He was very intelligent and had no difficulty understanding the complexities of his clients’ finances but somehow he had insurmountable problems with deadlines. He would leave things until the last minute, stay up all night working crazily and would almost always succeed in getting the work done on time. But these last-minute all-nighters were becoming tiresome not only to my patient but to his associates as well. As a consequence he was under pressure to work in a more steady and even manner and he was depressed at his difficulties in doing so.

Careful questioning revealed that he had suffered from atten-tional difficulties since childhood, had never performed up to his potential and had always relied upon the intense pressure of deadlines and the prospects of failure to motivate himself to get anything done. In lectures and classes he would lose track of what the lecturer or teacher was saying. He was extremely distractable and often left tasks – particularly boring and unpleasant ones such as paperwork – half completed as his attention shifted to something which at that moment he found more interesting. I diagnosed him as suffering from attention deficit disorder (ADD), prescribed Ritalin, a stimulant, and recommended certain behavioural changes in the way he approached his work. He responded immediately and favourably and his mood improved as well. He turned out to be someone whose depressed mood was the result of another problem which responded to treatments that were specifically helpful for that condition. An anti-depressant alone would have been unlikely to correct his fundamental problem, namely his attentional difficulties.

Even if a person is indeed depressed, it is worth going to see a doctor to determine whether some other treatable condition may be present in addition to the depression. Shakespeare noted that ‘when sorrows come, they come not as single spies but in battalions.’ And so it is that depression is often accompanied by some other condition, such as a drug or alcohol problem, attention deficit disorder or an eating disorder. If these conditions are present they deserve to be treated in their own right with the appropriate treatment. People with more than one condition often require more than one type of treatment to get the best results.

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What are the symptoms of grief or bereavement, and does Prozac help in their treatment?

We usually think of grief only in terms of the death of a loved one, but bereavement reactions also occur in response to the loss of a job, a large quantity of money, an important object such as a home, or even an idealistic concept that one has long pursued. Weeping, anxiety, sadness, anger, irritability, guilt, insomnia, and obsessive thinking about the loss are all common reactions, but if these symptoms do not begin to level off after three to four months,

psychiatrists usually diagnose major depressive disorder. In such cases, Prozac or another antidepressant, along with therapy, is indicated. Indeed, it may help earlier.

What are seasonal affective disorders (SADs) and can they be treated with Prozac?

Seasonal affective disorders are disturbances of mood that appear to be precipitated at a particular time of the year, usually in the fall or winter. Prozac, like all other antidepressants, as well as light therapy, is effective in treating the recurrent episodes of depression in the seasonal affective disorders, as well as the depression of a nonseasonal type.

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Prozac and the other SSRIs are highly specific in blocking the uptake only of serotonin, and not other neurotransmitters; that is why they are known as selective serotonin reuptake inhibitors (SSRIs). Because abnormalities in serotonin function have also been reported in obsessive-compulsive disorder, panic disorder, alcoholism, obesity, and other conditions, it is not surprising that some of these disorders have been successfully treated with Prozac and other SSRIs.

Tricyclic antidepressants, or TCAs, the most frequently used antidepressants over the past three or four decades prior to Prozac, were thought to alleviate depression by blocking norepinephrine and some serotonin uptake at the nerve terminals in the brain. This increased the levels of both neurotransmitters, permitting a return of normal nerve impulse flow, associated with the relief of depressive symptoms.

Other less commonly used older drugs, called MAOIs, or monoamine oxidase inhibitors, work in another way, by blocking the degradation of the enzyme monoamine oxidase at the nerve terminals. This leads to higher levels of norepinephrine and serotonin at the synapses and at critically important receptor sites. The final effects are similar to those achieved with the TCAs.

Prozac and other SSRIs including Zoloft, Paxil, Luvox, and Serzone, specifically block serotonin only.

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A dysphoric mood is an unpleasant emotional state with feelings of sadness, anxiety, and/or irritability. If short in duration, it is usually not severe enough to lead to a major impairment of functioning. Psychiatrists use the term to describe patients who complain of a shifting set of symptoms. These mood changes, if transitory, are often normal responses to ordinary (but momentous) events of life such as leaving home for the first time, falling in love, or losing a loved one. Dysphoric moods can also accompany medical disorders such as stroke or Alzheimer’s disease.

However, if the dysphoric mood swings become prolonged for weeks or longer, the patient should be evaluated. The dysphoria may evolve into a bona fide depression, which needs to be treated.

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However, a patient diagnosed with a given disorder doesn’t necessarily display every one of those listed characteristic symptoms. Of the nine symptoms listed for major depression, any five permit the diagnosis. Dysthymia also has a list of nine symptoms; only three are required for the diagnosis. A diagnosis of mania or hypomania also requires a specific number of symptoms, but mild hypomania, unlike mania, may cause little or no impairment of functioning and may be, in fact, desirable.

But what about patients who have only two of the traits needed for diagnosis of major depression? Or only one? Feelings of despair, hopelessness, and pessimism alone aren’t enough to diagnose major depression or dysthymia. Merely feeling depressed, sad, empty, timid, or withdrawn most of the time does not qualify as major depression or dysthymia, although these are certainly a few of the symptoms included in these syndromes. Some patients, normal in all other respects, may only exhibit sleep disruption or a severe drop in self-esteem or a fear of new social situations. Other patients may come in with a myriad of physical complaints, none of which can be explained by physical causes, and alone these complaints do not allow the physician to diagnose depression.

Because these patients fall short of the totality of the required DSM-IV symptoms for diagnosing major depression or dysthymia, manifesting only a single, or a few isolated symptoms of the illness (depression) they, therefore, do not qualify for one of the DSM-IV diagnoses. Instead, they are counted among the subclinically depressed and are often exclusively treated in psychotherapy, either sitting or lying on the couch, by the psychoanalyst, psychologist, psychiatrist, or social work-therapist.

People who fall into this category often remain incompletely diagnosed and untreated because they may continue to function fairly well and don’t feel enough pain to go to a psychiatrist. They may instead go to their internist or psychologist and be diagnosed with “irritable bowel syndrome” or “personality disorder”. They’re just miserable most of the time, and misery is not a formal psychiatric diagnosis.

Often considered ideal candidates for psychoanalysis, these patients have been called the “worried well”. They tend to seek psychotherapy, feeling that their timidity, lack of interest, difficulty competing with their peers, and low self-confidence are psychological problems, which will be “cured” on the couch. When the subclinical depressive symptoms have been chronic, therapy alone usually fails. But I have seen many patients with subclinical depressions who have responded very well to Prozac, in combination with personal short-term psychotherapy.

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