Can there be an unbiased view of Prozac (Fluoxetine)?
Don't ask me, I've only taken it (twice)! The Web sites I've seen either portray it as the best thing since sliced bread, or an evil drug that should be banned and, in fact, should never have been approved in the first place.
All I'm going to do here is to try to present my experiences of the drug and its effects. If you're expecting any startling revelations or rabble-rousing polemic on one side or the other, go somewhere else.
Background: Why an anti-depressant?
A few things in my private life had become difficult at the same time. I had a (cordial, but still present) separation to deal with, and had promised what felt like an arm and a leg in return for some funding for a start-up company in which I was involved. Recruiting staff for that company had been a long and difficult process, and the uncertainty over my own circumstances had lasted for over a year. Stress, uncertainty... some typical causes of depression. Matters came to a head when I needed to fly to a conference in a wonderful but difficult-to-reach location, and I realised that I simply couldn't do it.
The following day, I looked around the 'net for some information relating to depression - notably its diagnosis and treatment. I ended up at the UK National Health Service's site, NHS Direct. They had a special feature on depression, which isn't surprising as it's such a common condition. They've since taken the site down, for some unknown reason.r I read through the various sections, then took the online version of the Hospital Anxiety and Depression (HAD) test (again, now offline - test locations change pretty regularly, but your favourite search engine should pick one up). It showed that I was probably depressed and possibly anxious, and the advice given was to talk to my GP (general practitioner - family doctor for all you non-English out there).
I've got two advantages over many people. Firstly, I've worked with several GPs and hospital doctors in the past, and I know that doctors are neither infallible nor always wrong - they're human, like the rest of us, and most of them prefer to be treated as human. Secondly, I'm registered with a GP who has considerable experience with treating cases of depression. When I went in for a chat a couple of days later, he asked a few diagnostic questions - how was I sleeping, what was my mood like - and very quickly came to the same conclusion as the self-administered HAD test. I was depressed. His suggestion was that I should not simply treat this with counselling, but that I should have a course of anti-depressant treatment that would last 3-9 months; his suggestion was Prozac due to its lack of addictiveness and the fact that it is an alerting anti-depressant. It should be taken in the morning, and alerts you for the day, rather than alternatives like Dothiepin that are sedating anti-depressants, are typically taken at night, and tend to help you sleep. I was prescribed the minimum clinically effective dose of 20mg of Fluoxetine, once a day.
Like most people, I'd heard scare stories about Prozac, so I spent some considerable time that evening wandering around the Internet looking for information. The bulk of the pages out there were individuals or small groups campaigning against Prozac; the other pages were typically medical studies. I got a pretty good idea of expected side-effects (see below); the one thing I missed was just how bad alcohol was (also see below). I didn't see anything out there that was worse than the depression so, the following morning, I popped the first yellow-green capsule of what was to be an eight-month course of Prozac into my mouth.
The First Few Weeks
Either I'm unusually susceptible to odd effects, or the side-effects of starting Prozac are under-reported. I had several interesting side-effects, but none so bad that it was worth stopping the treatment. To give you some idea of what I experienced:
- About a week of disturbed sleep patterns. This started 7-10 days after I started the course; I was waking up at night, and couldn't stay awake during the late afternoon. A couple of times, I found myself nodding off in my chair at work at about 4pm. After that transitional period, my sleep patterns returned to normal.
- Twitching. This was the second longest-lasting effect, starting after about 2 weeks and continuing for about the next month. I usually have very steady hands, but found that I had some loss of motor control in my hands, and sometimes arms and legs as well. This was worst if I was tired.
- Sweating. Again, a well-known side-effect of Prozac. My body simply over-produced sweat. Not usually a problem as long as your personal hygiene is reasonable, but if I'm depressed then I'm far more likely to neglect myself. This started within a couple of weeks of starting the course, and continued to some extent throughout the period.
- Sensitivity to caffeine. You're always told to avoid caffeine and alcohol during depression as they can have unpredictable effects. My reaction to caffeine and Prozac was certainly unpredictable - it increased the twitching to the point that I felt I was shaking all over! Unfortunately, I discovered this when I was conducting a day of interviews during my peroid of disturbed sleep and had a cup of strong coffee at 3pm to try to stay awake. I don't know what the next candidate thought of me, or whether the effect was visible, but I've avoided caffeine and Prozac ever since. That includes many carbonated drinks, not just colas - check the ingredients.
- Emotional numbness. There was this cushion preventing me from feeling strong negative emotion - fear, anger, panic and so on - but I also seemed unable to feel strong positive emotions. Again, this lasted for a few weeks, then subsided.
It took a little over two weeks before I started to feel the anti-depressant effects of the Prozac. I chose to be very open with my family, friends and colleagues; I warned all of them that I was depressed, was on Prozac and that I wasn't certain quite how I would be reacting to events. This was quite hard to do, but very effective. I got a lot of unexpected support from friends, family and colleagues during the time I was on Prozac. Provided you don't use it as an excuse, I'd recommend this openness to anybody.
Once I'd been through the initial 5-6 weeks of side-effects, Prozac had only one irritating side-effect that I noticed - reduced sex drive. This is a well-known side-effect of most anti-depressant drugs, but it's not talked about as much as some of the other effects. Just accept it!
Another problem that was pointed out to me was that I was 'not the same person'; I was not contacting some of my friends with the same frequency or eagerness and some aspects of my personality appeared to have changed somewhat. I'm not sure whether or not this can or should be traced to the Prozac, as I entered a new relationship at about the same time, and I do tend to withdraw from the outside world in the early stages of a relationship. As this was only reported during my first (and most severe) brush with Prozac, I'm keeping an open mind on this one.
Timing the capsules
Fluoxetine and norfluoxetine (the immediate product when fluoxetine breaks down) have quite long half-lives - around three and seven days respectively. This means that you can vary the timing of taking the capsules quite considerably without totally screwing up the course. Taking them regularly once a day is still the best option, but if you forget one day then taking two capsules the next morning isn't a disaster. Check the leaflet that comes with each pack, but the advice on mine was to take a missed dose as soon as you could, even if that was a day later.
Oh yes - I had to travel quite a lot on business while I was on Prozac. I can be quite forgetful, and depression makes that forgetfulness worse. If you're in the UK and realise you've left your medication elsewhere, go into a pharmacy while your prescribing GP surgery is open and ask for an emergency prescription. They can phone the GP and hand you a few days' supply there and then - an expensive way of getting your meds, but better than not taking any for several days. After being caught out once, I simply made sure I had a week's supply in the rucksack I use as hand luggage.
Alcohol and Prozac
I messed up on this one - I missed it in my reading around the subject, and want to highlight it here. Put simply, don't consume alcohol while you're on Prozac. I'd noted that Prozac can enhance the effects of alcohol, and to me a glass of wine felt like half a bottle - not much for many people, I know, but I'm a cheap drunk. What I hadn't noticed was that alcohol reduces the effects of Prozac for several days after it's drunk, presumably because it knocks out some of the drug that's already in your system.
Eventually, some of my friends pointed this out to me - you know who you are, and thanks. Life got better rather faster after I stopped drinking.
The Decision to End the Course
I did not want to be on medication forever. In the initial appointment, my GP had told me 'probably 3-9 months', and I begrudged everything after the first three months. By the time it got to eight months, I'd left my stressful job, was past the stressful part of the separation and divorce, and had moved back to Manchester. I thought the worst of it was behind me, and persuaded my GP that I was well enough to come off Prozac.
In the immortal words of Homer Simpson, Doh!
The recommendation for most anti-depressants is to stay on the course for three months after the symptoms of depression have cleared up. In my case, I came off while I was still showing some symptoms, for little reason other than my pride. I bumped along for about a year, but the next setback had me back on the pills (see below).
My initial reason for constructing this page was that there seems to be a dearth of information about withdrawal symptoms of Prozac. Again, I can only present my own experiences. The approach I took was to reduce dose from 20mg per day to 20mg per two days for a week or so, then 20mg per three days for another week or so, then stop. Fluoxetine and norfluoxetine (the immediate product when fluoxetine breaks down) have quite long half-lives - around three and seven days respectively - so extending the time between doses doesn't cause huge variations in the effect. The approach seems to work, but I had to contend with a few withdrawal symptoms:
- Disturbed sleep patterns. As at the start of the course, I had periods of waking at night, and certainly more vivid dreams than usual.
- Twitching. Similar to the start of the course.
Second time around
Time to come back and update this page, almost three years on from first writing it and a year after coming off my second course of Prozac. This episode started after my wife was diagnosed with bipolar affective disorder. The associated hospital stay wasn't great for either of us - to put it mildly - and I went back to my GP about a month after Sarah came out, showing milder symptoms of depression than the previous time, but still significant. We agreed that the symptoms were worrying enough to need treatment, and we knew that Prozac had helped previously and that I hadn't had disastrous reactions... so, off I went again.
This second time was much easier, partly because I knew what to expect and partly because I made fewer mistakes. I came off caffiene and alcohol the day I started on Prozac. Same old side-effects at the start, with the notable exception that I didn't fall asleep at 4pm. Also the same side-effects on the sex drive, and the sweating also stayed throughout the period, but a notable change in that my friends reported that I stayed 'myself' throughout this second episode. I don't know whether that's because it was a milder episode, because I was in a stable relationship, or both, or something else completely - as I say, I can only report my own experience here.
I did one other thing 'right' - I swallowed my pride and stayed on the medication for three months after the symptoms cleared up, so this was a 7-month course, ending in October 2004. To date, I've not needed to go back on any long-term medication of any kind, despite a number of problems that would have knocked me off course before. It's worth swallowing my pride for that.
- The British National Formulary is the reference on drugs and drug interactions used by most UK clinicians. Free registration. Plenty of information on Prozac side-effects.