Epidemiological studies have shown that depression is increasing in frequency in young people. One possible reason for this increase may be the escalating stress placed on workers in modern organizations, where competition may be greater and job security and working conditions less appealing than in earlier decades. The modern workplace can be a very stressful and depersonalizing place. In many organizations, people are being expected to work harder for smaller rewards and with less control over their work environment. This can be extremely demoralizing. To address some of these problems, many people have attempted to gain greater control over their working environment by quitting their jobs and working as freelancers. Although in doing so they have sometimes had to take a cut in pay, many have found that the greater control they have over their lives more than compensates for this sacrifice. They enjoy setting their own hours, choosing their work and, best of all, not having a boss and a bureaucracy to answer to. If you are feeling disempowered at work, it may be worth considering whether an alternative situation will work better for you.

I want to sound one major cautionary note, however. If you are in the midst of a bad depression it is unwise to make any major life decision until the worst of the depression is behind you. When you are depressed everything seems bad, including your job. I have encountered people who have quit their jobs in the midst of a profound depression and then regretted it later after they feel better, at which time they may come to appreciate the more positive aspects of their former work. The best approach to this problem is to treat the depression medically, for example with St John’s Wort or some other anti-depressant, and after you are feeling a great deal better to consider the possibility that an unpleasant job situation may put you at risk of further depression or may hinder your complete recovery.

Just as it can be helpful to quit a bad job, so it can be healthy to leave a bad relationship. When this is a relationship of major significance, like a marriage, it is obviously worth spending a good deal of time and energy in making the decision as to whether to stay and try to work things out or to move on. Sometimes the most exciting relationships are also those that are most likely to trigger depressions. Dr Donald Klein described a condition that he called hysteroid dysphoria in which the affected person, usually but not invariably a woman, easily becomes enmeshed in a series of romantic relationships, each of which takes on the same pattern. Initially there is an intense feeling of falling in love, associated with enormous passion and elation. This is invariably followed by rejection or disappointment as the object of the woman’s affection either rejects her or no longer appears to be a prince on a white horse after all but rather, in the eyes of the angry and disappointed lover, the horse’s backside. A crashing depression ensues that is relieved only by the arrival of the next ‘prince’. While medications often help with such problems, making someone less vulnerable to being swept off her feet and then dropped unceremoniously, it is obviously critical to address the underlying issue as well, which is that the affected person is looking to her lover as a means of regulating her mood and, until she learns how to stop doing so, she is destined to suffer from recurrent depressions as a consequence. Psychotherapy and social support can help in this process.

Even more valuable than getting out of toxic relationships is learning how to avoid getting into them in the first place. Often the resolution involves entering a relationship with a different type of person, someone who is perhaps less thrilling than previous partners, but who is a more dependable and ultimately a more satisfying mate.

In the days when psychoanalysis was the dominant force in psychiatry, the idea of improving your mood by leaving a problem behind was often frowned upon and referred to somewhat pejoratively as a flight into health. The idea was that you needed to work on a problem to resolve it rather than to run away from it. Of course, it often makes sense to work on problems, as I have mentioned, but let us not underestimate the value of leaving a problem behind. It is after all a basic animal instinct to run from certain threats, and a principle of environmental medicine to recognize toxic influences and avoid them. There is no reason why that same good sense should not apply to the treatment of depression as well.

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In April 1994, the FDA approved Prozac’s use for bulimia. Behavioral therapy combined with medication treats bulimia the most effectively.

Is Prozac useful with any other disorders? Preliminary studies of a small number of patients diagnosed with borderline personality disorder and schizophrenia have reported definite improvement with Prozac. Although much research still needs to be done. For instance, in a ten-week study of eight treatment-resistant chronic schizophrenics, every one snowed improvement with Prozac. They became less aggressive, more socially interactive, and more involved in hospital programs. One of them was even discharged.

Substance abuse—whether it is alcohol, cocaine, or other addictive drugs—is most effectively treated – with Alcoholics Anonymous, self-help groups, and group therapies. Patients with depressive symptoms should be evaluated for concomitant use of antidepressants.

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Scientists do not have sufficient evidence that pharmacological agents such as Prozac cause actual changes either in character, which is acquired through environmental experience, or in the DNA-encoded traits that make up temperament, which is inherited. Character and temperament are the main components of personality.

We only have anecdotal evidence: individual reports of people who have not merely returned to the way they were before they got depressed (the psychiatric term for this is “premorbid personality”) but utterly changed, seemingly expressing traits completely unlike those of the person they used to be.

But in fact these traits are not completely foreign to them, as detailed questioning by a depression expert will reveal; they have simply been buried, frequently for a long rime, under a thick layer of dysthymia, a milder chronic form of depression that may have gone undiagnosed for months, years, or a lifetime. Nonetheless, it shaped the patient’s personality and character development, often with a mixture of “soft symptoms”, such as sluggishness, timidity, and anxiety—traits that might be aspects of someone’s normal personality but that could also be symptoms of subclinical depression. In the latter case, Prozac can lift the patient into a state of normalcy that he or she hasn’t felt for years. Both the patient and other people may then perceive the patient’s personality to have changed dramatically.

Essentially, I don’t believe you can refashion a person’s normal personality with Prozac. Depressive symptoms must be present before obvious changes in behavior and emotions can be brought about with an antidepressant. But when there is a past, often forgotten hypomania. the change may be greater and the patient may interpret this as a “transformed self* or a “new personality”.

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It is also used with some reported efficacy in instances where the depression is secondary to a primary medical or psychiatric illness such as panic disorder, phobic disorder, or even obesity.

Most of the scientific investigations of Prozac have focused on depression, with the result that Prozac has received FDA approval for use in major depression. It has not been approved for anxiety disorders because enough data haven’t been accumulated from scientifically conducted trials. Furthermore, from the data so far, the trend may not support using Prozac for primary anxiety disorders.

Nevertheless, when patients suffering from major depression and the milder form dysthymia are treated with Prozac, symptoms of anxiety typically lift along with the other symptoms of depression. To date, a limited number of studies indicate that Prozac does not seem to be useful for General Anxiety Disorder (GAD) but it is therapeutic for panic attacks and the secondary anxiety seen in major depressive disorders and dysthymia. Once the depression is relieved, the secondary disorder tends to disappear as well.

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Although this feeling of being revved up is a real effect of Prozac and some of the SSRIs, a major study has shown these activating effects to be only slightly greater than the activating effects seen in depressed patients taking a standard comparison drug, imipramine (Tofranil). In clinical studies, patients who made the decision to stop taking either drug blamed it on these adverse activating effects in approximately equal numbers.

How can restlessness and irritability that I felt when taking Prozac be reduced? A lower dosage may help. Although most patients take 10 or 20 mg a day of Prozac, as little as 2.5 mg a day may be effective in some patients who are sensitive to the usual recommended dose.

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