the credit card. Conversely, an insightful wife learns to discern her husband’s moods and bides her time before discussing with him how she could use more help from him around the house or with the children.

It is also important to recognize that depression frequently causes stress in a relationship. This is of course an additional reason to treat the depression biologically. The partner of the depressed person often feels neglected. Feelings of depression can be contagious and there is a natural tendency to want to avoid a depressed person, which can isolate the person further and deepen the depression. There are some important pointers for the partner or family member of a depressed person to bear in mind. First, don’t take the depression personally. It is not your fault. Frequently the family member feels responsible for the depressed person’s mood, which makes him or her angry since at times nothing seems to cheer the depressed person up and there is a tendency for friends and family members to give up on the depressed person and withdraw. Second, it is not your responsibility to turn the depressed person’s mood around. You can and should be supportive. It is particularly worth trying to help your friend or loved one get appropriate assistance. But you cannot expect to have a direct effect on the other person’s mood. It is too much of a burden to place on yourself and is bound to leave you feeling resentful. Finally, don’t ignore the depressed person and enhance his or her sense of isolation. Do what you can to include the person in activities in a non-demanding way. For example, a husband might suggest going out to a restaurant for dinner with his wife, who may feel cheered up by the food, the setting and the friendly attention. On the other hand, suggesting that it might cheer her up to have guests over is unlikely to have its intended beneficial effect because of the demands this will place on her to perform and be sociable, which might be the last things in the world that she feels like doing.

There is a great deal that a depressed person can do to keep his or her loved one involved even while in a depressed state. Simply acknowledging the depression and its impact can be helpful. For example, a wife is likely to respond favourably to her depressed husband if he says T know I have been down and not much fun lately, but I am trying to turn things around as best I can. Thanks for hanging in there with me.’ The partner of a depressed person becomes starved for any positive feedback and comments such as this are generally greatly appreciated. Even if you are feeling sad and detached, as is often the case when one is depressed, it pays to make a point of expressing appreciation to your friend or loved one for gestures of kindness. It can be also useful to pinpoint specific things that your loved one can do that would make you feel better. This helps him or her to feel useful and counteracts the powerlessness typically experienced by those who surround and care about a depressed person.

So important are interpersonal skills in helping people overcome and avoid depression that an entire type of psychotherapy for depression, called Interpersonal Therapy, has been developed around these principles.

There are many types of stress other than interpersonal difficulties which may confront a depressed person and make matters worse. These include physical illness, financial difficulties and loss of a loved one. For all these different types of situations, help can be obtained from different types of experts, for example a sympathetic and competent doctor, a financial advisor or a religious or spiritual leader. A good doctor should not only provide specific help for symptoms but also comfort and reassurance. I have seen people in serious financial difficulty who have been greatly relieved after turning their affairs over to a debt counsellor or obtaining help and guidance from a financial planner. And innumerable people have been comforted and supported over the centuries by their priests, ministers or rabbis. Of course, caveat emptor applies whenever one turns to any guide or authority figure for help. Ultimately you have to be the judge as to whether a so-called expert is helping you or not. As always, stay tuned to your mood barometer to judge the quality of assistance you are receiving.

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The relationship of medication to psychotherapy has been debated endlessly. Although it would be difficult to find a psychoanalytically trained psychiatrist who never prescribes medication or a psychopharmacologist who never recommends therapy, it is nonetheless true that most psychiatrists fall on one side or the other of this great divide. Either they passionately believe that psychotherapy (or another form of talk therapy) is die preferred treatment, or they believe, that medication should generally come first.

The issue is particularly important in terms of the treatment of depression. Few would argue the importance of medication for illnesses such as schizophrenia or severe manic depression. But people often feel different about depression, especially if it is mild or moderate. Increasingly few professionals question die necessity of medication in cases of moderate to severe depression. However, there is still a tendency, to blame the victims, to believe that if they will only get themselves together, confront their issues, and deal forthrightly with their fears either in treatment or by themselves, they would feel less depressed— without medication. Medication, in this sense, is seen as a weak second choice to be made only when therapy has failed.

Certainly there are times when therapy is all that is required, and in those instances it can be very effective, arming patients with much-needed support and hard-won insights and helping; them drop destructive old behaviors and substitute constructive new ones.

But often that doesn’t happen. There are too many patients who, after years of weekly or twice-weekly appointments, are still struggling with depression. And even when the therapy has been declared successful and the depression appears to have exited forever, it is merely dormant, awaiting its biological cue for spontaneous recurrence. In an enormous percentage of patients, depression returns.

It doesn’t have to. For an extraordinarily large number of patients who are now being given psychotherapy alone for various forms of depression, overt or hidden, Prozac or another antidepressant is the treatment of choice and should be given either in conjunction with psychotherapy or instead of it. Ideally, medication should be accompanied by some form of psychotherapy especially in the first three or four months. But if it is necessary to pick either medication or therapy, the choice is clear. Medication can return a depressed patient to a normal emotional state by eliminating symptoms, including the urge to commit suicide. If the patient wants to enter psychotherapy in addition to taking medication, so much the better, a number of studies have now demonstrated that patients recovering from acute episodes of major depression do better when they are receiving both therapy and an antidepressant drug than they do with medication alone.

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The most exaggerated claim that has been made for Prozac, acknowledging that most psychiatric clinicians and researchers agree on its superb antidepressant effects, is that it can also dramatically alter personality in people without an underlying diagnosable clinical or subclinical depression. According to this popular notion, people who are simply unhappy or don’t like themselves can, by taking a Prozac pill, become outgoing, assertive, sociable, and confident: new personalities with altered inner selves, creations of the dubious field of “cosmetic psychopharmacology.”

Most people, who are helped by Prozac, whether they were only mildly or seriously depressed, just return to their former, non-depressed selves. But some people do seem to undergo a rapid and remarkable metamorphosis. This phenomenon is understandable if one is armed with a full knowledge of the patient’s family history and genetic background. The signs that enable one to predict who these hyperresponders might be are all degrees of moodswing, ranging from the subtle highs and lows on one end of the bipolar spectrum to full-blown manic depression, along with what geneticists call behavioral equivalents of manic depression in the family history which have been shown scientifically to include alcoholism and drug abuse, suicide, gambling, sociopathy, as well as the less commonly recognized behaviors associated with manic excess such as compulsive buying of things not needed, promiscuity, nonstop socializing, excess telephoning without purpose, and finally, workaholism. Depressed patients whose personal or family histories show these tendencies, even in their most subtle, hardly recognizable forms, are the candidates who become Prozac hyperresponders.

Among these hyperresponders (no more than 10% of those taking Prozac), there are basically three types that scientifics classify clinically, according to the patient’s predepressive behavior, and genetically, according to the family history:

• Hyperthymic respondent are patients with depression, ranging from minimal to major, who become energetic, outgoing, assertive, efficient, able to organize and prioritize, and more often than not, able to correct the imbalances in their personal and professional lives once the depression has lifted. After taking Prozac, their depression and anxiety disappear. To all outward appearances, their personalities have changed positively. They feel great, and for good reason. They are their old, energetic, sociable—hyperthymic—selves.

• Hypomanic responders go one step beyond the hyperthymic. These depressives develop even more energy on Prozac, need very little sleep, and tend to work and socialize compulsively, often very successfully. Family, friends, and peers at the office who notice their rapid accomplishments and non-stop activities may respond at first with admiration but later with a feeling that something is not quite right, and they may describe these hyperresponders as wired or slightly crazy. Extremely demanding, impatient, and unreasonable, these patients are prone to sudden, intense enthusiasm, irritation that may turn into bursts of anger, and lack of judgment in areas as varied as money management (they overextend themselves financially and often commit fraud), sexuality, driving recklessly, and excesses of all kinds. The hypo-manic response to Prozac can be both positive and negative. When a patient on Prozac begins to show signs of hypomania, it can become serious and the dose should be immediately lowered or discontinued. The patient may need lithium, but by this time, many have quit treatment only to take a plane to Monte Carlo or Las Vegas.

• Manic responders are clearly recognizable and are extremely rare. They possess an unreasonable degree of energy and niay go for days on end without sleep, to be followed by collapse into depression and physical exhaustion. They are expansive, grandiose, or paranoid, and filled with unrealistic schemes and theories. They may call the White House, begin^suing everyone around them, or try to buy Trump Tower on Fifth Avenue in New York City. Their minds race, and they may become delusional. Their judgment is disastrous and they are unable to function in the workplace or the home. Many of these people are none to alcoholism as well. Mania requires hos-italization because it evolves quickly into manic psychosis with its complex paranoid systems, hallucinations, and delusions (many of which involve the F.B.I.. the C.l.A, and other institutions). This is an infrequent response to Prozac and other antidepressants, new and old, but when it does occur, it requires emergency hospitalization and treatment. This reaction in most cases can be predicted by the skilled psychopharmacologist and avoided by prior treatment with lithium.

The frequency of this last Prozac hyperresponse has not been adequately studied but I would estimate it to be no more than 1% to 2% of all those taking Prozac, depending on the population being studied. In my clinical experience, the more severe the manic episodes or genetic equivalents in the personal or family history, the more likely one is to get an undesirable hypomanic or manic response with antidepressant agents. When a person comes in with such a family history, even if he or she has never shown signs of hypomanic or manic behavior, the prescribing physician must begin gingerly, with a low dose and weekly monitoring. What you’re hoping for is a normal response—i.e., a lifting of depression—or even a hyperthymic response, which some psychiatrists may call transformation In order for this to happen, the genetic potential has to be there.

But occasionally, a chronically depressed person comes in, quickly becomes a Prozac hyperresponder and yet seems to have no past or family history of manic depression or its equivalents.

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The concept of depression has entered the public’s consciousness so fully that many people today use the word “depressed” in the same way that they might once have described themselves as dejected, discouraged, or simply glum. At the same time, many people who believe they are in a temporary down or think they are reacting in a normal, healthy way to difficult circumstances are in fact clinically depressed and should seek both diagnosis and treatment.

Clinical depression does not simply go away. Depression is worse than unhappiness, more than malaise, and not in the least like a stubborn refusal to “buck up.” “Depression” is a term that can be applied to a collection of disorders, each of which is characterized by a constellation of specific and debilitating symptoms. It is not a monolithic disorder. Just as major (or clinical) depression is riot the same as simply feeling down, major depression is also not the same as minor depression (now categorized by psychiatrists as dysthymia). Likewise, feeling manic is not the same as feeling happy.

The concept of “cure,” so basic for physicians with other specialties, is an elusive one for psychiatrists. Prozac does not cure depression or any other chronic or recurrent illness for which it is prescribed; thus, it is similar to all other psychotropic drugs that alleviate illness but do not cure it. From 75% to 80% of depressed patients have depression that tends to recur.

On the other hand, Prozac and other antidepressants sometimes appear to cure. Perhaps 20% to 25% of the patients whose depression is relieved by Prozac or other medications are never destined to have a recurrence. This does not mean that the illness has been cured by the antidepressant drug, although it certainly looks that way. Rather, the patient was destined through genetics and environment to have only one depressive episode in his or her lifetime.

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What is the total percentage of patients who stop taking Prozac because of the side effects? In clinical trials, 17% of those taking Prozac discontinued treatment, compared to a full 31% of those taking the tricyclic antidepressants.

Does the size of the dose determine the side effects? The incidence of most side effects, including nausea, anxiety, anorexia, diarrhea, insomnia, tremor, and drowsiness, increases with the size of the dose.

What are the most common sedating side effects of Prozac? About 12% of patients taking Prozac (compared to about 24% of these treated with tricyclics) complain of drowsiness, and 4% have reported a feeling of asthenia, or weakness. If the feeling doesn’t go away within a few days, a smaller dose of Prozac should be tried. In addition, in placebo-controlled clinical trials, 4.2% of the 1730 patients taking Prozac complained of fatigue and 1.9% reported feelings of sedation.

Has Prozac been adequately tested for long-term side effects? No, if you define long-term, as being 25 to 30 years. Prozac has only been available since 1987. Most patients who have been on long-term Prozac since then have been on it for a maximum of five to seven years. Not until patients have been adequately observed and tested on Prozac for fifteen to thirty years can one say that the medication has been adequately tested for long-term side effects.

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This phenomenon is not easily explicable but occurs with many medications, both in psychiatry and in general medicine. It is not uncommon to hear that a patient’s first experience with an antidepressant drug was not successful but that the second time it went extremely well.

One possible explanation of this is the so-called placebo effect, present in 10% to 15% of patients. The placebo effect is usually thought of as influencing patients in a positive way: that is, their positive expectations or belief in the doctor may cause them to see immediate improvements even before the drug theoretically is supposed to work. But the placebo effect has a negative side also, for if the patient is worried or even phobic about taking a given drug, the anxiety can produce side effects for which the drug itself is not responsible, and these negative expectations may cause the patient to discontinue the medication prematurely, before it has had a

chance to work. A related issue has to do with the patient’s overall confidence in authorities, in this instance a physician. The more the patient trusts the doctor, the better the reaction to the drug is likely to be.

A second possible explanation has to do with the patient’s metabolism, which may from time to time vary in its fluid and electrolyte balance, either as a result of taking other medications or of changing diet or fluid intake. Or the patient’s metabolism may have simply changed in some way that at first glance is not easily understood by either the patient or the physician.

Finally, the patient may have been given too much of the drug on the first occasion. On the second try, if the drug is given in a much smaller amount, with the dosage being raised gradually, the results may be highly effective, and rewarding.

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