Fisch and colleagues in Germany set out to investigate whether light therapy might enhance the response of depressed patients to treatment with St John’s Wort. They divided 40 depressed patients, whose mood changes bore no specific relationship to the changing seasons, into two groups of 20. Both groups received standard doses of Hypericum – 900 mg per day. In addition to this, one group was exposed to bright environmental light and the other to dim environmental light for two hours each day. They found that the group exposed to bright light showed superior antidepressant effects after two and four weeks of treatment. After six weeks, however, both groups fared equally well. They concluded that light therapy may speed up the anti-depressant response to Hypericum. Even if enhanced environmental lighting did no more than this, it would still be worth considering since the weeks before an anti-depressant kicks in may seem interminable to a person suffering from the painful symptoms of depression. It is especially difficult to keep up one’s spirits and optimism during the early weeks of treatment since there is no guarantee that the medications will actually work. Signs of an early response are therefore particularly welcome.

It is possible that enhancing environmental lighting may do more than simply speed up the response to an anti-depressant -it may actually enhance the response. Although this effect has not yet been demonstrated for St John’s Wort, Siegfried Kasper and colleagues in Germany studied a group of depressed patients who had failed to respond to an adequate trial of Prozac. These researchers treated half of their patients with bright light and half with dim light while keeping them on Prozac. After two weeks, the patients receiving bright light showed significantly greater improvements than those receiving dim light treatment, an advantage that increased over the following two weeks of the study.

These studies suggest that combining bright light therapy with anti-depressant medications, including St John’s Wort, may be a valuable strategy for enhancing the speed and magnitude of the therapeutic response even in those depressed patients who have not suffered exclusively from winter depressions.

The known interaction between light and Hypericum has raised concerns about possible harmful effects to the eyes in people receiving light therapy while on St John’s Wort. So far, the only study that has addressed this question directly is that of Kasper and colleagues, who examined the eyes of their patients after two weeks of such combination therapy and found no visual changes. A recent study by Brockmoller and colleagues in Germany, showing very little increase in skin tanning in patients on clinically relevant doses of Hypericum, is also encouraging in relation to the safety of this combination. Nevertheless, if you experience any eye irritation while on the combination, check with your doctor about it. What I recommend for my patients if they experience eye strain or irritation while receiving light therapy is that they try to decrease their exposure to bright light either by shortening the daily duration of treatment or sitting further away from the light source until their eyes feel comfortable.

Warning: If you have any history of eye problems, you should always consult an eye doctor before undertaking light therapy.

As the quote from A. Cornelius Celsus suggests, it is possible to derive benefits from enhanced environmental lighting without any formal therapy simply by brightening up the interior of your house. This can be done with more lamps, including indirect lighting bounced off lightly coloured surfaces. Bright colours, especially yellows and oranges, also seem to have a cheering effect on many light-sensitive people I have treated over the years. Finally, there is no substitute for natural lighting and a walk outdoors in the sunshine can combine the healing effects of exercise and light. This benefit was actually documented by Dr Anna Wirz-Justice and colleagues in Switzerland, who showed that as little as half an hour of walking in the morning had a markedly beneficial effect on her patients with SAD. I would wager, though, that other types of depressed patients would stand to benefit from such a daily prescription as well.

*75\75\2*

Clinical drug studies generally fall into three categories. In phase I studies, patients in the hospital are treated with drugs in their earliest state of clinical development to determine dosages and safety. In phase II studies, both hospitalized patients and outpatients are given low, medium, or high doses to check for efficacy, tolerance, and side effects. In phase III studies, investigators usually compare the new drug to a placebo and to one or two other standard drugs that have been marketed for several years. Large numbers of outpatients in eight to ten centers throughout the country participate thereafter in a six-to eight-week trial. Most new drug studies go through these final phases of development prior to I approval by the PDA for marketing. In phase IV, drug studies take place after marketing in order 10 investigate the medication’s potential usefulness with diseases other than the initial illness for which the FDA gave its approval. The people who participate in these antidepressant trials may include treatment-resistant patients who have tried other antidepressants, including tricyclics, MAOIs and SSRIs, all without success. For them a new drug trial is the court of last appeal. The lack of cost to the participants and the extraordinary attention they receive from highly qualified doctors and nurses are major factors in the patient’s motivation to participate.

*110\22\4*

A study matching thirty members of the Iowa Writers Workshop with thirty nonwriters revealed that 80% of the writers—but only 30% of the non-writers—reported at least one episode of depression’ or manic depression (30% of the writers but only 6% of the controls, were alcoholic). In addition, the parents and siblings of the writers were significantly more creative and more prone to highs and lows than the relatives of the nonwriters. For instance, 20% of the writers’ brothers and sisters, but only 3% of the siblings of the control population, had a mood disorder; 14% of the writers’ siblings had experienced major depression, versus 3% of the control siblings.

This data strongly suggests a genetic link between mania, depression, and artistic creativity.

*90\22\4*

Leading the Scientology attack against Prozac is the Citizens Commission on Human Rights (CCHR), a group which was founded by Scientology in 1969 and which had in the past attacked the amphetaminelike drug Ritalin (widely used for helping hyperactive children achieve a normal attention span.) Once the CCHR set its sights on Prozac, it lobbied against it, sent out mass mailings, and, in October 1990, filed a citizen’s petition with the Food and Drug Administration requesting the withdrawal of Prozac from the market—only a few months after the FDA reaffirmed Prozac’s safety and efficacy as an antidepressant.

As ammunition, the CCHR made extensive use of an article published in February 1990 in the American Journal of Psychiatry by several Boston psychiatrists. The report stated that after two to seven weeks on Prozac, six out of 172 high-risk mental patients who had not been responsive to other drugs became preoccupied with violent, obsessive suicidal thoughts, and that two of them tried (without success) to kill themselves.

Nothing about this was in the least extraordinary to psychiatrists who are familiar with and treat depression. Depressed people are often suicidal: it’s a symptom of the disease. About 15% of patients with diagnosed depression eventually commit suicide; about 80% of all patients who commit suicide or make a serious attempt to do so are depressed. At the time and now, most leading psychopharmacologists in the United States felt that it was not a surprise that a few of the deeply depressed patients in the Boston study were suicidal. In addition, four of the six were taking other medications (in one case, five other medications). It was also noted that, although none of these patients seemed suicidal when they began taking Prozac, five of the six had had suicidal thoughts in the past.

Nonetheless, because serotonin, the neurotransmitter Prozac specifically affects, may be linked with aggression, there was reason for concern. It was speculated that in a few instances, Prozac might “tip the balance in the wrong direction, toward violence and aggression.”

When the article came to the attention of the CCHR, they took the figures, which were based on a small group of nonresponsive mental patients, and extrapolated them to the entire population. Using the article’s statistics, they asserted not only that “up to 140,000 people in the United States have become violent and suicidal by Prozac” but also that Prozac could easily promote killing sprees, a prediction they backed up with one unique story of mass murderer Joseph Wesbecker. In 1989, Wesbecker attacked his co-workers at the Standard Gravure printing plant in Louisville, Kentucky. Using an AK-47 assault rifle, be killed eight, wounded twelve, and then shot himself.

Why did he do this? Speaking on the “Phil Donahue Show,” Dennis Clarke, president of the CCHR, announced that he did it because he was taking Prozac. Before that, Clarke said, Wesbecker “had no history of violence.”

However, as the Wall Street Journal revealed in April 1991, this was completely untrue. Wesbecker had made twelve previous suicide attempts, had often talked of killing his employers, and had accumulated a collection of guns, with which he regularly practiced shooting—all before he started taking Prozac.

The attack on Prozac was well under way when, on May 6, 1991, Time magazine ran a cover story entitled “Scientology: The Cult of Creed.” The

Church of Scientology struck back with a $3 million ad campaign in USA Today that suggested that Time had attempted to forward Hitler and included an attack against Eli Lilly, the manufacturer of Prozac.

The result of all this? Sales of Prozac, by then a full 25 percent of the antidepressant market slipped to 21 percent. In a dozen cases around the nation, defense attorneys argued that their clients were not responsible for their actions because they had been taking Prozac. Even more disturbing to me and other psychiatrists, many patients decided on their own to discontinue the drug, with the predictable result that their depression worsened and in some cases their suicidal thoughts became more intense. Worst of all, some patients needed to be hospitalized as a result of going off their medication.

In July 1991, the FDA rejected the CCHR petitions, once again reaffirming the safety of Prozac. Two months later, the FDA Advisory Committee and an independent scientific advisory committee unanimously announced that Prozac and other antidepressants do not cause suicide or violent behavior, in fact, Prozac seemed to protect against violent behavior, and large clinical trials indicate that patients taking Prozac are actually less suicidal than those taking a placebo or other antidepressant drugs.

Nonetheless, the CCHR and a handful of attorneys have continued this campaign against Prozac, twisting the scientific data, misrepresenting the clinical experience, and discouraging patients from taking a drug that has been accepted in more than sixty-three countries around the world as a safe and effective way to treat depression. The anti-Prozac campaign has been thoroughly discredited by the FDA, the American Psychiatric Association, and all leading medical authorities. Unfortunately, the ultimate victims of the disinformation campaign are the patients, their families, and the medical profession.

*70\22\4*

Is it safe to take Prozac and other medications at the same time? The more medications a person is taking, the greater the chance for potential problems. Drugs interact. So whenever a second medication is in the body, it should mean extra caution on the part of the physician and patient. Potential drug interactions should always be researched by the treating physician.

Has Prozac had any effect on male or female reproduction or fertility? Limited studies have shown no effect on reproductive functioning or fertility in bow sexes. Men are able to take Prozac throughout their reproductive life without any harmful effects on sperm count.

Does Prozac damage the brain? No brain damage whatsoever has been detected in animal or human studies, even after Prozac has been given in doses many times higher than that which is normally considered safe.

*48\22\4*

With Prozac, on the other hand, the appropriate dosage, for the most part, corresponds simply to weight and age. Patients of average age and weight (for men that is 150 pounds, mean age 35; for women that is 120 pounds, mean age 35) need approximately 20 mg of Prozac a day, with the very young and very old taking smaller doses. But the average dose is not necessarily the correct one for a given individual. Ultimately, the way a patient feels is the most important determinant of the final dosage, along with the patient’s specific metabolism and genetic factors.

*29\22\4*