Prozac opened a new era in psychiatry practiced principally by general practitioners rather than mental health professionals. Some refer to this as cosmetic psychopharmacology. Currently the top 25 drugs prescribed in America include 3 antidepressants. Once heralded as a great advance, professionals are increasingly questioning whether doctors initiate therapy for inappropriate reasons.

Of even more concern, many continue therapy for lengthy intervals. Attempts to cease treatment often result in a condition known as the discontinuation syndrome. Its symptoms are routinely mistaken for recurrence of the original depression. Unfortunately the response generally involves even more therapy.

Studies routinely fail to demonstrate a significant difference from placebo in mild to moderate depression. Prozac clearly improves severe depression, however this may be most appropriately managed by psychiatrists rather than general practitioners and internists. The way medicine is currently practiced dictates the overwhelming majority of people suffering from depression will never meet with a psychiatrist.

Unfortunately the vast majority of prescriptions for Prozac originate in brief interactions with non-specialists less than adequately schooled in the nuances of depression. A cursory evaluation during a hurried visit followed by a prescription with multiple refills seems almost guaranteed to miss the essentials of depression.

Prozac became the first modern antidepressant and belongs to the family of selective serotonin reuptake inhibitors or SSRIs. Other members of the class include Paxil, Zoloft, Celexa, and Lexapro. None demonstrate significant superiority in treating depression and all share a common side effect profile. For reasons unique to an individual, some people prefer or respond more favorably to one pill rather than another.

Common side effects include nausea, diarrhea, difficulty sleeping, anxiety, tremors and excessive perspiration. Sexual dysfunction affects more men than women with erectile difficulties, loss of libido and lack of orgasm occurring in anywhere between 1-70%. Obviously the lower numbers arise from drug company funded studies.

Bleeding difficulties may occur especially in those receiving aspirin or anticoagulants. Monitoring for weight change, either gain or loss, low blood sugar and falling levels of blood sodium remain essential.

Combination with triptans for migraine, other antidepressants, St. John’s wort, lithium or fentanyl may lead to the serotonin syndrome. Manifestations include dizziness, sweating, elevated temperature, increased heart rate and blood pressure, tremor, agitation, hallucinations and delirium.

Complaints suggestive of the discontinuation syndrome include headache, irritability, dizziness, sleeplessness, fatigue, crying spells, shakiness and a form of mania.

Prozac is not appropriate for pregnant or breast feeding women.

Despite its suggested activity in boosting serotonin, the drug’s mechanism of action remains unsettled. Neither elevating nor lowering serotonin levels guarantees a change in mood. Emerging concepts clearly indicate abnormalities in many brain chemicals underlie depression. Serotonin’s role in the process is under review. The recently released Spravato – esketamine – treats depression by targeting a different area, the NMDA receptor.

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