In the summer issue of The Carlat Psychiatry Report, I wrote an article covering this controversial topic. I tend to be more in the Goldberg camp (antidepressants are safe) rather than the Ghaemi camp (antidepressants worsen bipolar). Here are my bottom line conclusions after reviewing this vast literature:

1. Antidepressants are likely safe and effective for an acute episode of depression in bipolar disorder, particular if the patient is already on a mood stabilizer.

2. The newer antidepressants probably are not more likely than placebo to induce manic switching, even in patients with bipolar I disorder. Tricyclics are probably more dangerous in this regard.

3. Antidepressant monotherapy (i.e., without a mood stabilizer) is probably safe and effective for patients with bipolar II depression.

4. Maintenance treatment with antidepressants may be ineffective for preventing depressive relapses, and, depending on how you interpret the studies, may actually worsen the course of bipolar disorder for patients who are rapid cyclers. So try to wean patients off these meds 6 to 12 months after remission.

5. All this advice is based on the relatively little high quality data available, so our treatment guidelines are likely to change drastically over time, as larger studies are reported.

Posted by: Daniel Carlat at August 12, 2008 06:27 AM

I don't know much about this, actually. Probably I should after being here for as long as I have been. But I decided long ago not to tell any md that I actually woke up from my depressed funk for a couple of days once or two a year. Their immediate response was to recommend lithium--without bothering to find out if I was having a manic episode or maybe the chronic (hypothyroid induced, I now know) depression merely lifted sufficiently so I could clean my house for a day or two. In short, I've avoided any possibility of being diagnosed BP so I haven't learned much about it over the years.

But I am puzzled by what I hear about this BPII business. When I read statements like "bipolar II depressed patients with no mixed features, no recent mania" I find myself wondering how the heck is this different from garden-variety major depression? Has major depression lost its sex appeal amongst psycho-taxonomists while I wasn't looking? I just don't see how you can say someone's BP when they've had depression with no mania. How is that different from Major Depression and, if there's no difference, why the change?

Obviously I'm missing something here. I would welcome any explanation anyone has to offer. In my jaded little worldview, alas, I'm expecting it must have something to do with an opportunity for capitalistic exploitation of the health-care system.

I miss my naivete, even if it didn't serve me well.
Sherry

Posted by: Sherry at August 12, 2008 07:02 AM

Sherry,

I have been doing quite a bit of research on the whole bipolar business

once upon a time there was

depression

and

mania

and someone thought the two words would look good together and described some people

then later in the feel good about mental illness stigma reduction phase someone felt compelled to market manic depression as bipolar disorder

in that same phase several syndromes in the DSM 3 became disorders in DSM 4

then over time bipolar went from being for a few people (bipolar 1)

to some people (bipolar 2)

to a lot of people (cyclothymia)

to just about everyone else that missed out on previous dx (dysthymia)

then someone decided that adults should not have all the fun and suddenly or not suddenly, children were given the same standards and the same drugs

gradually bipolar has gone from a serious mental issue to pathologizing normal human behavior, normal depression, normal excitement, normal mood swings and impulses all became disease markers that you were supposed to identify in yourself an ask for meds for.

As I recall, mania was a stand alone mental illness on the DSM 3

it was possible to be *just manic* and not be told that clinical depression was the inevitable result of the mania

personally I think the biggest screw up in this whole deal was joining the two distinctly separate conditions of mania and depression and making one disease out of them

the original manic depression has some usefulness but these other bipolars, 2, 3, 4

that just sells drugs.

cyclothymia and dysthmia were basically designed for people who wanted to be in the bipolar club but their symptoms were just not demonstrably hardcore enough for bipolar 1 or 2

those are not mental illnesses

the problem with the unified manic depression business is all the problems with meds!

the constant quest to find the med that fixes manic depression

except depression and mania are two totally separate phenomenas

the mistake was ever putting the two of them together and making one ailment out of them

I say this from personal experience.

I have been depression free for since 1997-98 ish

for one or two years afterward, I still had manic symptoms

gradually the program I used to perform spiritual recovery got the mania under permanent control

eventually bipolar was gone as though it was never there

during that process I realized that mania and depression were really two entirely different issues caused by different things

somehow stand alone depression and stand alone mania are no longer sexy

it is all about getting people to microanalyze their own behavior to find the slightest depressive or manic like symptoms and to basically tell the Pdoc where under the bipolar spectrum your symptoms fall under

hypomania is a scam it really is

you can artifically induce hypomanis in anyone who has ever spent 24 hours awake on coffee and pepsi doing college finals, work projects, world of warcraft or D&D

sleep deprivation, B vitamin deficiency and stimulants will almost guarantee some form of manic/hypomanic episode.

you take that one step further give someone meth

they are awake for a couple of days on mental and physical stimulants and they will come down with full on paranoid delusions, basically manic psychosis, until they come down and crash.

the phenomena of pressurized speech, racing thoughts, grandiosity,

that stuff has nothing, nothing at all to do with with morbid depressions.

Ultimately, the fact that they are actually not related, is why you can have a mixed episode.

your emotions do one thing, your thoughts do another

you sit at home too depressed to do anything while your mind races around and around fixating and obsessing and getting irritated at every little thing.

I am not psychologist, psychiatrist or social worker

I am a meditator and my results come from being brutally self honest about my own internal world and learning to separate the fiction of manic depression inside my own being.

Posted by: Jane Alexander at August 12, 2008 08:20 AM

-the number of times people get labeled bipolar by virtue of a adverse reaction to an antidepressant alone is enough to make it absolutely out of the question for anyone who has ever had anything resembling mania---and I think Daniel Carlat's last statement is the most important of all he said:

5. All this advice is based on the relatively little high quality data available, so our treatment guidelines are likely to change drastically over time, as larger studies are reported.

so why in god's name is he willing to play god with the "little high quality data" and risk peoples sanity and health?

Little high quality data? That somehow sounds like double speak to me.

I know several people who have had these reactions to antidepressants and were coerced to take more drugs but figured out that it was indeed just an adverse drug reaction and are now healthy off all drugs...most people who get labeled as such are not so lucky and spiral down on more and more drugs...

Posted by: Gianna at August 12, 2008 09:28 AM

To quote Dr. Carlat: “Antidepressants are likely safe and effective for an acute episode of depression in bipolar disorder. . . ” I greatly respect Dr. Carlat's work on CME but I have to say I heartily disagree with this statement. If they are effective it’s most likely because someone already has a history of treatment with antidepressants and thus may be benefiting from a cessation of withdrawal symptoms by resuming an antidepressant. Withdrawal, let’s remember, and rebound effects go on for months after the drug is stopped and also of course occur during treatment when dose tolerance has been achieved. In my view antidepressants are never “safe and effective.” Sure they provide a stimulant or, in some cases, sedating effect over the short term, but that comes at a price – increased sensitivity to depression, mania and a host of physical and psychiatric side effects down the road.

“The newer antidepressants are not more likely than placebo to induce manic switching. . .” Whew, if this is based on data it’s only because the so-called placebo data has probably been distorted. Often data that is labeled placebo data in these trials is really withdrawal data and you can be sure someone who has been withdrawn (often abruptly) from previous treatment is more susceptible to manic switching. So when Dr. Carlat says his conclusions are based on "relatively little high quality data" he isn't kidding -- in fact, I'd wager a bet that a lot of the "literature" he's reviewed are full of lies and deceit, albeit in many cases not necessarily deliberately so, just impossibly naive and unsophisticated.

“Antidepressant monotherapy . . . is probably safe and effective. . .” Well, I never think it’s “safe and effective” but, if it were, it would only be at the very smallest dose and for a short period of time. What is meant by “effective” anyway? Does that mean “blunted and dulled” and at risk for sexual dysfunction, even persistent sexual dysfunction? Plus sensitized to “rebound depression” for the rest of one’s life? The only thing antidepressants are good for IMO are preventing withdrawal, which is often far worse than any depressive episode that preceded treatment. Let’s just be sure it’s not withdrawal we’re referring to here when we label symptoms “depressive relapses.” This is one of the biggest hoaxes ever perpetrated on an unsuspecting profession and public, that the symptoms one experiences when one stops an antidepressant are “relapse” and not withdrawal.

Frankly antidepressants, as popular as they are, should be relegated to the rubbish bin of history. They have caused so much pain and suffering with long term use, as well as untold acts of violence towards self and others, that it boggles the mind that 20 years later medical professionals haven’t figured this out.

Posted by: Sara at August 12, 2008 10:05 AM

I like the way Dr. Jim Phelps explains the controversy surrounding antidepressant use with moody people on his website here: http://www.psycheducation.org/bipolar/controversy.htm

Some months ago I attended a NARSAD symposium in Washington D.C. and a prominent researcher whose name shall remain nameless explained away the mania, kindling and rapid cycling in difficult children and adolescents following antidepressant trials by saying that the antidepressants helped unmask bipolar disorder.

Unmask bipolar disorder?!! LOL Heaven help us.

Cheers,
Moira

Posted by: Moira at August 12, 2008 12:14 PM

yes..Moira,
You're talking about the same phenomena I was talking about but made your point much more clearly...

I've heard that term used before too...unmasking bipolar...what a load of crap...

My "bipolar" was unmasked by a hallucinogenic and it amounts to the same end as those who take AD's and get labeled bipolar...MISDIAGNOSIS....I never needed any drugs, certainly not long term and an antidepressant does to many exactly what a hallucinogen did to me. It's called an adverse drug reaction...

Posted by: Gianna at August 12, 2008 12:26 PM

Sara was nice enough to call Dr. Carlat on his statement #3 in clinical, academic terms. I would simply call it bull-$#!+. I'm probably sicker today than I would have been if I hadn't had such monotherapy for over two years.

Furthermore, my own clinical experience is that I have done much better with mood stabilizers alone even than with a combination of antidepressants and mood stabilizers.

Some on this comment board, and perhaps Philip himself, would accuse me of being blindly pro-medication. If that's the case, why have I spent much of the last 24 hours frantically trying to convince a friend of mine whose 7-year-old daughter is on Risperdal (RISPERDAL?! For a SECOND GRADER?!) to find a way to get her off of it safely -- and look at Philip's site for guidance on the dangers of atypical antipsychotics?

I'm NOT blindly pro-medication. But I'm certainly not anti-medication, either, unlike some. I'm pro-smart use of medication -- where the medicines in question are properly, LEGALLY tested, labeled and marketed by pharmaceutical companies, and prescribed by doctors who've done more than cursory study of said products.

Posted by: Larry at August 12, 2008 12:47 PM

hah! a decade ago in 1999 while being given Imipramine(antidepressant)for bed wetting, then Luvox (antidpressant for "OCD" due to "intrusive thoughts(imipramine)then Zoloft--wow that speech was given to me about my daughter at the beginning of the Biederman Brigade Era.

"Early onset Childhood Bipolar" one way to "discover" bipolar was to take an antidepressant and see if a person flipped out.

Dr.Carlat also thinks some antidepressants are safe to be OTC (over the counter). I've written about it on my blog; my concern with that? what about innocent ppl thinking they are dealing with "Advil" in their mind safety-wise, then withdrawals hit, or worse: birth defects!

Posted by: Stephany at August 12, 2008 03:17 PM

Good points, Larry. My son, now dead from Zyprexa, did well for many years on lithium, once he had been accurately diagnosed (original dx, schizophrenia). Though stress seemed to cause breakthrough severe episodes three or four times, I honestly do not believe to this day that he would have had all those good years if not for the lith, and regular lith level checks. I've never heard of the idea of mania and depression being artificially hooked together, as described by an earlier poster, and can't imagine this idea applying to my son.

As to antidepressants only being okay for someone with bipolar, I saw with my own eyes what happened to my own daughter when given two different "rocket fuel" antidepressants, having come off lithium. It has taken her four years to get her life back. I go with Dr. Ghaemi.

Posted by: Sorrowful at August 12, 2008 03:22 PM

Sorrowful, I am sorry to hear about your son.

I totally agree with Franco Bennezzi. I think that if you have bipolar II and are severely depressed than anti-depressants might be safe but if you have mixed depression in bipolar II than I wouldn't touch anti-depressants.

I have had 3 suicide attempts within around 2 weeks of starting anti-depressants. I was already severely suicidal before my first attempt and in a mixed episode for my others. All three resulted in me being on life support.

I was then told by two professors that I should be on mood stablizers and even then not to add an anti-depressant.

Bottom line, antidepressants are dangers in mixed episodes of bipolar disorder. Dr Franko Benazzi spot on from my own experience.

Posted by: icu_baby at January 20, 2009 02:39 AM

Name:


Email Address:


URL:

Remember personal info?
YesNo
Comments: