Antidepressants Dont Work For Bipolar Depression
People fall on both sides of this argument but one thing we know for sure is that enough studies havent been done to draw an absolute conclusion either way. Not enough studies have been done comparing antidepressant use in bipolar vs. unipolar depression. Moreover, when you take into account bipolar II, things become even murkier.
Antidepressants with positive study data for bipolar depression include paroxetine, bupropion, and imipramine. Data on efficacy of an antidepressant combined with a mood stabilizer includes venlafaxine, sertraline, and bupropion. This evidence is not perfect though as it doesnt account for confounding factors in a heterogeneous population.
The Controversy Rages On
In one of the first research papers on an antidepressant, The Treatment of Depressive States with G22355, Imipramine Hydrochloride, the author noted that in individuals who are predisposed the drug could give rise to manic-like states or even a manic state. This observation has been thoroughly confirmed since that paper was published in 1958, and the predisposed individuals are now recognized to be persons with bipolar disorder.
Antidepressants have been implicated in a whole range of problems for bipolar patients who take them. Psychiatrists spend a lot of time trying to persuade bipolar patients already taking antidepressants to stop and patients who request one not to start. Why?
As that early paper reported, full-blown manic episodes can be triggered by antidepressants, especially by the older tricyclic drugs, but SSRIs, SNRIs, and other antidepressants have also been reported to trigger mania.
More controversial is the assertion that antidepressants, when taken by bipolar patients over the longer term, cause an increase of mood cycling, with more frequent episodes of mania, hypomania, and depression, too. Talk about counter-intuitive!
They found that over a quarter of the patients had a worsening of their course of illness that could be attributed to antidepressants. They also reported that over a third of these patients had experienced an antidepressant-induced manic episode.
Assessment Of Family History
Of this triad, the most robust predictor is family history of bipolar disorder, especially in early onset youth. Family history of completed suicide along with male sex are the only known predictors of completed suicide in this group . The most valuable course predictors are recurrence and early age of onset of depressive symptoms. The most consistent symptom-related factors are subsyndromal hypo/manic symptoms and mood lability .
Family history, like recurrence and age of onset of first symptoms are readily available to the clinician who spends some time. It is often the first piece of information presenting to the treating clinician before any treatment commences. However, poor quality of family history information in routine clinical practice is a frequent critique in the literature . While earlier studies endorsed under reporting of indirectly collected family history bipolar, the recent colloquialization of the term bipolar has led to concerns in the opposite direction .
Table 2 Factors to consider in assessing family history of hypo/mania from an informant.
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Antidepressants In Bipolar Depression: Conceptual Concerns
When antidepressants are prescribed for unipolar depression and mood stabilizers for bipolar depression, the only concerns are those of efficacy and side effects. There are no credible reasons to worry about the proposed treatment exacerbating the disorder. . The two added concerns when treating bipolar depression with antidepressants are switching into mania/hypomania and/or the induction of rapid cycling. Switching into mania/hypomania, now called treatment emergent affective switch has been well recognized since the first use of antidepressants to treat bipolar depression. Yet, without proper control groups, assigning causality to the use of an antidepressant and the emergence of mania/hypomania is fraught with difficulties since a substantial portion of bipolar patients show a naturalistic pattern of depression followed by mania/hypomania without treatment. In any individual case, it is impossible to know whether the post-depression mania/hypomania is due to the antidepressant prescribed or to the natural history of the disorder. In order to deal with this conundrum, a reasonable definition of definite TEAS would be the emergence of a syndromal mania/hypomania within 8 weeks of either the initiation of the antidepressant or an increase in its dose . Likely or possible TEAS should be considered if hypomanic symptoms not meeting syndromal criteria emerge within 12 weeks of antidepressant initiation or dose increase.
Antidepressants Cause A Switch To Mania In Bipolar Disorder
This concern came to light in the 1960s when Tricyclic antidepressants were used to treat depression in bipolar disorder . This concern continues today and now includes concerns with bipolar II. Therefore, some doctors are very reluctant to prescribe antidepressants in cases of bipolar.
However, it is extremely difficult to ascertain whether a switch into mania or hypomania is related to an antidepressant or simply a natural factor of the disease. It should be noted that it is thought in cases of true antidepressant-induced polarity switches, symptoms may continue even if the antidepressant is stopped.
Switching into mania or hypomania, or increasing rapid cycling is a dangerous effect that can result in worsening, or more, depressions. Recent literature suggests that about 10% – 25% of the reemergence of mania or hypomania symptoms can be attributed to antidepressant use.
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Who Is More Likely To Experience Antidepressant
People already living with bipolar disorder are more likely to experience a sudden episode of mania after taking certain antidepressants. But not everyone with the condition.
A 2018 review of bipolar depression notes that antidepressant-induced affective switching appears more common among people who:
- changes in weight
Different antidepressants may come with side effects more common to their class.
Selective serotonin reuptake inhibitors , for example, are known to have common side effects of dizziness, anxiety, headaches, and restlessness.
Other Common Treatments For Bd
The US FDA approval process relies on a review of manufacturer-provided information regarding safety and effectiveness of a drug for specific indications. Once approved for a specific indication, off label use is allowed. There are several drugs not approved by the FDA that are commonly used off label for treatment of BD-D and have substantial supporting evidence.
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Is Fluoxetine Any Good
It is an interesting question. But unfortunately you cant evaluate that from an internet forum. You should ask your doctor what he thinks about it. I can tell you about my experience though. I am 23 years old. I was diagnosed with depression and anxiety at the age of 10. I tried a lot of anti-depressants and anxiety medication until I found fluoxetine. I have been taking it for over one year now and I feel fine. I am not sure if it is good or bad, but it definitely helps me..
Can You Take Fluoxetine If You Are Bipolar
Fluoxetine is also known as Prozac. It is is a type of antidepressant called a selective serotonin reuptake inhibitor , which means that it makes more serotonin available in the brain. SSRIs are the most commonly prescribed type of antidepressant. Fluoxetine can be taken by people without bipolar disorder, but people with bipolar disorder should not take fluoxetine. So the answer to the question is no, it is not safe to take fluoxetine if you have bipolar disorder..
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Cycle Acceleration From Antidepressants
As described above, aside from TEAS, cycle acceleration, first described decades ago, comprises the other major clinical concern when antidepressants are prescribed to bipolar patients. A number of studies from the tricyclic era seemed to suggest a link between antidepressant use and cycle acceleration . It is less clear whether this phenomenon is seen in any consistent way with more modern antidepressants-SSRIs, bupropion, SNRIs-especially if the patient is also on mood stabilizers . In one study using modern antidepressants, an association was found between prescription of antidepressants and rapid cycling . However, as noted earlier by Coryell et al. , since episodes of depression often precede rapid cycling, the relationship between rapid cycling may be associative, not causal. Overall, only some of the prospective studies demonstrate a link between rapid cycling and antidepressant use .
‘it Just Exacerbates The Manic Episodes’
Scottish bipolar patients ‘missing best treatment’
Jamie Stewart is a 37-year-old graphic designer from Dundee. He was diagnosed with bipolar disorder aged 23 and has been prescribed antidepressants at various times since.
Now on a course of two medications including lithium, he says antidepressants did nothing to stabilise his moods.
Jamie says: “It just exacerbates the manic episodes. The only way I can describe taking antidepressants is that it kind of cycles my mania – I would always end up back in the same place that I was.
“I would say, however, that in the times when I was just depressed, the antidepressants did seem to have a positive effect. I was still depressed but I was brought up slightly.
“But when the mania was there, it just tipped it right over the scales. It really didn’t do anything to balance it out. Being a bipolar person, I’m always looking to ‘middle out’ and it didn’t do that for me.
“There’s a high that I’m really comfortable with but there is a high when I feel, this is really bad. Then you get mixed mania, where you feel high and low, and it’s a really uncomfortable place to be.
“You know you’re not going to be able relax for a long time and it’s just an uneasy feeling. It’s scary when you know that train isn’t stopping any time soon and you’re going to have to stay on it.”
Daniel Smith, a professor of psychiatry at Glasgow University who led the study, said: “These findings are a matter for concern.
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How To Get Off An Antidepressant
Slowly. Really. If theres one word to remember its slowly, followed closely by the world gradually. You want to decrease the dosage of the antidepressant as gradually as you can over the longest period of time.
For example, if youre on 200mg of drug A, you wouldnt simply cut the drug in half and go to 100mg. You would talk to your doctor, find out that 25mg tablets are available, and decrease from 200mg to 175mg.
What Is Bipolar Disorder
- There are different types of bipolar. Those with type 1 experience periods of manic highs and depressive lows. Those with type 2 experience severe depression and mild manic episodes – known as hypomania – that last for a shorter period of time. Those with cyclothymia experience fewer severe mood swings, but they can last longer.
- During a manic episode, those with bipolar disorder can feel euphoric and have lots of energy, ambitious plans and ideas. But they can become aggressive, and experience symptoms of psychosis.
- The exact cause of bipolar disorder is unknown. Some experts believe it can be developed as a result of severe emotional distress as a child, as well as genetic and chemical factors.
- One in every 100 UK adults will be diagnosed with the condition at some point in their life.
The study looked through the hospital records of patients and found bipolar patients being prescribed other medications such as antipsychotic and anticonvulsant drugs was on the increase.
That is despite, researchers claim, neither of these being proven to be as effective as lithium in managing the disorder long-term.
Alison Cairns, chief executive of Bipolar Scotland, said: “We’ve been concerned for some time by the number of people being prescribed antidepressants without an accompanying mood stabiliser.
“Doctors should strive to improve prescribing practice and bring this into line with the scientific evidence and treatment guidelines.”
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Tips For Getting The Most Out Of Medication For Bipolar Disorder
Avoid antidepressants. The treatment for bipolar depression is different than for regular depression. In fact, antidepressants can actually make bipolar disorder worse or trigger a manic episode. Try mood stabilizers first and never take antidepressants without them.
Take advantage of natural mood stabilizers. Your lifestyle can have a huge impact on your symptoms. If you make healthy daily choices, you may be able to reduce the amount of medication you need. Mood stabilizers that don’t require a prescription include keeping a strict sleep schedule, exercising regularly, practicing relaxation techniques, and developing a solid support system.
Add therapy to your treatment plan. Research shows that people who take medication for bipolar disorder tend to recover much faster and control their moods better if they also get therapy. Therapy gives you the tools to cope with life’s difficulties, monitor your progress, and deal with the problems bipolar disorder is causing in your personal and professional life.
Continue taking medication, even after you feel better. The likelihood of having a relapse is very high if you stop taking your bipolar medication. Suddenly stopping medication is especially dangerous. Talk to your doctor before you make any changes, even if you believe you no longer need medication. Your doctor can help you make any adjustments safely.
Are Antidepressants Mood De
Quoting from an editorial in the American Journal of Psychiatry, March 2008, by Nassir Ghaemi, one of the principal investigators in the STEP-BD, a large bipolar research trial :
Mood destabilization with antidepressants should be distinguished from an acute manic switch. Antidepressant-induced mania, or switch, is a short-term phenomenon one might define it as happening within 2 months of the beginning of antidepressant treatment. Mood destabilization is a long-term phenomenon, reflecting more mood episodes over time than would have occurred by natural history.
Antidepressants may cause long-term mood destabilization without a short-term manic switch, and vice versa. Although some agents may have low rates of acute manic switch, especially when used with mood stabilizers, the data from STEP-BD suggest that even the new generation of antidepressants can produce long-term mood destabilization.
In that editorial, Dr. Ghaemi also emphasizes an approach Ive been espousing for years: if a mood stabilizer is tried with an antidepressant also in use at the same time, and the mood stabilizer doesnt work, that was an unfair trial of the mood stabilizer. It will need to be tried again later with no antidepressant in the picture.
I think theyre right, that antidepressants can have a stabilizing effect for a while. Consider two cases.
Want to see more data on this question? Dr. Ghaemi refers to two randomized trials. More.
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Bipolar Patients ‘could Be On The Wrong Drugs’
A quarter of patients with bipolar disorder are being prescribed drugs which could make their symptoms worse, a new study has claimed.
Research led by Glasgow University has found many bipolar patients are on a combination of medication which is out of line with clinical guidelines.
The study shows a decline in the first recommended treatment for people with the mental health condition.
Experts have described the findings as a “concern”.
Lithium prescribed on its own is the recommended first treatment for bipolar disorder.
But the study of more than 23,000 patients across Scotland between 2007 and 2016 found its use is declining, and it is now only prescribed to one in 20 people with the condition.
The drug is recommended as the first stage treatment as it has proven effectiveness in preventing episodes of depression and mania.
Experts say this approach can run the risk that the antidepressants cause worsening moods and episodes of mania.
Antipsychotic Medications For Bipolar Disorder
If you lose touch with reality during a manic or depressive episode, an antipsychotic drug may be prescribed. They have also been found to help with regular manic episodes. Antipsychotic medications may be helpful if you have tried mood stabilizers without success. Often, antipsychotic medications are combined with a mood stabilizer such as lithium or valproic acid.
Antipsychotic medications used for bipolar disorder include:
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Controversy Surrounding Antidepressant Use
In terms of the efficacy of antidepressants in BD-D, several reviews and meta-analyses have come to differing conclusions, likely reflecting differences in statistical techniques and inclusion criteria and pointing towards a need for further investigation. Two of the most recent meta-analyses found no significant benefit of adding antidepressants to mood stabilisers for the treatment of BD-D. In agreement with these findings, the STEP-BD trial, which included 4360 patients, found that adding antidepressants to mood stabilisers did not result in better clinical outcomes than those achieved with mood stabilisers alone. In contrast, naturalistic studies suggest that there is likely a sizeable subgroup of patients who respond to a mood stabiliser plus an antidepressant with no increase in switching. Interestingly, there is more consistent evidence of benefits when antidepressants are added to SGAs. Whether this reflects additive effects of antidepressants combined specifically with SGAs or some other factors is unknown. A separate meta-analysis comparing different antidepressants found no significant difference in rates of clinical response between antidepressants, but it did report lower switch rates for bupropion when compared with sertraline, venlafaxine and desipramine. Importantly, the analysis concluded that the results are significantly limited by lack of high-quality studies.
B Bipolar Features: Depression With Short Duration Hypomania
Another area where we see this is short duration hypomania. About 1 in 20 patients with recurrent depression have brief hypomanias that are classic and recurrent but never last long enough to meet DSM criteria for bipolar they last less than 4 days. Jules Angst published a remarkable study where he showed the chance mood worsening on an antidepressant rises steadily with the duration of hypomania from 1% in patients with no history of hypomania, to 9% if theyve had it for less than a day, 14% for 2-3 days, and then we get into the real bipolar levels 4 days the cut off for bipolar II the risk is 27% and if theyve ever had hypomania for more than a week the risk of getting worse on an antidepressant is 38%. But, still, thats only 38% its not 100% none of this is absolute.
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