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No pill is a panacea and Prozac and family are no exception. Years ago when Valium and its relative drugs, the benzodiazepines, were first introduced we were not aware of their addictive potential, or that they slowed down thinking and seriously interfered with motor coordination skills. They were hailed as new and wonderful antianxiety agents and far safer than earlier, similar drugs. Indeed they have been safer and helpful to millions of people. However, as we gradually discerned their negative potential, we realized that the side effects could have disturbing results.
For example, benzodiazepine withdrawal anxiety and insomnia can be more intense than the original anxiety and sleep disturbance that often motivated starting the medications in the first place. Cognitive slowing and changes in motor coordination can be devastating, especially for the elderly. It took us a while to understand these more subtle side effects. For instance connections were not always made between these drugs and thinking deficits to some related car accidents. The more recent sleep agents, Ambien and family, are benzodiazepine like drugs that target the same neuroreceptor, Gabba, as the benzodiazepines. They are called hypnotics as they induce sleep, but they have a similar side effect profile as the "Valium and Xanax family drugs". So they too must be used with discernment.
Prozac and other Serotonin agents have also been an amazing improvement over previous antidepressant and antianxiety drugs. Many of the earlier related medications, called Tricyclic Antidepressants, resulted in excessive weight gain, among other things. In the past few years we have become aware that the Tricyclics may induce a cardiac arrhythmia that can be serious, on occasion fatal for some patients, again particularly for the old and young. Both the new Serotonin and the old Tricyclic antidepressant/anti-anxiety drugs have recently received a "black box warning". This means that the Food and Drug Administration (FDA) that oversees medications in our country is urging serious caution with their use. This warning involves potential increases in suicidal thinking and gesture for some patients, especially adolescents. Paxil, one of these family drugs, has been given a second recent FDA warning regarding congenital malformations that may be produced in women taking this medication during the first trimester of pregnancy.
As time passes and the use of Prozac type drugs has become common place, certain side effects have gradually become clear to us. We have known for period that most of the people who use these medications lose sexual interest. Now researchers are beginning to be aware that these medications may actually produce a kind of "relationship indifference and apathy." Once the terms "relationship indifference" and "apathy" are used, many patients and doctors realize that these side effects has been present for some all along. We knew that emotional modulation was a good benefit of these drugs, but the indifference and apathy were more subtle and harder to discern. These troublesome issues have been difficult for many people taking these medications and for their family members as well. Relationship indifference and apathy may have serious quality of life consequences.
RELATIONSHIP AND PURPOSE IS A MEDICATION
It is true that when one is overwhelmed with feeling states of anxiety and depression that detachment and apathy may be a part of the disequilibrium of emotional upset. Unfortunately, along with the solace of modulation of feelings that these newer medications bring, can be this new sense of indifference to family relationships and life. A recent large scale study from Harvard indicates that depression and suicide are primarily driven by two basic deficit components: one is the need to belong and connect in relationship, and the other is to feel effective and purposeful. The importance of attachment and perceived effect on significant others has enormous impact on human wellbeing. It is interesting how often people in today's world will act (or vote) against self interest so as to feel connected. Suicide bombers, for example, are led primarily by group emotional influence and culture to kill themselves, and others. Through group relationship and highly emotionally charged cultural belief, they bypass self destruction and fear to celebrate martyrdom and self sacrifice. (A recent World Health Organization study of 400 suicide bombers indicated that most were educated but led by friendship to groups like Al Qaeda to sacrifice self interest to the "cause" of the group). In this painful contemporary example we see people driven to suicide and murder by cultural pressure based on strongly felt belief and relationship. These factors of relationship and life purpose can be demonstrated as powerful life (or death) forces. They clearly are of seminal relevance to human wellbeing or angst.
MEDICATION PARADOX
It is distressing that a primary side effect of our medications for depression and anxiety have the possibility to promote some of the bad effects of the problems that they were intended to cure. The potential side effects of the Prozac family drugs to induce emotional and motivational states of disinhibition, indifference and suicide are a paradox. For a long time we have known that depression significantly increases cardiac risk. As mentioned, a side effect of the earlier Tricyclic antidepressants has also proved to be a harbinger of cardiac problems. Because of this they are rarely used today, especially with elderly and children.
Recently a massive study by the Journal of American Medical Association found that erectile dysfunction contributed to a 45% increase in cardiac risk. It is difficult to know if this reflects a physiological state related to blood perfusion for example, or to depression. Unfortunately our antidepressant Serotonin drugs frequently promote erectile dysfunction. It has been said that men need sex for intimacy and women need intimacy for sex. We know that attachment is one of the two most seismic forces related to depression.
BRAIN CHEMISTRY CAN CHANGE WITH LIFESTYLE
People used to come into therapy saying that they had a "chemical imbalance" that resulted in their depression. We know that there may be a genetic proclivity for depression. However, today we also know that our genes are interfacing with our environment, and each is shaping the other. It is clearly not an issue of genes or environment. It is both that determine much of our physical and mental states. For instance, your brain chemistry changes with exercise, light, social support, sleep, and thought patterns. Negative thinking literally generates a depressive biochemistry, while anxious rumination increases heart rate, blood pressure and induces a biochemical state of fear. Medications for emotional dysregualtion are often necessary. No one doubts that. Would it not be best to urge people to use the mediations to make lifestyle changes so that they may, at least for some people, only be needed a period of time? Recent research protocol indicates a year of antidepressant/antianxiety medications for a serious episode. Some experts in the field generally say that a second occurrence of severe depression or anxiety would require medication for life. It is important to know that many of these studies have not been with patients in active psychotherapy. They were primarily studies done on patients with medication as the only treatment. If only medication is used as treatment, brain imaging has clearly shown us that the dysregulation that is seen in depression and anxiety will reemerge rather quickly when medication is stopped. On the other hand, it has also demonstrated that with cognitive behavioral and lifestyle therapeutic change while on medication, dysregulation in most patients does not tend to reoccur once medication is withdrawn. The most robust research for the relief of depression and anxiety has been with medication and cognitive behavioral psychotherapy combined.
Setting up your best self is rather like working on a business proposal. There are a number of factors that must be addressed for success. Remember that as you think, so you feel. Your thoughts generate brain chemistry also, and negative rumination is inimical to well being. A recent study from social psychology tells us that the happy people actively work at being the kind of person that they would like to be. Acting like a good person seems to make it so. The side effect, the study says, is an increased sense of personal happiness. Being kind to others tends promote self esteem by making you feel like a kinder person. Does this sound like simplistic advice? Perhaps so, but now it is evidenced based. So it seems that the good that we do comes back to us-probably the bad does also.
Sleep is particularly involved in brain chemistry restoration. It is a primary factor in mood regulation and cognitive recovery. By-the-way, the most robust activation of REM (rapid eye movement-dream) sleep happens in the final ninety minutes of an eight hour sleep cycle. It is primarily in REM sleep that memory consolidation takes place. Imagine the important daily regeneration of cognitive fluency and memory consolidation that may be lost with chronic sleep deprivation that misses this significant last hour and a half phase of the end of an eight hour sleep cycle. Who has not felt the effects of an "unhappy foggy brain" after loss of restful sleep? If we are to thoughtfully guide emotional states, sleep is essential. Researchers say even Einstein needed eight hours of sleep! Like diet, many different "nutrients" are needed for biochemical balance and wellbeing. Staying emotionally and physically healthy is part of the same puzzle. Emotional biochemical states respond like health to internal and external life habits.
How we live is who we are. A good (happy?) person is careful in thinking and other basic life habits. How a person controls and expresses emotion is of essence to character. A thoughtful, balanced life literally sets up our brain/body chemistry so that we may clearly think our way through emotional states and life experiences, as much as possible inducing a biochemical state of well being. Life is complex and of course, we can't control everything that happens to us. But, we can set up life habits (including thinking habits) that will increase our abilities to thoughtfully modulate emotional states. Medication may be necessary but working actively to alter depressive/anxious producing life patterns is probably the bottom line for therapeutic biochemical change. How many people do you know who seem to lack thoughtful control over mood? How many regularly numb themselves with alcohol or drugs, thus avoiding higher order thinking and speaking that may facilitate needed change to find purposeful lifestyle or constructive relationship communication? How much trouble in our world is caused by people acting on feelings without thoughtful guidance? Medications are important, but there is a downside to each of them. Sometimes they are necessary, and for certain people their use is indefinite. But for many, understanding how to address emotional modulation constructively on a daily lifestyle basis can surely help. Therapy gives you more control even over your brain chemistry and medications.
- Dr. Linda Klaitz, Medical Psychologist
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