QUESTION

My primary care doctor prescribed Prozac for me but I am afraid to take it. What are the side effects that I should be worried about when taking this medication?

ANSWER:

Prozac belongs to a class of medications that are based on their mechanism of action; medications belonging to this class are called selective serotonin reuptake inhibitor’s or and SSRI’s; low serotonin levels in the brain are thought to play a significant role in mood and anxiety disorders; this group of medications increase serotonin levels in the brain by selectively inhibiting the uptake of serotonin after it has been released; bottom line, serotonin levels are increased which in turn is correlated to an improvement in symptoms related to depression and anxiety disorders.

The most common side effects of this class are:

• Allergic or Toxic – Rash, Pruritus (skin inflammation)
• Neurological – Headache, Tremor, Dizziness, Asthenia
• Behavioral – Insomnia, Anxiety, Nervousness, Agitation, Abnormal dreams, Drowsiness and fatigue
• Autonomic – Excessive sweating
• Gastrointestinal – Nausea, Disturbances of appetite, Diarrhea
• Respiratory – Bronchitis, Rhinitis (inflammation of the nasal mucous membranes), Yawning
• Endocrine – Weight loss
• Musculoskeletal – Muscle pain, Back pain, Joint pain
• Urogenital – Painful menstruation, Sexual dysfunction, Urinary tract infection, Frequent micturition
• Miscellaneous – Chills

Keep in mind that not all SSRI’s cause all the above side effects and that different individuals respond differently to different SSRI’s; your doctor and you have to work together to see which medication suits you the best; always check with your doctor if you have any side effects (symptoms that were not present prior to starting a particular medication) and ask him or her if other options are available; also, keep a small journal of how you feel when starting any new medication; note down any changes in mood, appetite or energy; be sure to bring your notes to your visits with your physician; make sure to address your questions during your follow up visits; don’t be afraid to ask questions related to your working diagnoses and treatment plan; you have a right to ask questions of your health care providers and deserve answers if they are known; Lastly, only take prescription medications under the supervision of a physician. Take care of your self and keep the lines of communication open.

QUESTION

Dr. Raj,

A close friend of mine has been seeing the same psychologist every other week for over 4 years.  This friend is college educated and intelligent. He does not abuse drugs or alchohol.  He has a problem with anger management, often reacting out of proportion to events.  His reaction can range from melancholy to temper tantrums that include shouting insults.  He can go up to six weeks without having what I call a “melt down”.  How do I know this?  Because I have actually tracked his mood swings on a calendar over 12 months.  The melt downs can last 2 days, 1 week or he may have one very few days for 2 weeks.  Then, he will recover and appear happy and content for 2 to 6 weeks.  I know this is probably bipolar disorder.  Or maybe it is post tramatic stress, since he grew up with domestic violence between his parents.  The point is…my friend does not appear to be “getting better” in light of all the therapy he has gotten.  I can see no changes in his behavior!over the 3 1/2 months I have known him.  I know my friend speaks openly to his doctor and is honest to a fault.  He does realize he has problems with self esteem, depression, mood swings and handling his anger.  I know not every doctor is the same caliber, too.  What type of therapy shoud my friend be getting? Talk therapy? Cognitive behavior therapy?  What strategies can you suggest?

ANSWER

Dear iNTj,

It does seem that you have alot of insight into your friends problems and that you genuinely care about his well being.  You mentioned that he see’s a therapist every two weeks, how often is he seeing his psychiatrist?  What is the working diagnoses that his psychiatrist is treating?  Is he on any psychiatric medications and have any helped?

We now know that the most effective treatment will address the Biological-Psychological-Social domains individually.  What this means is that once, the presenting problem is understood, a health care practioner should address each of these domains to get the most effective treatment response. The Biological domian usually involves medicaton management, the Psychological involves getting into psychotherapy and the Social domain involves looking at and understanding social facotrs that are contributing to the persons presenting complaint(s) i.e. family dynamics.

Remember that it takes time to corrently diagnoses and understand the dynamics of human behavior.  I know this can be frustrating for many individuals but the number of diagnostic tests in psychiatry are limited.  Our most useful tool is obtaining a through history from our patients and their families in order to come up with a working diagnoses and over time it is verified or adjusted.  Many times I hear from people, “My Psychiatrist only spent 2 minutes with me, how could he have correctly diagnosed me?”  My response to them is usually to find somone else who will spend the time obtaining the proper history to properly formulate a treatment plan.

As far as therapy goes, I think going every other week is not as effective as going every week.  In my opinoin, much happens in two weeks and the session usually becomes about “catching up” versus working on insight.  Their are also many different types of therapy that range from working on supporting the individual to working on insight around internal conflicts.  Their are also therapies that focus on one’s thoughts (Cognitive Behavioral Therapy) as well as being more mindful about one’s behaviors (Dialectic Behavioral Therapy).  Which approach is best is dependent on the individual who is entering it.  As a genral rule of thumb those in treatemnt do better than those who are not in treatment.

Thus, I commend your efforts in understanding your friend’s current challenges but remember that he must make the committment to find the appropiate answers.  You can not do his work for him but only support him along the journey.  He’s lucky to have you in his life.

QUESTION

I hear about people who say they take a “xanax” pill when they fly so they fall to sleep. What is this and can anyone get it?

ANSWER

Xanax is a medication that belongs to the class known as benzodiazepines.  The benzodiazepines are considered to be minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties.

I think great caution should be taken when using a medication from this class of drugs because of it’s addictive potential.  However, in an individual with minimal abuse potential short term use can be appropriate.  In some situations, such as in your question, some individuals can become very anxious when they fly and require a minor tranquilizer to be able to tolerate the flight.

One aspect that I find very concerning is inappropriate use of this class of medications.  Many persons will go to their physician due to situational anxiety (an anxiety related to a particular stressor in ones life) and want something to relieve their symptoms.  What often happens is the person will find effective symptom relief and begin to psychologically become dependent on the medication.  I have seen many cases in which “pill popping” becomes a coping strategy.  Remember, I said that this class of medications is addictive.  Thus, what would have been a good short term strategy has turned into something that the person is now dependent.

What I suggest is asking your physician about addictive potential for any medications that are prescribed to you (Benzodiazepines are only available by prescription from your physician).  Make sure you ask the questions up front so that you don’t find yourself with a bigger problem down the road.

QUESTION

If you take a lot of psychiatric medication, like zoloft or prozac, will it affect my sex drive?

ANSWER

Zoloft and Prozac fall under the category of Selective Serotonin Reuptake inhibitors.  SSRI’s as a group have been associated with sexual side effects.  There is no way to tell if one agent will necessarily cause it while a different agent won’t.  The only way to know if you will or will not have sexaul side effects if to have a trial of a given medication.  It will be critical to monitor and communicate any sexual side effects that you may experience with your prescribing physician .   If sexual side effects present they usually present as ejaculatory dysfunction and/or decreased libido.

When thinking about if one should take a medication or not based on possible side effects, I think it becomes about close evaluation of the risk to benefit ratio.  If the benefits out weigh the risks (i.e. side effects) and if the individual is willing to accept them, then it may be appropriate to continue the medication as prescribed under the guidance of your physician.  Of course, if other medications are available, one could be put on a trial of a different medication to determine how well it is tolerated.

Remember to always communicate to your physician about side effects that you may be experiencing (sexual or any other) to determine the best course of action.

QUESTION

Dear Dr. Raj, I am currently struggling with my mental health. Following many years of taking anti-depressants and anti-anxiety meds I decided it was time to detox, and in Jan. discontinued taking Effexor XR and buspar.  I weaned myself with physician guidance, but not necessarily approval.  I’m sure you are aware that discontinuing the Effexor w/o the proper guidelines is awful.  It was difficult enough…since that time I have undergone, treatment by an accupuncturist for my depression.  However I feel like as hard as I try to be “happy” I continually struggle.  I’ve listened to Oprah’s “The Secret”, recently read The Four Agreements, constantly tell myself, I am enough, I have enough, I do enough.

My question and concern are if I do have altered brain chemistry can I correct it through will power, and positive thinking? How do I avoid my dark side?  Should I go back on meds?  If so what’s out there that doesn’t cause sleep disturbances or sexual side effects?  Since currently I feel like my system is clean are there herbs or supplements that you might suggest?  Thank you so much for your time and consideration.

ANSWER

Dear Cara,

It seems that you are committed to overcoming your depression which I commend you on; sometimes making the commitment to getting treatment can be one of the hardest steps.

First, it will be important for you to identify and understand what gives rise to your “unhappiness”; it is through this understanding and insight that you will eventually find “Happiness”.  The first question that comes to mind is, what is happiness to you?  It will be important to know what this word exactly means to you, as we all have different definitions. It is important to note that one can be satisified and “happy” with certain aspects of one’s life while simultaneously discontent or “unhappy” in other areas.  It does not have to be mutually exclusive.

With regards to depression, it has both a biological and a psychological basis and can be a part of a variety of clinical presentations; again, the key is to have a good understanding to what’s giving rise to your symptoms. Medications may be necessary if your symptoms interrupt your normal function; I would suggest you to discuss this with your psychiatrist; if you feel that your psychiatrist does not spend an ample amount of time with you, find another one who will; you deserve to have one that is interested in listening to you and one that is genuinely committed to finding the right diagnosis and treatment.

Remember, prescription medications must be taken under the care of a physician and should be monitored closely for any side effects as well as efficacy; as a category, the Selective Serotonin Reuptake Inhibitors (SSRI’s) have a high association of sexual side effects; this doesn’t mean that they will all cause this as each individual is different; one SSRI may cause sexual side effects in one person and not in the next; there are anti-depressant medications that do not have a high association of sexual side effects; one such anti-depressant is Wellbutrin; again, the decision to be on Wellbutrin should be made with a physician and be taken under his or her guidance.

As far as herbal preparations for mild depression, please read the answer I posted for a question on homeopathic medications for mild depression (on May 27th; you can click on medication? under categories).

Your question about thoughts changing our brain function is an area in which there as been a great deal of interest recently; research has shown that talk therapy does change brain function and hence structure. I find it fascinating that after every conversation we have with someone, our brain has changed in some way; this then means that after every session in therapy, our brain has changed; now keep in mind that talk therapy is more time consuming and requires a great deal of effort but I believe that it gets to the deeper causal layers (psycholigically speaking) and is tremendously important to include in a treatment plan.

Thus, I highly recommend finding a good psychiatrist and therapist who you can work with in understanding the biological and psychological underpinnings of your “unhappiness”; this will be fruitful in the long run.  Remember, you are enough, you always have been and you always will be. Healing will take time and will happen as long as you are committed and stay in treatment; if your need support, please send in any questions that I can help you with.