QUESTION:

Dear Dr. Heller,

I do not react well to Prozac (severe agitation), and have been put on Tofranil (Imipramine). Have you had any experience and/or success with this tricyclic antidepressant?

ANSWER:

I much prefer avoiding tricyclic antidepressants. Side effects and the strong potential for a lethal suicide attempt limit their use. Additionally, the research shows they’re not that helpful.

Everyone I’ve encountered who had your reaction to Prozac (severe agitation) also had the generalized anxiety disorder (GAD) - particularly the cognitive component. It’s a genetic trait causing persistent worry and/or thinking. I highly recommend you look at the screening test I use for my patients. I go over the disorder at length in "Biological Unhappiness."

The combination of the GAD and BPD is a chemical imbalance: some areas too high, some too low. Prozac and other SSRI’s raise serotonin, raising the already high ones which increase anxiety and therefore the agitation by dysphoria (anxiety, rage, depression and despair) being triggered. When BuSpar (to treat the GAD) is given first, the Prozac can then subsequently be added to avoid the Prozac side effect.