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Re: Antidepressants and Bipolar Disorder? » McPac

Posted by Ron Hill on June 7, 2003, at 17:40:19

In reply to Ron, Re: Antidepressants and Bipolar Disorder?, posted by McPac on June 6, 2003, at 23:17:34

Hi McPac,

> Ron, is it very common that if a bipolar were to be put on ONLY an anti-depressant (MONOtherapy) that the bipolar would have a very bad reaction---such as SEVERE anger/irritability/agitation?

For some bipolar patients this is their primary reaction to SSRI mono-therapy. For example, Colin Wallace falls into this category. You might want to talk to him. For me, however, SSRI mono-therapy causes rapid cycling and the hypomanic phase is primarily the euphoric variety, but some periods of dysphoric hypomania (anger/irritability/agitation) also occurs.

> Is that a "tip-off" to a shrink, that if someone who did NOT know whether they were unipolar OR bipolar, took ONLY an anti-dep., and then reacted TERRIBLY to it with terrible anger/agitation/irritability---would that be a "tip-off" that that person was bipolar and not just unipolar?

Yes, AD induced hypomania (either euphoric or dysphoric) is a possible diagnostic indicatior of bipolar disorder. If you have not already, please read what Dr. Phelps says regarding the controversy surrounding bipolar patients taking ADs.

http://www.psycheducation.org/bipolar/controversy.htm

> Finally, WHY is it that an anti-dep. in monotherapy makes many bipolars completely "lose it" and become much worse? (I understand why they would get the euphoric 'high' but why do anti-dep's in monotherapy cause incredible rage/anger/worsening of symptoms?

I don’t know the pharmacological mechanism(s) at work, but as I understand it, the general consensus is that SSRIs can cause mood instability in some bipolar patients, and this instability can express itself as euphoric, dysphoric, or other unwanted mood states.

> So, are you aying that EVEN WHILE ON a mood stabilizer that some bipolars get anger/temper/irrit./agitation when adding on an SSRI or TCA? I'd heard that some or many bipolars had trouble with SSRI's but didn't know that they had trouble with an ssri while also being on a mood stabilizer.

Again I refer you to the link to Dr. Phelps’ web site. I will likely continue to have a bias against the use of SSRI's to treat bipolar II depression (even with a moodstabilizer in place). I can say without hesitation that SSRIs do not work for me. However, I need to allow for the fact that not all BP II's have the same response to SSRIs. Even with a good functioning moodstabilizer, the slightest pinch of an SSRI gives me a couple days of hypomania (euphoric type), followed by a couple days of normal non-depressive state, and then it turns me into what my wife affectionately calls her "do nothing boy". In the latter state, I'm not really depressed and I'm not irritable. But I have no motivation, my energy is low, and I'm completely numb emotionally. When I'm healthy (i.e.; not depressed and not on an SSRI), I am an emotional person.

For me, of all the SSRIs, Prozac is the least offensive and Paxil is the worst. I attribute these adverse SSRI side effects to the fact that; “Chief among the brain’s reactions to artificially elevated serotonin levels is a compensatory drop in dopamine.” I took this quote from page 20 of the introduction in a book entitled “"Prozac Backlash"” by Joseph Glenmullen, M.D. He is a clinical instructor in psychiatry at Harvard Medical School, is on the staff of Harvard University Health Services, and is in private practice in Harvard Square. His credentials look impressive, but he appears to be somewhat extreme in his views regarding the dangers of SSRIs. If you want, you can read the Introduction and Chapter 1 in their entirety for free at the following link or at the Amazon link provided above:

http://www.glenmullen.com/prozacBacklash.html

I thought it was worth the time I spent scanning the available portions of his book. There have been numerous discussions on this board regarding the issue of SSRIs adversely affecting dopaminergic pathways and, thereby, inducing atypical depressive symptoms. However, this is the first time that I personally have seen a doctor state this in print (I'm sure there are others, however, that I have not come across).

I suspect that the main reason I cannot tolerate even a pinch of an SSRI add-on these days is because I took a ton of the stuff prior to getting the correct dx. In the time period between 1996 and 1999 my initial pdoc had me labeled ADHD and was feeding me a bunch of Ritalin and SSRIs (primarily Paxil). At one point, I was taking 80 mg/day of Paxil! Boy, I wish I knew then what I know now about mental disorders and medications. I don't know a lot about these issues even today, but I knew almost nothing when I went to my initial pdoc appointment. Never again will I subject myself to a doctor’s care without first doing my homework!

> I didn't know that the TCA's bothered some bipolars, I thought it was just an SSRI thing.

I have never taken a TCA, so I have no experience to share. Dr. Phelps seems to think that if a bipolar patient absolutely must take an antidepressant, then the MAOIs tend to work better, generally speaking, that the SSRIs and TCAs because the latter two tend to cause mood instability. However, this is controversial and definitely not a hard and fast rule. Examples of exceptions to this rule is Barbara Cat, a bipolar patient getting good results with lithium and a TCA, and Colin Wallace, doing well on Lamictal and a low dose of an SSRI.

> Ron, when you say "pushed you into a full blown mania", do you mostly mean symptoms like rage/anger/irrit./agitation? You don't mean euphorically happy, do you?

Yes, primarily euphoric, but I also periodically cycled into dysphoric mood states.

>> The lithium controls my hypomania very well but it does little or nothing for my depressive side.

> I wonder if perhaps a higher dose might?

At higher lithium dosages I start to get side effects (lethargy, rash, etc). I am convinced from the research that at low blood levels lithium provides neuroprotective properties. At high blood levels, however, lithium is toxic. Therefore, I like lithium but I insist on keeping my blood levels in the lower end of the therapeutic range.

>> In addition to doing a great job on my irritability, niacin has antidepressant qualities. I’m told that niacinamide (another form of vitamin B3) is even better than niacin for irritability. Therefore, I may conduct a trial of niacinamide (either with or without niacin)".

> Bummer for me...can't take niacin/niacinamide....long story.

I’ve got time to read it if you have time to write it. Tell me your story.

> I know your post wasn't intended for me Ron but it sure did help me too!

Good! The goal here in pbabbleland is to help one another. We all owe Dr Bob a heart-felt thank you for providing the forum. This site sure has helped me.

-- Ron


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poster:Ron Hill thread:102831
URL: http://www.dr-bob.org/babble/20030604/msgs/232237.html