Emotional Support Sisters

Prozac poop-out. If you know, you know. You know?

The general population doesn’t understand how antidepressants work. I don’t mean in the nitty-gritty scientific details kind of way, with pharmacokinetics,  pharmacodynamics, metabolites, autoreceptors, etc.¹ I mean that most people don’t have a clue about the actual experience of taking antidepressants. The general (mis)understanding is that there are medications like Prozac that you can take and they make you happy. Often people assume it’s the easy way out, a way to not deal with the problems in your life that are making you unhappy.

If only it were that easy. 

I will probably do more than one post about antidepressant medication. There’s a lot to talk about. I can talk about different classifications of antidepressants, different generations of antidepressants, the mechanism of action of antidepressants, the side effects of antidepressants, the controversy about antidepressants, the myths about antidepressants… There’s a lot there.

Right now I’m talking about the experience of taking antidepressants.

I started taking Prozac when I was 11. I have been taking antidepressants ever since. It hasn’t always been Prozac. I actually have a Google doc titled “Antidepressant history” that keeps track of all the med changes within a 5 year period because we were doing a lot of experimenting. 

Experimenting? Experimenting with drugs? Just say no!

No, not that kind of experimenting with drugs. But yes, there’s a lot of trial and error when it comes to finding an antidepressant that works for you. Because not every antidepressant will work for every person. There are some DNA testing type things you can do to try to figure out which ones will work for you, but mostly it’s just trial and error. 

“Amelia,” you may ask, “what does that sort of thing look like?”

I’m glad you asked. Let me describe the general formula for getting an antidepressant prescription.

Step 1. Set up an appointment with the doctor.

Step 2. Go to the doctor.

*If you already have a depression diagnosis you can skip to step 6.

Step 3. Tell the doctor what’s been going on.

Step 4. Receive a depression diagnosis (maybe an official diagnosis, maybe unofficial).

Step 5. Begin discussing treatment options.

Step 6. Decide to try pharmaceutical treatment. (Unless you choose to go with talk therapy only, in which case you won’t be taking antidepressant medication, but that’s not what we’re talking about right now.)

Step 7. If this is your first foray into the world of antidepressants, your doctor will probably prescribe you Prozac (generic name is fluoxetine). It’s a pretty good medication that works for a lot of people without too many side effects.

Step 8. Fill your prescription at the pharmacy.

Step 9.  Take medication daily for approximately 1-4 weeks.

Step 10. Have a follow up appointment with your doctor.

*If you are now feeling better and things are going well, go to step 11. If not, go to step 13.

Step 11. Tell the doctor how you are feeling much better.

Step 12. Continue taking the antidepressant for as long as it is helpful. (Meaning until you no longer need an antidepressant or until it isn’t working anymore.)

Step 13. Tell the doctor how you are still feeling lousy.

Step 14. Discuss options.

Step 15a. Increase the dose of the medication you are taking.

OR 

Step 15 b. Change to a different antidepressant.

OR

Step 15 c.² Add a mood stabilizer or second antidepressant.

Go back to step 8.

I would like to draw your attention to step 9. This step is rather annoying. Antidepressants don’t work quickly. You won’t know after only a day or two if it is working³. It typically takes 1-4 weeks for the medication to really start making a difference. I, personally, don’t notice any change for a solid 2 weeks. That’s to start feeling a difference. It takes a couple more weeks for me to really know if that medicine at that dose is doing what it needs to be doing. 

Those are 2 weeks of coming off the old medication and getting on the new medication (rarely will a doctor have you go cold turkey off one medication, generally it is titrated down) so neither medication is really at full strength and they are sometimes doing weird things with each other⁴. 2 weeks of still feeling pretty depressed but knowing that what I’m feeling is… well… it is real. I was going to say it isn’t real, but it is. It is also kind of not real in the sense that it’s coming from temporarily very out of whack brain chemistry, not from how I really think and feel about life/myself/others/the situation I’m in/everything. Due to where it originates from, the method of dealing with it is basically just trying to make it through that time. For me, at least, there’s no point in trying to deal with my emotions or solve my problems in some sort of “let’s face my problems head on” or “let me analyze why I’m feeling this” kind of way because what I’m thinking and feeling won’t be improved by any of it⁵. I often end up white-knuckling it through this time period and/or using mindless distraction to survive. It’s not pretty. It gets me through. 

After 2 weeks of basically paying little heed to my emotions, then I spend the next 2 weeks constantly asking myself, “Am I feeling better?” Because now I’m in the time when I can start to tell if this medication change is going to be effective or not. Sometimes, blessedly, the medication is obviously effective because I’m feeling so much better. Not always though. Sometimes those next 2 weeks involve a lot of second guessing how I’m feeling. Or just guessing what I’m feeling. Because it’s not always easy (or possible) to tell. 

For the astute reader, you will notice that this whole trial and error thing means I’m feeling depressed for at least 2 months before I even go to the doctor⁶ because I wait until I know it’s depression and not something else that will go away on its own. Then 2 weeks of riding out the medication change. 2 more weeks⁷ of observing myself. And sometimes the medication change doesn’t work. Sometimes the follow-up appointment brings another medication change, which leads to another month of fun⁸. And guess what, there’s no guarantee that this next one will work either.

“But Amelia,” you say, “if Prozac worked for you, why would you ever change medication?” Here’s another fun fact about antidepressants: they can work for a while and then stop working. The fancy, scientific term for this is tachyphylaxis⁹. The more colloquial terminology (and the one I actually use) is “Prozac poop-out”. It really should be “antidepressant poop-out”, but then you lose the alliteration, and no one wants that. Over time, an antidepressant (not necessarily Prozac, it can happen with most¹⁰ of them) can stop being effective. That’s the bad news. The good news is that this poop-out is specific to that particular antidepressant. So if you poop-out on Prozac, you can switch to Zoloft and reset the poop-out timer, as it were. Eventually, you can even go back to Prozac and it will once again be effective. There are some hypotheses why this happens, but no one has a conclusive explanation backed with a lot of good research. It is pretty well documented that it does happen to a lot of people though. 

I was on Prozac throughout my teen years and did just fine. I did have to increase the dose as I got older, but that could be because I was getting bigger, not because of Prozac poop-out. Once I hit college, though, I ended up experiencing Prozac poop-out, and Zoloft poop-out, and I don’t remember which antidepressant poop-out. I eventually found a combination of antidepressant and mood stabilizer that was effective for a number of years. Then I had another bout of changing things up pretty frequently (those 5 years when I had to write everything down in a Google doc that I mentioned earlier). Once again we found a winning combination that worked for quite a few years. Sometimes it only takes once through steps 3-15 to find that winner. Sometimes it’s a much more iterative process. For me, it’s just part of life.

I do want to leave you with some hope, for all that Prozac poop-out is depressing¹².

First off, while it takes a while for antidepressants to start working, I’ve found that I find immediate relief whenever I start a new medication. That’s the power of hope. 

Second, I put up with the med changes and the fun that goes along with it because it is worth it to me. Medication helps me manage my depression. Medication helps me. Antidepressants are no miracle cure. They are a useful tool for me.

---

Footnotes

¹  Yup. I’m showing off. I know these words. I don’t really know what they mean, but I know that it is fancy scientific lingo about drugs and stuff.

²  Step 15c typically doesn’t happen until you’ve repeated the process a few times.

³  You can, however, sometimes know after only a couple days if it is NOT working. And by this I mean there are some antidepressants that some people have a bad reaction to. For instance, there is one antidepressant I will not try again because it made me feel like I had influenza. That’s a thing that can happen. It’s lots of fun. NOT!

⁴  I don’t know if they are actually doing weird things with each other, that’s just how it feels.

⁵  I’m having a little bit of an internal debate on phrasing it this way. Most professionals (at least most professional advice I’ve come across) would agree that throwing your hands in the air and saying “Why should I even try? It’s not going to do any good anyway!” is not consistent with a healthy mindset. I generally agree with them. So I am not telling you to follow my example. This is not advice. This is just my experience.

⁶  Fine, even the astute reader has no reason to know that part. Now you do.

⁷  I don’t know why 2 seems to be the magic number.

⁸  *eye twitch* My favorite kind of fun.

⁹  At least that’s what Google says. But when you look up tachyphylaxis some places say that it is a sudden decrease of efficacy, others say it is a gradual decrease. I’m not entirely sure what to make of this discrepancy. 

¹⁰  It might happen with all of them. I don’t know. I’m playing it safe by avoiding absolutes. Because I’m not a sith.

¹¹  This is not a royal “we”. I’m not just talking about myself. I don’t change my meds on my own. I do it with my doctor and even with my parent’s advice. So sometimes I talk about how I changed my meds and sometimes I talk about how we changed my meds. I’m the one who is in charge and who is saying what is working and what isn’t working–in that sense I am the one making changes. But this is not a solo venture. Nor should it be. For legal and safety reasons, as well as because of “no man is an island” kinds of reasons.

¹²  See what I did there? Pun intended.