All about Prozac

By Carol Turkington, Eliot Kaplan, M.D.

"I realized after taking Prozac that I'd been depressed all my life. I could never really answer the question 'Why do people live? What's the point?' When I was depressed, I couldn't function. A big day was getting the newspaper out of the driveway. Now I'm totally optimistic about everything."
-- Joan, 42, business owner

It looks ordinary enough, this little green-and-white capsule called Prozac. Not even its manufacturer, Eli Lilly, claims to know exactly why its product works. But more than 10 million people have taken this drug for depression, and more than 70 percent of them have gotten better. Prozac today is the most popular anti-depressant ever.

"I used to walk around with a black cloud over my head," explains Marie, 41. "I was chronically depressed. That's how I felt about life; it was an abyss. But after taking Prozac, my depression is simply gone. I'm not a different person, but I'm a better person."

If you've had a depressive episode recently, odds are that the first drug your doctor tries will be Prozac (fluoxetine) or one of its cousins, all members of a new anti-depressant class called the selective serotonin reuptake inhibitors (SSRIs). These include Zoloft (sertraline) and Paxil (paroxetine), Luvox (fluvoxamine), and Serzone (nefazodone), not an SSRI but a serotonin-related antidepressant.

These drugs have moved to the forefront of modern psychiatric treatment because they work as well as any of the older antidepressants while causing far less serious side effects. Prozac in particular appears to work for a wide range of other mood disorders in addition to depression. Your doctor may also recommend Prozac if you suffer from anxiety or panic disorders, post-traumatic stress, or eating disorders, although the FDA has approved Prozac as a treatment only for depression and obsessive-compulsive disorder. As this book goes to press, the FDA advisory panel has recommended that Prozac be approved to treat bulimia, but final approval has not been granted.

How Prozac and Other SSRIs Work

If you lived in a brand-new custom home and a light bulb burned out on the second-floor landing, you wouldn't call in an electrician to rip out all the wiring in the walls -- you'd just replace the bulb. There's just no need to disrupt all the activities in the entire house to fix one simple problem on the second floor.

It's the same way with depression. If you've got a malfunction in one neurotransmitter system, there's really no need to take a drug that will interfere with other neurotransmitter systems and receptor sites throughout your brain. But for many years, antidepressant drugs did just that.

No one knew how to design a drug that would home in on the light bulb and ignore the wiring in the rest of the house. Yet it appears that some people do seem to get depressed as a result of something as specific as a malfunctioning serotonin system -- the neurological equivalent of a burned-out light bulb.

For 10 years, scientists searched for this specific drug, looking at different models of nerve transmission and tailoring chemicals to affect these basic processes. They finally found what they'd been looking for in Prozac. With this chemical, scientists finally had a way to simply replace a burned-out bulb without rewiring the whole house.

The beauty of this new class of drugs is that they're so specific. Unlike the shotgun approach of older drugs like tricyclics or monoamine oxidase inhibitors, which interfere with neurotransmitters and receptor sites all over the brain, Prozac and other SSRIs zero in on serotonin without affecting other brain systems.

The blocking of different neurotransmitters causes different side effects; the greater the number of blocked neurotransmitters, the greater the variety of side effects. For example, blocking the reuptake of norepinephrine can produce tremors, sexual dysfunction, and rapid heart rate. Blocking the reuptake of dopamine can produce movement disorders and changes in the endocrine system. By specifically blocking serotonin alone, you can sidestep most of those problems (although you may still experience stomach upset, insomnia, and anxiety).

In addition, many of the antidepressants also block receptors on the other side of the synaptic gap that normally absorb the neurotransmitters. Blocking one type of receptor causes sedation and weight gain; blocking another type causes blurred vision, dry mouth, constipation, and memory problems.

It now appears that the serotonin neurotransmitter system may be far more complex than anyone had realized, linking areas throughout the brain in an interwoven tapestry of serotonin-producing connections. Not surprisingly, serotonin receptors are especially plentiful in the areas of the brain controlling emotion. What's more, within the past decade, scientists have realized there are at least six different receptor types in the serotonin system, each responsible for sending different signals to different parts of the brain. The next step is to find a drug that can affect just one of these receptor types, and to develop a simple lab test that can identify specific serotonin malfunctions.

While it's apparent that serotonin is of vital importance in the development of depression, scientists aren't so sure that it's a simple cause-and-effect relationship; the brain's biochemical pathways for emotion and mood are just too complex. While it may be true that you can directly relieve depression by increasing serotonin, it could be that monkeying around with serotonin causes slight effects in other neurotransmitter systems, and those changes relieve depression.

Why Is Prozac So Popular?

Prozac is not really that much different from other SSRIs. So why is Prozac's name on everybody's lips at cocktail parties, widely written about in the media and the topic of countless talk shows?

As the first of the SSRIs to hit the market, by the spring of 1990 Prozac had made the covers of both the New Yorker and Newsweek, touted as the "new wonder drug for depression." Having heard it praised as a breakthrough drug that eased depression, had no serious side effects, and helped you lose weight, people began flocking to their family doctors clamoring for prescriptions.

But its early media designation as some sort of happy pill that every American might someday want to take to become "better than well" began to raise concerns. Did this drug change behavior, or did it alter personality? It's a sort of chicken-and-egg question that continues to baffle mental health experts. If your mood improves, the outward appearance of your personality and behavior will also change. It stands to reason that if you've been depressed for a long time, you won't have any energy, you might feel negative, you'll mope around, you might have low self-esteem.

If you take Prozac and your depression improves, you begin to feel more positive, and this makes you feel more self-confident. You may begin to take better care of your appearance. It may seem that your entire personality changes. But does it? Where does a mood disorder end and personality begin?

If you're a sloppy, negative lout when you're depressed, is that really who you are or just a symptom of your mood disorder? If you can take a pill and alleviate the depression, revealing a buoyant, capable, healthy person, is that really your true self, or has the pill somehow altered the essential core of your personality?

While Prozac has gotten all the press, experts note that the same process of behavior and personality change occurs with other newly developed antidepressants. It's just that they haven't managed to land on the covers of magazines.

It's also important to note that Prozac won't make healthy people "high" the way marijuana or cocaine might. It won't improve your mood if you're already happy, and if you weren't clinically depressed when you took the pill, odds are Prozac won't do a thing for you.

"I was resistant to seeing Prozac as a cure-all," says Miriam, 26, a Virginia artist. "I never felt it was a lifesaver, but it really did give me a calming effect. It got me out of the house, brought me up from the depths, and removed my feeling of panic."

Miriam said she hated her job as salesclerk and, in a happy relationship for the first time, felt panic as she "waited for it all to fall in. When my emotions reached an overwhelming level, I shuffled from one doctor to another until I saw a psychiatrist, who gave me Prozac."

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 fact is that many people in America are looking for a quick fix for minor personality quirks, and others are looking for a safe high. When the media began to imply that anybody could pop a Prozac and eliminate all negative personality traits, these stories naturally created a lot of attention.

Many doctors believe Prozac's reputation as a personality pill has been blown out of proportion. There have been no scientific studies that can back up the claim that Prozac is capable of changing personality in most people. It is true, however, that about 10 percent of users will feel much better than they ever did before on this antidepressant -- they will feel "better than well."

What Can Prozac Do for You?

About 70 percent of depressed people who take Prozac will experience complete remission within two to six weeks; the rest either don't respond or can't deal with the nausea or insomnia that often occur for the first few days.

Prozac is ideal if you're depressed but sleep normally and need to be able to function during the day. It's also a good choice if you didn't respond to a tricyclic or an MAOI, or if you can't take the side effects of these older drugs. Moreover, if you have weight problems or struggle with obsessions, Prozac might be for you, since studies suggest that people with atypical depression (the symptoms of which include oversleeping and overeating) respond better to Prozac than to tricyclics.

If you don't respond to Prozac, you might do better with one of the older antidepressants (such as the MAOIs or tricyclics), or you might respond to a different SSRI, such as Zoloft or Paxil, or on the just-approved Serzone, a serotonin-related drug. You might also do better on a structurally unrelated antidepressant such as Effexor or Wellbutrin.

It is also possible that you're one of the very few people who don't respond well to any antidepressant yet on the market.

Should Every Depressed Person Take Prozac?

No. Obviously, if you're allergic to Prozac (look for hives or a rash), you shouldn't take this antidepressant. And if you have serious problems with your liver or kidneys, it's not a good idea to take Prozac because this drug is metabolized in the liver and excreted in the kidneys. If you have serious problems with either of these organs, Prozac could build up in your blood to toxic levels.

You should also be cautious about taking Prozac if you have a history of seizures or epilepsy, even if you're taking anti-seizure medication. Studies of more than 6,000 people revealed that 12 patients experienced seizures with Prozac (a rate of 0.2 percent), about the same rate as that of other antidepressants. If you have such a history, your doctor will want you to have a full neurological workup with an EEG before proceeding. You'll have to take smaller-than-usual doses at first, and you'll probably need a series of EEGs and blood tests (to monitor anticonvulsant levels) during treatment.

Prozac vs. Other SSRIs

What Prozac and all of the other SSRIs do equally well is alleviate depression in most people who try them, without causing a host of unpleasant side effects. This lack of any serious side effects is one reason why physicians are so eager to prescribe the SSRIs, especially for mild depression (dysthymic disorder). Moreover, there has been no evidence of any damage to heart, kidneys, liver, or bone marrow with Prozac.

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.

Now for the Down Side

What concerns some doctors -- including Listening to Prozac author Peter Kramer -- is that the drug's long-term effects are largely unknown. A series of studies in humans has shown no connection between antidepressant use and cancer, but there are some concerns about whether antidepressants promote tumor growth in cancer patients or in those exposed to cancer-causing substances (such as nicotine in cigarettes). This concern is primarily due to a small study published in 1992 that found that after being injected with cancer cells or cancer-causing substances, rats subsequently injected with antidepressants had more tumors than control rats.

Cost is also an issue. Older antidepressants like the MAOIs and the tricyclics are cheaper than Prozac and the SSRIs because their patents have expired; they are less expensive compared to these wholesale price tags of some of the newest.

Tolerance is also a concern. (A person develops drug "tolerance" when the drug suddenly stops working, requiring larger and larger doses to be effective.) About one in 50 patients will develop tolerance to any drug, doctors say, and there have been reports of tolerance with Prozac.

Sherry, 38, has suffered for some time with many health problems, including obesity and chronic pain from arthritis. Depressed over these health worries, she began taking one capsule of Prozac daily, which eased her depression at first. She's now up to five tablets daily (100 milligrams), a very high dose indeed.

"The crying episodes have stopped," she reports, "but Prozac is just not very effective anymore. Before, I was always able to pull myself back from depression. Now I'm just crazed, and I've lost faith in traditional medicine."

Some people report strange feelings of loss on Prozac. They feel as if they have changed in some very basic, profound way. They appear to be a little uncomfort-able at the thought that while they are not depressed, neither are they the same person. Some mental health experts believe this could be the result of suddenly achieving normal mood after years of having adapted as a depressed person.

"What's unsettling is that before, I was internal. I meditated and I prayed a lot," says Jean, 42. "Now that's hard to do. It's hard to hold onto that internal state. I told my doctor I feel shallow. I feel as if I lost an entire dimension of myself. My introspective side has been such a part of me that it's alarming not to be in touch with that side of myself."

Is it disturbing enough to stop taking Prozac? Not to Jean.

"Even if my personality has changed," she says simply, "it's better than being suicidal and living in hell."

This uncomfortable feeling of loss is not unique to Prozac; people taking other SSRIs report similar experiences, especially among those who have battled depression for many years.

"At first, after taking Paxil I didn't know who I was," reports Helen, 39. "It scared me. Relating to people was different, too. When you're depressed, you feel empty inside and you want to fill it up. Once I got un-depressed, I didn't have the neediness that depressed people have."

Her psychiatrist explained her discomfort very simply. "Helen," he told her, "you've just got to figure out who un-depressed Helen is."

"When I first took Paxil and started feeling better," she says, "I got extremely irresponsible. Before, I worried, worried, worried. Now I just don't care what people think, because I have more self-confidence and self-esteem."

But Helen says she doesn't feel Paxil changed her personality at all. "The core of who you are never changes," she explains. "Before I felt sick all over, and now I feel pretty darn good."

Prozac and the other SSRIs can have a profound effect not just on the individual but on his or her family as well. Living with someone who is depressed can be an extremely draining, difficult experience as the mood disorder disrupts everyday family life, dragging others down into depression as well.

Experts in family systems psychology have shown that the successful treatment of anyone in the family will create a sort of ripple effect.

"When I was depressed," says Dan, 43, "I wasn't available to my family. My wife had more of a burden with the kids. I never wanted to go anywhere or do anything. Once I started taking antidepressants, I started enjoying my family again. And they started feeling better too. The whole family environment changed for the better."

Drug Interactions

There's nothing wrong with taking both Prozac and over-the-counter pain medications like Tylenol or Advil. And while a few reports suggest that Prozac slows down the rate at which the body breaks down antianxiety drugs such as Valium (diazepam), this doesn't appear to cause any serious problems. Lots of people who are depressed are also anxious, and many people take Valium as part of their treatment. A slowdown in the metabolism rate of Valium simply means the drug will remain in your body for a slightly longer period.

Prozac mixed with tricyclics or a tetracyclic such as Ludiomil isn't dangerous, although Prozac can enhance the effects of these drugs and cause insomnia, appetite loss, and anxiety. And the risk of heart problems and seizure already associated with tricyclics increases when Prozac is added.

But it's very dangerous to take Prozac with MAOIs (Nardil, Marplan, or Parnate). This combination could cause a fatal reaction, including nausea and vomiting, high blood pressure and shock. This is why you should wait at least two weeks after taking an MAOI before taking Prozac, and at least five weeks after taking Prozac before taking an MAOI.

Combining Other Drugs with Prozac

While you may be started out on a single antidepressant, the current trend in treatment-resistant depression is toward combinations of two medications, either to boost their efficiency or to counteract potential side effects. For example, Desyrel (an antidepressant unrelated to SSRIs or older drugs) is sometimes added to Prozac if a patient has trouble sleeping when taking Prozac alone.

"I take Desyrel right before I go to sleep," says Sarah, 42. "Before taking antidepressants, I was having a lot of trouble sleeping because of my depression. But Prozac didn't help that. So after a few weeks on Prozac, my psychiatrist added Desyrel, and I started sleeping again for the first time in years."

Some research suggests that a combination of Prozac and lithium may help some people who don't improve on either drug alone.

What about Those Suicide Reports?

There's an ongoing controversy about whether Prozac causes people to try to kill themselves, or whether suicide attempts by users of Prozac are the result of the depression itself.

Studies have shown that at the beginning of treatment, 10 percent to 15 percent of patients feel more anxious after taking Prozac, but this anxiety eventually passes.

There also have been reports of anger and irritability among users of Prozac. Very irritable patients usually find their temperaments improving on Prozac, but it's a different story with manic-depressives. If manic highs involve anger, paranoia, or irritability and you take Prozac without first being stabilized on lithium, the manic side of your mood may break through and you could experience these symptoms. Many scientists believe that Prozac may initially increase manic symptoms because the drug increases a person's energy before it has successfully altered mood. This could suddenly prompt a suicide attempt in someone who had previously been too lethargic to make the effort. Indeed, several studies have suggested that people who are slowed down by depression in this way do appear to have a temporary increased risk of suicide as the depression eases.

Prozac experienced a temporary backlash in 1990 after reports circulated that it induced violent and suicidal tendencies in some users; the Church of Scientology led the attack against the drug, which focused on a small group of patients who had suicidal or violent thoughts.

In 1990 the church filed a citizen's petition with the U.S. Food and Drug Administration asking that Prozac be withdrawn from the market, citing a Harvard Medical School study published in the American Journal of Psychiatry stating that 6 out of 172 high-risk mental patients who had been resistant to other drugs had become preoccupied with violent suicidal thoughts while on Prozac. Two of them tried unsuccessfully to kill themselves. Although none of the six had appeared to be suicidal when they started taking Prozac, five had had suicidal thoughts before. At the time, four of the six were also taking other medications (one was taking five other drugs).

The Scientologists took that study's findings of the six individuals and extrapolated them to the entire United States population, claiming that 140,000 people in the United States have become violent and suicidal on Prozac and charging that widespread use of Prozac would promote waves of violence. They backed up this claim by pointing to mass murderer Joseph Wesbecker, who killed himself and eight coworkers at a printing plant in Louisville, Kentucky, with an AK-47 assault rifle. A Scientology group alleged that Wesbecker, who they said had no history of violence, went berserk because he took Prozac. Subsequent media reports revealed Wesbecker had a large gun collection, had tried to kill himself 12 times in the past, and had often talked about killing his employers.

Because so many depressed people are also suicidal, the fact that a few severely depressed patients taking antidepressants became suicidal didn't surprise researchers. The FDA was concerned, however, because Prozac affects serotonin, a neurotransmitter known to be linked with aggression. After further study, however, in 1991 the FDA rejected the petition, reaffirming Prozac's safety. This decision was followed two months later by a unanimous announcement by the FDA advisory committee and an independent scientific advisory committee that Prozac and other antidepressants do not cause violence or suicidal behavior, and that Prozac, on the contrary, appears to guard against violent behavior. The announcement included the information that large-scale studies show that people taking Prozac are less suicidal than those taking a placebo or other antidepressant drugs. This affirmation of support was backed by the National Mental Health Association and the American Psychiatric Association.

The research the groups relied on included an extremely large comparison of 3,065 patients on anti-depressants published in the British Medical Journal. The study found no evidence of increased suicide risk or suicidal thoughts in people taking Prozac or tricyclics. In the study, Prozac caused fewer substantial suicidal thoughts than did tricyclics or placebo. Of those people who did have suicidal thoughts when they started taking the drugs, those given a placebo had the highest increase in those thoughts, with Prozac showing the least increase (17.9 percent for placebo, 16.3 percent for tricyclics and 15.3 percent for Prozac). Most patients taking Prozac and tricyclics experienced a decrease in suicidal thoughts (about 72 percent).

By January 1994, 78 suits against Eli Lilly (Prozac's manufacturers) had been dismissed and 160 others had been filed, charging that Prozac causes everything from rashes to violent death.

"When I first went on Prozac, it was in the early days when everyone was talking about suicide and this drug," Marie says. "I was somewhat concerned about that. My friends asked me if I was sure I knew what I was doing."

Indeed, despite the suits and bad publicity, the popularity of this drug never declined; Lilly's Prozac sales haven't had a bad year since the drug was released in 1987. In 1993, sales reached $1.2 billion worldwide ($880 million in the United States alone), surpassing the sales of all previously used antidepressants around the world. Sales are expected to increase another 12 percent in 1994.

As we've seen from the above discussion, if you're depressed, it's possible you might have some suicidal thoughts; between 40 and 60 percent of people with major depression do. Tell your doctor immediately if you start feeling self-destructive.

How Prozac Is Administered

You'll probably be started out on 10 to 20 milligrams daily, and if you haven't responded within a month, your dosage may be increased to as much as 40 milligrams. Most patients don't take more than 80 milligrams, however, and some studies suggest that lower doses usually work better. (In a few cases, very obese people have responded to doses over 80 milligrams although this excessive dosage is not recommended in general because of safety concerns.)

Like all antidepressants, Prozac doesn't work overnight. It will usually take two to three weeks before you start to notice a difference in how you're feeling, although some people insist their depression improves within the first week. In most cases, depression lifts within one to two months. You should take the full dose for at least six weeks before deciding that it's not going to work. If you do have a good response, most doctors recommend you continue taking Prozac for six to eight months before stopping. If you're contemplating stopping, it's better to wait until you appear to have no upcoming stress, such as divorce proceedings or a major sales presentation. When you and your doctor decide it's time to stop taking Prozac, your doctor will teach you how to tell if your depression is returning.

Withdrawal

Unlike a few other antidepressants, Prozac produces no withdrawal symptoms when you stop taking it. Because of its long half-life, you can stop taking Prozac abruptly without complications. However, some doctors suggest you taper off your doses and closely watch for any indication of a relapse.

If you begin to feel lethargic, have low moods, or experience appetite or sleep problems, your depression could be returning. These are not the symptoms of any sort of withdrawal. If it is your depression returning, you can start taking Prozac again and it should work as well as it did before.

Unfortunately, some people do experience depression again and again. Because of the underlying biological component of depression, there's at least a 50-percent chance you may experience another episode. For those who've already had two episodes, the chances of a third jump to about 90 percent. Therefore, for cases of recurrent depression, experts today sometimes recommend taking Prozac indefinitely to prevent future occurrences.

Side Effects

The most frequent complaint about Prozac is nausea; you may not feel very hungry for the first few days. But this nausea usually disappears after about two weeks. It may help to take your medication with a meal, or to divide your dose in half for awhile; ask your doctor about this. But if your nausea doesn't go away in a week or two, or it gets worse, you may have to switch to another antidepressant.

Other common side effects include nervousness and anxiety. Prozac can be very stimulating, and some people feel a caffeine-like buzz after first taking this drug. "When I take Prozac, I feel jittery," Joan says, "sort of like drinking five pots of coffee. Other than that, I don't have any physical side effects."

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.

"Prozac made me speed up," says Julie, a 38-year-old woman with a family history of manic depression. "I was scouring every nook and cranny. I had two vacuums going in the bedroom at once, one for the corners and one for the floor. I hadn't cleaned that much for two years, because I was depressed. Once I took Prozac, suddenly I felt like doing a really good job. The night before I went on the cleaning binge, I lay in bed for two hours thinking that I could smell the dust. As soon as I told my psychiatrist, he immediately took me off Prozac and put me on Paxil."

What If You're Pregnant or Breast-Feeding?

Animal studies haven't found any problems with taking Prozac during pregnancy, even in 10 times the normal human dosage. However, animals and people sometimes react differently.

A study in the January 1997 New England Journal of Medicine concluded that taking Prozac or tricyclic antidepressants during pregnancy doesn't affect the IQ, language development, or behavior of the child, at least throughout the preschool years. In a study of more than 200 preschoolers, there also were no significant differences in temperament, mood, activity level, distractibility, or other problems, according to researchers at the University of Toronto in Ontario, Canada. Moreover, there were no developmental differences between infants who were exposed to antidepressants only during the first three months of pregnancy and those whose mothers took the drugs throughout pregnancy.

Previous research has shown that infants who were exposed to the antidepressants in the womb were no more likely to have major birth defects than those who were never exposed. Although one study indicated taking Prozac during the third trimester of pregnancy might lower an infant's birth weight and increase the risk of preterm delivery, the new study found no evidence of such problems.

At the time the children were born and when they were tested for learning and behavioral problems, their weights, and heights were similar regardless of whether their mothers had taken an antidepressant during pregnancy. Moreover, the study found that women who had taken the drugs during pregnancy were no more likely to give birth prematurely than those who hadn't taken them.

Because depression during pregnancy is a big problem, birthing experts felt reassured that at last there are some reassuring data about the safety of these drugs. Untreated depression can have a negative effect on pregnancy, especially if a woman has problems eating or sleeping.

While this study is encouraging, experts really can't be certain yet about the safety and effects of antidepressant use during pregnancy Most doctors recommend that, if at all possible, you not use Prozac (or any other antidepressant) if you're pregnant or trying to conceive. However, if you become severely depressed without medication during pregnancy, you and your must weigh the severity of the depression with the available information on how the drug might affect a developing fetus.

Like most antidepressants, Prozac is secreted in mother's milk. Since scientists just don't know what effect this might have on the baby, most doctors recommend that you not plan to breast-feed if you're taking Prozac. You'll need to weigh these decisions, however, since Prozac and many other antidepressants are effective in treating postpartum depression.

Prozac and Youth

While antidepressants have not been widely studied in children, a few studies suggest children and adolescents may be given Prozac provided they are carefully screened for manic depression in themselves or their family.

Because Prozac doesn't appear to cause the cardiovascular problems in children that sometimes occur with other antidepressants, some doctors find this a good choice. And Prozac has proven to be very effective against both bulimia -- so troubling in adolescence -- and obsessive-compulsive disorder, which often appears in childhood.

Studies suggest younger people respond with very small doses, possibly as small as 5 to 10 milligrams daily to start. Studies also show that a sizable portion of young people who do not respond to other antidepressants do respond to Prozac.

Studies also suggest that younger people experience slightly different side effects than those experienced by older patients. Restlessness and sweating are the most commonly reported side effects, together with drowsiness, dry mouth, tremors, and thinning hair.

Prozac and the Elderly

If you're over 65 and depressed, chances are you'll respond just as well to Prozac as you would to a number of other antidepressants (such as nortriptyline, a tricyclic antidepressant). However, because side effects like dry mouth and constipation aren't such a problem with Prozac and the other SSRIs, you're more likely to be able to tolerate treatment. And, as we've discussed above, Prozac is ideal for older people because it doesn't interfere with blood pressure or heart function. In fact, Prozac and the other SSRIs (plus Wellbutrin) are among the safest antidepressants for people with heart disease. For these reasons, more and more psychiatrists are reaching for Prozac and other SSRIs for their older patients.

There have been a few reports noting that some older people taking Prozac have low levels of sodium in their blood, causing them to retain water, which can lead to swelling. Your doctor will advise you if you are likely to experience this problem.

Prozac and Obsessive-Compulsive Disorder

Since Prozac affects the serotonin system, and because serotonin has been implicated in a host of other disorders, it's not surprising that Prozac appears to help lots of other problems besides depression.

In July 1993, the FDA approved Prozac for the treatment of obsessive-compulsive disorder. This disorder is surprisingly common in this country, affecting 5 million Americans with symptoms commonly beginning as early as age 10.

People with OCD become obsessed with certain thoughts and bogged down with repetitive activities like washing their hands or rechecking doors and windows. (A "compulsion" is a rigid behavior that is repeated over and over every day.) If you have OCD, you may be fearful about dirt, disease, or toxic chemicals, or you may need to count, align, check, or apologize constantly.

People with OCD are not out of touch with reality. They know their behavior isn't reasonable, and about a third are so upset about their problem that they become clinically depressed.

Studies have shown that Prozac can help up to 70 percent of these people, although it can take up to 10 weeks to notice improvement. Patients usually take higher doses of Prozac for OCD on a long-term basis. And because Prozac does not carry many of the harmful side effects that interfere with antidepressant use in children, it has been given to young OCD patients with favorable results. One study reported that four out of eight youngsters given up to 80 milligrams of Prozac daily completely stopped their handwashing rituals after two months.

The SSRI Luvox (fluvoxamine) and the tricyclic Anafranil (clomipramine) are also very effective treatments.

Other Disorders and Prozac

Prozac has also been used to treat a wide variety of other disorders; studies have shown that at least some people have improved when taking Prozac for PMS, nicotine withdrawal, exhibitionism, dementia, Tourette's syndrome, and even itchy skin under certain circumstances. Some of the more common disorders that are being treated with Prozac include:

Premenstrual Syndrome

Surveys have shown that between 3 and 8 percent of North American women suffer from premenstrual syndrome. Recent studies have shown what physicians have already found to be true -- many women find relief from symptoms when taking Prozac.

A recent Canadian study of 180 women found that half of the subjects taking Prozac daily for six months had at least a moderate improvement in their symptoms. By contrast, only 22 percent of those taking a placebo reported a moderate decrease in symptoms. In addition, significantly more women taking the Prozac reported better than 75 percent improvement in their symptoms, and both small (20 mg) and large doses (60 mg) were equally effective. The smaller dose, however, caused fewer side effects (nausea, fatique, dizziness, and concentration problems).

While it is not clear why PMS responds to Prozac, scientist note that many of the features of PMS are similar to those of depression.

Body Dysmorphic Disorder

People with body dysmorphic disorder (the false perception that a part of the body is abnormal) generally feel better with a SSRI.

Alcoholism

Several studies have found that Prozac may help alcoholics decrease the amount of alcohol they drink, while other SSRIs increased the number of days alcoholics can abstain from drinking.

Panic Attacks

If you've ever experienced the frightening wave of panic common to those with panic disorder, you'll be happy to hear that many patients respond to Prozac. In one study, about half of people with panic attacks become free of panic after taking Prozac, while the other half reported they become more anxious with this drug. Another study found that seven of eight people with panic disorders found complete relief with Prozac. A third found that 19 out of 25 panic patients showed moderate to remarkable improvement. And by reducing panic, it's possible also to ease the agoraphobia (fear of being in places where they feel vulnerable) that often is associated with panic attacks. Behavioral therapy together with Prozac or another antidepressant may be the best treatment for panic attacks.

Mental Disorders

Studies suggest that Prozac can improve functioning in patients suffering from either schizophrenia or borderline personality disorder. Schizophrenics, for example, may become less aggressive and more interested in social activities.

Prozac and Eating Disorders

Bulimia

Prozac has been approved by the FDA advisory committee for the treatment of bulimia, a sometimes-fatal disorder of compulsive eating binges and self-induced vomiting and laxative abuse. Estimates of bulimia sufferers range from 1 percent to 10 percent of all American women and up to 14 percent of college-age women.

Some research suggests that depression can be an underlying cause of eating disorders; one study of bulimics found that three out of four bulimic patients were depressed.

Studies suggest that Prozac can help ease eating binges in up to 63 percent of people with bulimia nervosa. While MAOIs also help with bulimia, the side effects and rigid diet restrictions often cause problems for patients. And because many patients taking MAOIs gain weight, the chance is small that patients will stick with this medication regimen considering their intolerable fear of weight gain. In fact, a recent study of 27 bulimic patients found that while they responded well to the drug, 24 stopped taking the drug within four months because of the side effects.

Some scientists believe that Prozac may be helpful in correcting bulimia because it reduces appetite; some studies found that rats given fluoxetine and then deprived of their favorite food for a day ate less than they would normally eat. Other experts believe the drug corrects the underlying serotonin malfunction, pointing out that other antidepressants that don't affect appetite but do affect serotonin are also effective against bulimia.

In another study, up to 65 percent of bulimic patients responded to antidepressants, although many did not respond to the first drug that was tried. In this particular study, 6 of the 17 patients who experienced remission of their symptoms were taking Prozac.

A combination of psychotherapy and Prozac has been the most effective treatment for bulimia.

Anorexia Nervosa

Anorexic patients have antidepressant needs that are a little different from bulimic subjects. Still, a new study by the University of Pittsburgh Medical Center found that Prozac can help patients with anorexia. When 16 women with the eating disorder were given Prozac, 10 stayed at a healthy weight and didn't relapse, while only three of 19 anorexic women placed on a placebo were able to remain healthy. This study is the first to show an antidepressant could help prevent anorexia relapses, according to study director Walter Kaye, M.D.. Prozac may help by altering brain chemicals that affect both mood and appetite. Experts were hopeful because a medication that can help patients maintain a healthy weight outside of a hospital and prevent relapse can ultimately save lives. Currently, there is no anorexia treatment that has been approved by the FDA.

What Prozac and other antidepressants can do is to address the underlying biological problem that may be causing the eating disorder; this treatment, combined with supportive psychotherapy and nutritional counseling, may help break the cycle of anorexia.