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Subject: alt.support.depression FAQ Part 2[5]

This article was archived around: 25 May 2006 04:23:30 GMT

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Archive-name: alt-support-depression/faq/part2 Posting-Frequency: bi-weekly Last-modified: 1996/02/13
Note: This is a minor and emergency update to this section only, and is not complete in it's editing. The other sections will be updated very soon. Part 2 of 5 =========== **Causes** (cont.) & What causes depression? - What initiates the alteration in brain chemistry? - Is a tendency to depression inherited? **Treatment** - What sorts of psychotherapy are effective for depression? - What is Cognitive therapy? **Medication** - Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug? - How do you tell when a treatment is not working? How do you know when to switch treatments? - How do antidepressants relieve depression? - Are Antidepressants just "happy pills?" - What percentage of depressed people will respond to antidepressants? - What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant? - What are the major categories of anti-depressants? - What are the side-effects of some of the commonly used antidepressants? - What are some techniques that can be used by people taking antidepressants to make side effects more tolerable? - Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects? - What should I do if my antidepressant does not work? + Can someone build up tolerance to Prozac or other anti-depressants so that they stop working after a while? + What about the rumors and studies that Prozac causes suicide and/or acts of violence? Causes (cont.) -------------- Q. What causes depression? The group of symptoms which doctors and therapists use to diagnose depression ("depressive symptoms"), which includes the important proviso that the symptoms have manifested for more than a few weeks and that they are interfering with normal life, are the result of an alteration in brain chemistry. This alteration is similar to temporary, normal variations in brain chemistry which can be triggered by illness, stress, frustration, or grief, but it differs in that it is self-sustaining and does not resolve itself upon removal of such triggering events (if any such trigger can be found at all, which is not always the case.) Instead, the alteration continues, producing depressive symptoms and through those symptoms, enormous new stresses on the person: unhappiness, sleep disorders, lack of concentration, difficulty in doing one's job, inability to care for one's physical and emotional needs, strain on existing relationships with friends and family. These new stresses may be sufficient to act as triggers for continuing brain chemistry alteration, or they may simply prevent the resolution of the difficulties which may have triggered the initial alteration, or both. The depressive's change in brain chemistry is usually self-limiting. After one to three years, brain chemistry reverts to normal without medical treatment. However, at times, is profound enough to result in suicidal thinking or behaviors. A large number of untreated seriously depressed people will in fact attempt suicide. As many as 17% will eventually succeed. Depression must be thought of as a potentially fatal illness. Friends and relatives may be deceived by the casual way that profoundly depressed people speak of suicide or self-mutilation. They are not casual because they "don't really mean it"; they are casual because these things seem no worse than the mental pain they are already suffering. Any comment such as, "You'd be better off if I were gone," or "I wish I could just jump out a window," is the equivalent of a sudden high fever; the depressed person must be taken to a professional who can monitor their danger. A formulated plan, such as, "I'm going to jump in front of the next car that comes by," is the equivalent of sudden unconsciousness: an immediate medical emergency which may require hospitalization. Depression can shut down the survival instinct or temporarily suppress it. Therefore, depressed suicidal thinking is not the same as the suicidal thinking of normal people who have reached a crisis point in their lives. Depressive suicides give less warning, need less time to plan, and are willing to attempt more painful and immediate means, such as jumping out of a moving car. They may also fight the impulse to suicide by compromising on self-injury -- cutting themselves with knives, for example, in an attempt to distract themselves from severe mental pain. Again, relatives and friends are likely to be astonished by how quickly such an impulse can appear and be acted upon. Q. What initiates the alteration in brain chemistry? It can be either a psychological or a physical event. On the physical side, a hormonal change may provide the initial trigger: some women dip into depression briefly each month during their premenstrual phase; some find that the hormone balance created by oral contraceptives disposes them to depression; pregnancy, the end of pregnancy, and menopause have also been cited. Men's hormone levels fluctuate as deeply but less obviously. It is well known that certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, and Parkinsonism. This seems to be the result of a chemical effect rather than a purely psychological one, since other, equally traumatic and serious illnesses don't show the same high risk of depression. The typical chemical changes that characterize depression can also be caused by psychosocial factors. Q. Is a tendency to depression inherited? It seems there are some people whose brain chemistry is predisposed to the depressive response, and others who are at much lower risk of depression even if exposed to the same physical or psychological triggers. The close relatives of manic-depressives are at a higher risk for unipolar depression than the population at large or their adopted/by marriage relations. There seems to be a link between high creativity and the gene for manic-depression: artists and writers often are not manic-depressive themselves, but have a family member who is. Studies of families in which members of each generation develop manic-depressive illness found that those with the illness have a somewhat different genetic make-up than those who do not get ill. However, the reverse is not true: not everybody with the genetic make-up that causes vulnerability to manic-depressive illness has the disorder. Apparently additional factors, possibly a stressful environment, are involved in its onset. Major depression also seems to occur, generation after generation, in some families. However, depression can occur in people with no family history of any form of mental illness. And there probably is no human who is entirely immune to depression if stressed enough. Psychological triggers: many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to astonishingly virulent and inappropriate guilt and self-hatred. So what they identify as a cause of the depression is not the true cause. Also people are generally more comfortable thinking that their depressions had a specific trigger rather than thinking of them as occurring for no specific reason. The (genuine) life events that are most often associated with depression are varied, but the distinguishing features of such events are: loss of self-determination, of empowerment, of self-confidence. More profoundly: a loss of self, of the abilities or activities that a person identifies with herself. Stereotypically: a man loses the job that had defined him to himself and others, whether that definition was "executive" or "breadwinner"; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. In general, any life change, often caused by events beyond one's control, which damages the structure that gave life meaning. The ability of a person to respond to such an event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors which may best be explored in talk therapy: why is the person's self-esteem so bound up in the position or state that has been lost? Can she find a new source of self-esteem? Therapy can be immensely helpful here. Obviously, not everyone to whom this sort of event happens becomes depressed, and not every person who becomes depressed has had this sort of catastrophe befall them. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious physhological or biological trigger. Once the depressive state has started, both physical and psychological problems will be generated in abundance. What faster way to lose a job or a spouse than to be too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically maintained, profound self-hatred? And what can be worse for self-esteem than watching one's appearance and household disintegrate as one loses the motivation and energy to shower, straighten up, wash dishes or laundry, or choose attractive clothes? Health deteriorates as well: some depressed people can't sleep or eat, others sleep constantly (a real help on the job!) and eat incessantly, sometimes in order to stay awake, sometimes because it's the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, so there may be an element of self-medication here); almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression. The question, "Is depression mostly physical or psychological," is rather beside the point. There is only one of you, not a separate physical you, and a psychological you. Depression may be triggered by either physical or psychological events. Most commonly, both seem to be involved, though it is often difficult to separate the two when one is talking about psychology and neurochemistry. However it begins, depression quickly develops into a set of physical and psychological problems which feed on each other and grow. This is why a combination of physical and psychological intervention has been shown to give the best results for many patients, regardless of any diagnosis. Treatment --------- Q. What sorts of psychotherapy are effective for depression? Two effective methods of psychotherapy for people with depressions are cognitive therapy and interpersonal therapy. Both psychoanalysis and insight oriented psychotherapy have not been shown to be effective treatments for people with a depressive disorder. Cognitive (and cognitive-behavioral) therapists can be found in most major cities. For a referral to a properly trained cognitive therapist practicing close to your location, contact: Aaron T. Beck, MD. The Center for Cognitive Therapy 3600 Market Street Philadelphia, PA 19101 (215) 898-4100. While many therapists call themselves cognitive therapists and interpersonal therapists, only a few have had proper training. To find an interpersonal therapist with the best training, contact: Myrna Weissman, Ph.D. New Your State Psychiatric Institute 722 West 168th Street New York, NY 10032 212-960-5880 Q. What is Cognitive therapy? A. Congitive therapy points out a number of misconceptions or "cognitive distortions" that affect the way we view ourselves. Some of these are: 1) All or Nothing Thinking: You look at things in absolute black-and-white terms. ("I don't think cognitive therapy will solve all my problems, so what's the point in even trying." "There's no point in getting started on this, I'm so far behind I'll never catch up.") 2) Overgeneralization: View a negative event as a never ending pattern of defeat. ("I always mess things up". "He's always late.") 3) Mental Filter: Dwell on negatives and ignore positives. (Example: your boss praises your report but wants a few changes. All you can do is dwell on the criticism.) 4) Discounting the positives: you insist your positive accomplishments "don't count" or are due to luck. 5) Jumping to conclusions: a) Mind reading ("My shrink only gave me half of the cognitive distortion list because he hates me." or b) Fortune-Telling --- arbitrarily predict things will turn out badly. 6) Magnification or minimization: Blow things out of proportion or shrink their importance inappropriately. 7) Emotional reasoning: Reason from how you feel: "I feel frightened therefore this must be really dangerous." 8) "Should statements": criticise yourself or other people based on how you think they "should" act or feel. "I shouldn't have so many cognitive distortions" "I shouldn't be so apprehensive about this". The only "shoulds', "have to" etc allowed are a) moral shoulds "Thou shalt not kill", b) Legal shoulds "You shouldn't try to smuggle chewing gum into Singapore" or 3) Physical Law shoulds "If I drop this ball it should fall to the ground." 9) Labeling: Identify yourself or others with their shortcomings: Instead of "I made a mistake" you think "I am an idiot". 10) Personalization: You blame yourself for something you weren't entirely responsible for or blame others and overlook your own behavior or attitudes. The first step in cognitive therapy is to learn to recognise cognitive distortions. At first you feel like your whole mind is a hypertext document and every thought you click on reveals some cognitive distortion. To say you "I shouldn't have so many cognitive distortions" or "Now that I've recognised my cognitive distortions I should _easily_ be able to change the way I act or feel " are cognitive distortions. To say "I feel stupid and incompetant when I see that I am always making cognitive distortions, therefore I must be a total idiot" is a whole bunch of cognitive distortions. Medication ---------- Q. Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug? There are very few kinds of depression for which there are specific antidepressant treatments. When it comes to people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause depressed bipolar people not just to come out of their depressions, but to develop manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed bipolar folks are on a mood stabilizer such as lithium, Tegretol or Depakote when they are started on an antidepressant. Q. How do you tell when a treatment is not working? How do you know when to switch treatments? Antidepressant treatment is clearly not working when the individual receiving the treatment remains depressed or becomes depressed again. When a recently started antidepressant fails to cause improvement, the depressed individual often asks that the medication be stopped, and a new one started. It generally does not make sense to change antidepressants until 8-weeks at the maximum tolerated dose have elapsed. With some tricyclic antidepressants, it is important to check the blood level of the antidepressant before it is stopped. The blood test can tell if the amount in the blood has been adequate. Only after an adequate trial of one antidepressant should another be tried. To have been on four antidepressants in an 8-week period means that one has not had an adequate trial on any of them. Q. How do antidepressants relieve depression? There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain's concentration of molecules, receptors, to which these transmitters bind. In some unknown way it is the changes in the receptors that are thought responsible for improvement. Q. Are Antidepressants just "happy pills?" No matter what their exact mode of action may be, it is clear that antidepressants are not "happy pills." There is no street-market in antidepressants, for unlike "speed" which will improve the mood of almost everybody, antidepressants only improve the mood of depressed people. Also unlike the almost instant effects of speed, the mood-improving effects of antidepressants develop slowly over a number of weeks. "Speed" induces a highly artificial state, antidepressants cause the brain to slowly increase its production of naturally occurring neurotransmitters. Q. What percentage of depressed people will respond to antidepressants? Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken, have an excellent chance of responding to another. Q. What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant? The most common description of the effects of antidepressants is that of feeling the depression gradually lift, and for the person to feel normal again. People who have responded to antidepressants are not euphoric. They are not unfeeling automatons. The are still able to feel sad when bad things happen, and they are able to feel very happy in response to happy events. The sadness they feel with disappointments is not depression, but is the sadness anyone feels when disappointed or when having experienced a loss. Antidepressants do not bring about happiness, they just relieve depression. Happiness is not something that can be had from a pill. Q. What are the major categories of anti-depressants? There are many classes of antidepressants. Two kinds of antidepressants have been around for over 30 years. These are the tricyclic antidepressants and the monoamine oxidase inhibitors. While there are newer antidepressants, many with fewer side-effects, none of the newer antidepressants has been shown to be more effective than these two classes of drugs. In fact, many people who have not responded to newer antidepressants have been successfully treated with one of these classes of drugs. The tricyclic antidepressants (TCAs) include such drugs as imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor). The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has recently been taken off the market in the U.S.A. for marketing rather than safety or efficacy reasons. One of the popular new classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in late 1994, or early 1995. Bupropion (Wellbutrin) is the only drug in its class, as is trazodone (Desyrel). The most recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug in yet another class of drugs. IVAN: ANOTHER COMMENT THAT I LEAVE TO YOUR JUDGEMENT: From: Ian Ford <ianford@dircon.co.uk> Date: Sun, 22 Jan 1995 20:33:09 -0500 To: cf12@cornell.edu (Cynthia Frazier) Subject: Re: alt.support.depression FAQ Part 2[5] Newsgroups: alt.support.depression,alt.answers,news.answers Ref your depression FAQ : Periactin <is> available w/out prescription in UK. It is a category "P" medication , i.e. it may be bought from a pharmacy when the pharmacist is present, but no prescription is necessary. Of course, self-medication is not necessarily a good idea and you may do best to talk to your doc. first. END COMMENT Q. What are the side-effects of some of the commonly used antidepressants? Below is a list of some of the more frequently prescribed antidepressants, and their most common side effects. The figure following each side effect is the percentage of people taking the medication who experience that side effect. Aventyl (nortriptyline): Dry mouth (15); Constipation (15); Weakness-fatigue (10); Tremor (10). Effexor (venlafaxine) Nausea (35); Headache (25); Sleepiness (25); Dry mouth (20); Insomnia (20); Constipation (15). Elavil (amitriptyline): Dry mouth (40); Drowsiness (30); Weight gain (30); Constipation (25); Sweating (20). Nardil (phenelzine): dry mouth (30); insomnia (25); Increased heart rate (25); Lowered blood pressure (20); Sedation (15); Over stimulation (10); Norpramin (desipramine): dry mouth (15); increased pulse (15); constipation (10); reduced blood pressure (10). Pamelor - see Aventyl Parnate (tranylcypromine) Dry mouth (20); Insomnia (20); Increased pulse rate (20); Lowered blood pressure (15); Over stimulation (15); Sedation (15). Paxil (paroxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (25); Sedation (25); Dizziness (15) Insomnia (15) Prozac (fluoxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (20); Headache (20); Nervousness (15); Insomnia (15); Diarrhea (15). Sinequan (doxepin): Dry mouth (40); Sedation (40); Weight gain (30); Lowered blood pressure (25); Constipation (25); Sweating (20). Tofranil (imipramine): Dry mouth (30), Reduced blood pressure (30), Constipation (20), Difficulty with urination (15). Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness (20); Decreased appetite (20); Zoloft (sertraline): Decreased sexual interest and/or problems achieving orgasm (30);Nausea (25); Headache (20); Diarrhea (20); Insomnia 15); Dry mouth (15); Sedation (15). Q. What are some techniques that can be used by people taking antidepressants to make side effects more tolerable? Listed below are some frequent side effects of antidepressants, and some techniques to reduce their severity: Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask the dentist to suggest a fluoride rinse to prevent cavities, visit the dentist more often than usual for tooth and gum hygiene Constipation: Drink at least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about taking a bulk producing agent such as Metamucil, also ask about taking a stool softener such as Colace, be sure to avoid laxatives such as Ex-Lax. Bladder problems: The effects of some antidepressants, especially the tricyclic medications may make it difficult for you to start the stream of urine. There may be some hesitation between the time you try to urinate and the time your urine starts to flow. If it takes you over 5-minutes to start the stream, call your doctor. Blurred vision: The tricyclic antidepressants may make it difficult for you to read. Distant vision is usually unaffected. If reading is important to you the effects of the antidepressant can be compensated for by a change in glasses. As you may compensate for the change in your vision, try to postpone getting new glasses as long as possible. Dizziness: Dizziness when getting out of bed or when standing up from a chair, or when climbing stairs may be a problem when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing posture slowly may help prevent this kind of dizziness. Drinking adequate amounts of liquid and eating enough salt each day is important. Be sure to speak to your doctor if this side-effect is severe. Drowsiness: This side effect often passes as you get used to taking the antidepressant that has been prescribed for you. Ask your doctor if it is safe for you to increase your intake of caffeine, and if so, by how much. If you are drowsy be sure not to drive or operate dangerous machinery. Q. Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects? Both lowered sexual desire and difficulties having an orgasm, in both men and women, are particularly a problem with the selective serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and the monoamine oxidase inhibitors (Nardil and Parnate). There is no treatment for decreased sexual interest except lowering the dose or switching to a drug that does not have sexual side effects such as bupropion (Wellbutrin). Difficulty having orgasms may be treated by a number of medications. Among those medications are: Periactin, Urecholine, and Symmetrel. None of these are over-the-counter drugs and they must be prescribed by a physician. Unfortunately, many psychiatrists are not familiar with using these medications to treat the sexual side-effects of antidepressants. Q. What should I do if my antidepressant does not work? Many people decide that their antidepressant is not working prematurely. When one starts an antidepressant the hope is for rapid relief from depression. What must be remembered is that for an antidepressant to work, you must be on an adequate dose of the drug for an adequate length of time. A fair trial of any antidepressant is at least two months. Prior to a two month trial the only reason to abandon an antidepressant trial is if the medication is causing severe side effects. With many antidepressants the dose has to be increased at intervals far above the starting dose. Unfortunately, the two-month period mentioned above, refers to two months following the most recent increase in the dose, not the time from starting the particular antidepressant. Q. Can someone build up tolerance to Prozac or other anti-depressants so that they stop working after a while? Tolerance to Prozac and the other SSRIs is a relatively rare phenomenon. What looks like tolerance may develop because the SSRIs also have effects on the dopamine systems of the brain, and these effects can slow one down dramatically. When an SSRI sems not to be working as well as it once did, it often can be helped to work once again by adding small doses of a dopaminergic agonist such as dextrroamphetamine, Ritalin, or bromocriptene. Also, certainly with Proxzac, and possibly with other SSRIs, too much of the drug is as ineffective as too little. If raising the dose does not help, an certainly if it makes things worse, a lowering of the dose may do much to bring back a response. I am convinced that many patients respond best is they are treated with one of the SSRIs + a tricyclic antidepressant such as desipramine (Norpramin), or nortriptyline (Aventyl). Such combinations are often effective when an SSRI by itself fails to do the job Q. What about the rumors and studies that Prozac causes suicide and/or acts of violence? PROZAC-VIOLENCE LINK NOT PROVED BUT MOOD DRUG DOES HAVE LITANY OF NEGATIVE EFFECTS Medical Information Service Q. I am an inmate in the state correction system serving 10 years for repeated driving under the influence of alcohol and vehicular manslaughter. My problems started when I was diagnosed as suffering from depression and was prescribed an anti-depressant called Prozac. Before using that drug, I was devoutly against drunken driving, but about three months after starting it I became very jumpy, restless, got three arrests for driving while drunk and then the vehicular manslaughter charge. Could Prozac have caused me to act differently? What problems occur with Prozac? -- M.J., Grovetown, Ga. A Prozac is an anti-depressant known to cause problems such as nervousness, tremor, seizures, nausea and headaches, but it has not been shown to be a direct cause of violent acts, including suicide. People taking Prozac or other anti-depressants may experience personality changes for a range of reasons: The stress of waiting for improvement may worsen their mental state or the anti-depressant may produce symptoms of a different, undiagnosed mental illness. Finally, depressed people often abuse drugs and alcohol. DEPRESSION COMMON An estimated 20 million Americans experience depression at some time in their lives, although most are never diagnosed. Depression is a serious disorder and considered life-threatening. Nearly 80 percent of all depressed people contemplate suicide, and 20 percent to 40 percent of those attempt it. Over the past 25 years, anti-depressant drugs have been the dominant treatment for depression. Most anti-depressants are descendants of and improvements on one of the very first mood-controlling drugs, imipramine. The newer types of anti-depressants are called selective serotonin reuptake inhibitors, or SSRIs, which have the positive qualities of imipramine but try to remove or reduce some of its negative aspects, such as abnormal heart rhythms. SSRIs include serraline, paroxetine, fluvoxamine and fluoxetine, known by its brand name of Prozac. ABOUT THE DRUG Manufactured by Eli Lilly and Co., Prozac was first introduced in 1986 and is the most widely used anti-depressant. More than 10 million people have been prescribed it. Studies show it is as effective as other anti-depressants, but it has fewer side effects. According to several studies, the side effects of Prozac can include nervousness, tremor, jitteriness, nausea, insomnia, headache, fatigue, mania or manic symptoms, dizziness and, rarely, seizures. REPORTS ABOUT PROZAC Over the past several years, there have been numerous reports of violent acts and suicide by Prozac users. Although medical journals have numerous reports of such acts, medical studies have not found evidence that Prozac causes violence or suicide. A recent study of 3,065 depression patients taking Prozac by Gary Tollefson, a researcher at Eli Lilly, supported other researchers' studies in finding that there was no increased risk of suicide. The study was published in the June issue of the Journal of Clinical Psychopharmacology. In Tollefson's study, about 2 percent had suicidal ideas and 0.2 percent of the patients attempted suicide. ''Suicide is so common in a population suffering from depression that you can't necessarily blame the drug. As an analogy, if a migraine sufferer is given medication and then has a headache, do you blame the medication? The situation is similar with depression,'' said Susan Sonne, a researcher in the department of psychiatry at the Medical University of South Carolina, Charleston, in an interview. However, people taking Prozac or anti-depressants may experience personality changes for a range of reasons, experts say: -- Most depressed people do not seek help until their problem is serious and often desperate. When placed on anti-depressants, including Prozac, the side effects of the medicine start immediately but the therapeutic benefits may take four to 12 weeks. During the first few weeks, a patient may become more distressed and panicked that the drug hasn't made significant changes, and as a result may act even more irrationally. -- There may be too little or no therapeutic effect from the medication. The drug may reduce the symptoms by 50 percent, which is considered a therapeutic level, but the effects experienced by the patient are not enough. Or the drug may have no therapeutic effect at all, which occurs in about 30 percent of patients. The drug dosage may also be too low and thus ineffective. Experts believe this can panic the patient and make the depression much worse. These situations may also trigger new or increased alcohol consumption ''A depressed person who isn't responding to medication may resort to self-medication with alcohol,'' said Dr. Alexander Morton, professor of psychiatry and behavioral sciences, also at Medical University of South Carolina, in an interview. Alcohol and drug abuse occurs in more than half of those with depression. -- The patient may be receiving treatment for depression, but actually has an underlying, undiagnosed bipolar disorder, such as manic-depressive disorder. Research shows that an anti-depressant can somehow trigger a switch from depression to a manic state. Symptoms typical of mania include euphoria, high energy level with poor judgment, risk-taking, delusions of grandeur and a need for excitement. ''Since a patient suffering from depression may be very compromised and, by virtue of their condition, incapable of helping themselves, it is important for family and friends to intervene when strange behavior is seen. For instance . . . after one uncharacteristic DUI I would intervene, find an alcohol or drug treatment program and try to receive a full evaluation of the situation,'' Morton said. Doctor Data is written by the Medical Information Service of Menlo Park using medical data bases. For a list of Bay Area data-base services or to submit medical questions, call (800) 999-1999, fax (415) 326-6700 or send a self-addressed envelope to Doctor Data, Science & Medicine, San Jose Mercury News, 750 Ridder Park Drive, San Jose, Calif. 95190. END COMMENT .IVAN: HERE ARE SOME SUGGESTIONS/QUESTIONS THAT HAVE COME IN ON THE MEDICATION SECTION: The FAQ's are excellent. In the next edition, I would like to put in plug for protriptyline (Vivactil). It's not widely used and not widely known, but probably should be included in the list of medications. It's claim to fame is that it is a tricyclic antidepressant with a very uncharacteristic tricyclic effect--it is very stimulating and doesn't cause an increase in appetite. For people whose symptom profile includes a low energy level and for whom the SSRI's just don't seem to work, Vivactil can often do the job, because it's main action is on reuptake of norepinephrine, not serotonin. It does increase constipation (like the other tricyclics), but it's not an antihistamine and it's other main side effect is also dissimilar to the other tricyclics--insomnia. I suspect that if the SSRI's had never been invented, Vivactil would be a lot more popular than it is; however, for some people, it's just right. Again--great work on the FAQ's. Scott Newman snewman@wsc.colorado.edu 2) would like definition of 'half-life' 3) would like alternate names of drugs used in other countries (e.g. Canada!), though I realize this might be a bit of a nightmare. END COMMENT