But the relationship between sleep and mood is not always so obvious. In the 1970s, Dr Thomas Wehr and colleagues, working from a theory that a fundamental problem in depressed people was that the timing of their sleep was too late in relation to their other body rhythms, devised an anti-depressant treatment called ‘phase advance of sleep’. These researchers showed that if you move the onset and offset of sleep several hours earlier in some depressed patients, for example, to 5 p.m. and 1 a.m. respectively, a remarkable improvement in mood will result within several days. Although this finding was of theoretical interest, it was regarded as impractical largely because people were unwilling to go to sleep and wake up at such inconvenient hours. Another curious relationship between sleep and depression, discovered even earlier than the phase advance treatment, is that in a depressed patient a night of sleep deprivation is often followed by a remarkable improvement in mood on the following day. This counterintuitive effect was discovered accidentally by a depressed German woman, who observed that her mood was much better on the day following an all-night bicycle ride. Sleep deprivation has been disappointing as a treatment for depression because its benefits are generally rather short-lived, dissipating the very next day after a night of recovery sleep.

Recently, Dr Mathias Berger and colleagues in Germany have developed an ingenious way of combining sleep deprivation and phase advance of sleep so that the combined treatment is both effective and practical. In controlled studies they have deprived depressed patients of sleep for a single night and followed this up with a regimen of phase advanced sleep for several nights afterwards. After achieving an anti-depressant response, the researchers then moved the timing of sleep progressively later, an hour per night, over the next six days until they reached the patient’s accustomed times of sleep onset and waking. Remarkably, without any medications whatsoever these researchers obtained stable antidepressant responses in a high percentage of their patients. Although I have not as yet used this new combined sleep modification therapy in my own clinical practice, I am waiting for an opportunity to do so. Once again, a valuable anti-depressant treatment is being developed in Germany and we would be well advised to pay attention to it sooner rather than later.

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Much progress has been made. New drugs not yet on the market are being tested. There is good reason to believe mat antidepressants even more effective than Prozac will eventually be developed. Since the 1970s, lithium has brought unimagined help to manic depressives. Now Prozac and other newly developed antidepressant compounds are offering relief from forms of depression that the older antidepressants failed to eliminate. New drags being tested today should increase the number of patients who, though they may currently feel marooned on a desolate island or isolated beneath a dark cloud that never lifts, can in the near future look forward to a better, happier, more productive life that is symptom-free.

*109\22\4*

Prozac can alleviate this block by eliminating the depression and lifting the mood, thereby igniting the creative spark.

It cannot, however, make a creative artist out of a person who has never been creative—unless a depression has somehow hidden or blocked the creativity.

In some patients, Prozac brings the individual out of a depression into a revved-up, slightly hypomanic state. Patients claim that in that state they work fester and focus better. The creativity may be unchanged, but the productivity zooms. Consider -Vincent van Gogh. During periods he described as “furies of painting,” van Gogh stopped eating and sleeping for days at a time and was incredibly productive. In 1888, he painted two hundred canvases in two months. But although these manic highs were productive and creative, they were also dangerously unstable. Sometimes, he calmed down and had periods of lucidity and calm (a serenity reflected in the style of the paintings he made at these times); but lop often, the productive high led inexorably to psychotic periods of mania, paranoia, and violence. In addition to being repeatedly hospitalized, van Gogh attacked his friend Gauguin with a razor, cut off his own ear, threatened to shoot his friend Dr. Gachet, algid ultimately, at the age of 37, took his own life.

*89\22\4*

So far, not a single court has said that Prozac caused suicide or violent behavior in any of the cases brought to trial. Indeed, although, approximately a hundred cases are soil pending, fifty-one s have already been dismissed. One such case is that of Bonnie Leitsch, a Louisville woman who was the national director of the Prozac Survivors Support Group, another organization opposed to Prozac. In November 1990, she brought a $150 million lawsuit against Eli Lilly and Company, claiming that after she started taking Prozac as a “pick-me-up” prescribed by her doctor, she became hostile, argumentative, and impulsive, developed violent thoughts, and for the first time in her life tried to commit suicide. “I wanted to die,” she said. ‘That seemed to be the only answer. Death was the only escape from Prozac.” She repeated this dramatic “story not only in court but also on “Geraldo” and “Phil Donahue” and “60 Minutes.” The case was dismissed when it turned out that Leitsch had taken an overdose of sleeping pills in 1960, had a history of depression in her medical records dating from 1976, when her stepdaughter was shot to death in a gas station robbery, and had recently endured the suicide of her 21-year-old daughter.

So what caused her to try to take her own life? Eli Lilly representatives maintained that it was her disease: depression.

The FDA continues to proclaim Prozac’s safety as an antidepressant and has consistently refused to list any warning in the insert package regarding possible suicidal or violent impulses resulting from taking the drug.

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However, general caution should be exercised with patients who have high blood pressure or other heart disorders. The dosage of the drug should be watched carefully on initiation and in many cases decreased to 10 mg per day, where the patient would otherwise begin at 20 mg daily.

How does Prozac compare to other antidepressants for patients with heart disease? For patients with heart disease, Prozac is one of the safest antidepressants on the market. Patients taking tricyclics and MAOI antidepressants are at a higher risk of cardiac complications than patients taking any of the SSRIs such as Prozac, Paxil, and Zoloft, as well as Wellbutrin and Effexor.

*47\22\4*

Furthermore, the family should consult with the doctor and read as much material as possible in order to understand the purpose, effects and side effects of Prozac and other psychopharmacologic agents. This is especially true when the patient is a young adolescent or an elderly person who is dependent on the family for keeping regular appointments with the psychopharmacologist and sometimes with a second therapist, whom I also recommend for about a third of my depressed patients on antidepressants. The family members need to understand that these repeated visits serve an important monitoring function of me patient’s clinical state, side effects, and general blood chemistries.

*28\22\4*