• The first hurdle is to understand your own sleeping problem. Insomnia is very common and about 20 per cent of healthy normal adults suffer from insomnia at some time during their lives.

    What is insomnia? Insomnia is the distress and the anxiety of not being able to fall asleep when you want to. Insomnia does not equate with not sleeping. Some people who suffer from insomnia can stay up all night playing card games or enjoying themselves at wild parties without any distress at all. People complain of insomnia only when they stay in bed and cannot sleep. They develop a phobia of sleeping in bed. They may be able to sleep happily in the park or on the sofa in front of the television. They may try to exhaust themselves by reading in bed until their eyes are so heavy and red that they can hardly stay open. They are fearful of their inability to sleep whilst in bed. They feel distress when they lose control of their innate mechanism to sleep.

    Sleep is something we have no control over. We cannot close our eyes and give the magic word sleep, as sleep may not follow. In studies of how people fall asleep, it is observed that we are not folly awake one second and asleep the next. We all go through a very brief hypnotic state, which is called the Transitional Hypnotic State or THS. Although we have no control over sleep itself, we can be taught to go into THS. Once you can go into THS, which is the precursor of sleep, you will have indirect control on sleep itself and consequently substantial control over falling asleep.

    THS is the transit stage between the awake mode and the sleeping mode.

    People who suffer from insomnia appear to have a block between the awake mode and the THS mode. THS is the switch, and with practice you can have full control of the switch and switch off every night.

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  • One of my favourite New Yorker cartoons consists of two panels. In the first panel a drowning woman cries out to her sheepdog at the edge of the lake, ‘Get help, Lassie, get help.’ The next panel shows the obedient dog lying on an analyst’s couch. Getting help does not always mean subjecting yourself to deep psychological examination. It can be quite concrete. An overwhelmed mother might find it invaluable to get more help with babysitting or housework. An overwhelmed student might need some special tutelage. Depressed people – like all who are ill – often feel overwhelmed by what they have to do but are ashamed or reluctant to reach out and ask for help. If you had backache or hepatitis, you wouldn’t think twice about getting help so that your life might become more manageable. Well, depression is just as legitimate a condition, even if there are no X-rays or lab tests to demonstrate it. Part of getting better is accepting that you are suffering from a medical illness – depression. As one patient put it, ‘Just understanding what is going on is half the battle.’ Once you accept that fact, you will feel better about taking all the steps needed to help you feel better again, including reaching out to those who can make life easier for you.

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  • A trivial remark or a minor slight, however unintended, can feel like a major blow to people who are temporarily suffering from depression. For others, sensitivity to rejection (real or imagined) can seem to be a lifelong personality trait, virtually inborn, although it does not have to be categorized as an inevitable part of personality.

    Sensitivity to rejection, as proposed by Donald F. Klein, can also be one of the symptoms that characterize atypical depression, along with overeating, oversleeping, and reactivity to the environment. By alleviating the overall atypical depressive syndrome, Prozac can reduce the exquisite sensitivity that causes patients to feel so easily hurt, rejected or snubbed. MAOI antidepressants have this same property, but because their side effects are more intrusive, Prozac may be the better solution for a patient who is easily hurt and becomes depressed each time.

    Would taking Prozac make me more sensitive to the sun? No. Major tranquilizers such as Thorazine and Mellaril do have this side effect but patients who take Prozac do not show any increase in photosensitivity to light or sun. Major tranquilizers are mostly used for schizophrenia, schizoaffective disorder, and during the first ten days of manic psychosis until lithium takes over.

    Will Prozac affect my cholesterol count? Cholesterol count does not seem to be related to Prozac intake.

    Is the central nervous system in any way affected adversely by Prozac? Prozac is remarkably benign, all in all. But as with any drug, there are the rare exceptions. For instance, twelve patients out of six thousand studied had seizures—a rate similar to that of most other antidepressants. Infrequently, there have been reports of abnormal gait, apathy, central nervous system stimulation, delusions, depersonalization, along with dysphoria, hallucinations, hostility, incoordination, paranoia, and other reactions. In very rare cases, an abnormal electroencephalogram has been reported.

    As with all the antidepressants, there are other highly unusual side effects as well. But it is reassuring to note that the worst of these reactions occurs in fewer than one patient out of a hundred (and often fewer than one patient in a thousand). The most common adverse effects on the central nervous system, reported in more than 1% of the patients, are abnormal dreams and agitation.

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  • We live in a violent society. Over 4 million individuals in the United States are victims of violence each year. Data from the National Center for Health Statistics report 8.7 premature deaths due to homicide per 100,000 people in the United States in 1985, making homicide, the second leading cause of injury or death among children. Furthermore, homicide is the leading cause of death among black males ages 15 through 24, and the third leading cause, after motor vehicle injury and suicide, among white males 15 to 24 years of age. Nonfatal violence is even more widespread. In 1985, some 113 violent interactions occurred for every 1000 married couples, and 620 violent interactions occurred for every 1000 children and their parents.

    Despite the fact that violence is so common in the population as a whole, violent events have rarely been reported in association with Prozac. Once in a while, a patient on Prozac has been hauled into court for some harmful act. Nonetheless, in every one of those instances, Prozac has been exonerated of responsibility. Not a single one of the criminals who have come to court armed with the so-called Prozac defense has succeeded in convincing a judge or jury that the crime was committed because the defendant was on Prozac. In all of the cases, the criminal has been convicted and the medication acquitted: a 100% victory for the pharmaceutical company.

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  • Tricyclic antidepressants (TCAs), so-called because they have three rings in their chemical structure, work in the brain by making certain that the neurotransmitter norepinephrine (NE) and, to a lesser extent, serotonin (SE), remain in the synapse between nerve fibers rather than being taken back up into the nerve cell itself. The end result of this is that the amount of neurotransmitter in the synapse increases, thereby allowing the flow of nerve impulses to return to normal. This is associated with an antidepressant response in the patient.

    First-generation tricyclics include:

    * the first TCA, imipramine (Tofranil), which was introduced in 1958

    * amitriptyline (Elavil)

    * desipramine (Norpramin)

    * nortriptyline (Pamelor)

    * protriptyline (Vivactjl)

    * clomipramine (Anafranil)

    * trimipramine (Surmontil)

    * the European medication amineptine (Survector).

    Although side effects vary from drug to drug and person to person, the side effects generally associated with TCAs include dry mouth, constipation, blurred vision, weight gain, an increased heart rate, drowsiness, urinary retention, memory problems, impotence, decreased blood pressure and dizziness when standing up. It generally takes between 7 and IS days before the drug begins to have an antidepressant effect.

    Related medications called tetracyclics include maprotiline (Ludiomil), amoxapine (Asendin), and the European drug mianserin (Bolvidon).

    Monoamine oxidase inhibitors (MAOIs) work by preventing the breakdown of the neurotransmitter hormones norepinephrine and serotonin, which in turn has the effect of increasing the amount of those substances in the synapses.

    MAOIs include:

    o isocarboxazid (Marplan)

    o phenelzine (Nardil)

    o tranylcypromine (Parnate).

    Besides such side effects as restlessness, dizziness, and weight gain, MAOIs have one unique problem. You have to be very careful what you eat while taking an MAOI. Ordinary foods that contain tyramine including—but not limited to—cheese, Chianti wine, yogurt, lima beans, pickled herring, smoked meats, liver, and large amounts of caffeine or chocolate can trigger a sudden rise in blood pressure that has been known to cause blood vessels in the brain to burst, the so-called cheese effect A stroke or even death can be the outcome. A related MAOl is the European drug Deprenyl, which is marketed in the United States as an anti-Parkinson drug, not an antidepressant It requires less attention to dietary restriction.

    Selective serotonin reuptake inhibitors (SSRIs) block the uptake only of serotonin, thereby causing it to increase in the nerve synapse. SSRIs include:

    * fluoxetine (Prozac)

    * sertraline (Zoloft)

    * paroxetine (Paxil)

    * fluvoxamine (Luvox)

    * nefazadone (Serzone)

    * citalopram (under development in U.S., available in Europe as Lipramil or Seropram).

    These drugs relieve depression as effectively as the TCAs and MAOIs, but their side effect profile is considerably milder.

    Lithium, although primarily used as a mood stabilizer with manic-depressive disorders, can also play an important prophylactic role in recurrent unipolar depression and even a therapeutic role in major depression when it is added to an antidepressant as a step-up treatment. It comes in these generic forms under various trade names:

    o lithium carbonate; slow-release lithium carbonate

    o lithium citrate syrup (liquid).

    Structurally unrelated compounds used for the treatment of depression include a number of other medications, such as:

    * trazodone (Deseryl)

    * buproprion (Wellbutrin)

    * venlafaxine (Effexor).

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  • Since its introduction, over 11 million patients worldwide and 6 million in the United States have taken Prozac. These people cover the gamut from children to adolescents to the elderly, from lifelong depressives who, with the help of Prozac, are beginning for the first time to structure their lives in responsible ways, to many highly successful, productive people who have had from one to numerous bouts of depression in their lifetime. Name any randomly chosen group of successful people in society, business, politics, or the arts, and it is likely that 20% to 30% of them are either taking Prozac or have been given Prozac at some point over the last several years. Actors, politicians, housewives, business people, and artists have flooded

    i talk shows, newspapers, magazines, and books with stones of how Prozac has helped them. People of all classes, races, and religions have benefited from and talked about the miraculous effects of Prozac in reversing their despair, chronic lack of pleasure, poor functioning, and persistent low-level depression and in raising them to a level of functioning so much better than their previous state that patients have sometimes used the term “new self.”

    In the past, lithium and other antidepressants have also unleashed a torrent of dramatic claims and testimony in books, articles, and talk shows. But after media reports about the possibility of transforming the self and developing a new personality, Prozac has caused a deluge like no other.

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  • As with every drug in existence, the list of less common side effects is long and extends into virtually every system in the body. At least 1% of the patients on Prozac have complained on at least one occasion of chills, disturbed dreams, bronchitis, agitation, or excessive yawning.

    Other side effects experienced by at least one patient in a thousand include, among many other reactions, feeling hung over, jaw pain, neck pain, excessive belching, gingivitis, thirst, hypothyroidism, anemia, weight gain (a larger number of patients lose weight), arthritis, bursitis, acne, loss of hair, conjunctivitis, ear pain, eye pain, and various urinary disturbances.

    Infrequent cardiovascular side effects include angina pectoris, arrhythmia, hypertension, hypotension, and migraine headaches.

    Infrequent nervous system reactions include abnormal gait, amnesia, apathy, convulsions, hallucinations, hostility, and paranoia.

    Then there are the “rare” side effects, which occur in fewer than one person in a thousand. These extremely unusual events include enlarged abdomen, thrombophlebitis, colitis, duodenal ulcer, increased salivation, hepatitis, jaundice, stomach ulcer, goiter, hyperthyroidism, dehydration, gout, osteoporosis, rheumatoid arthritis, antisocial reaction, eczema, unwanted hair growth, psoriasis, and many other side effects too numerous (and uncommon) to name here.

    The important point is that compared to the older classically used antidepressants, the side effects of Prozac are infrequent and mild—even in overdose.

    Most of the older antidepressants have similarly long lists of side effects, most of which are rare, although they are listed in the Physicians Desk Reference and the package inserts, often to protect the manufacturer as well as the patient.

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