Antidepressant Risks
Two interesting new articles on this issue (about which I've written extensively on my Antidepressant Controversies page):
First, a review by Dr. Joe Goldberg, well-known expert in this area, cites the latest data on the issue and arrives at conclusions very similar to mine: antidepressant-induced switching into mania is disturbingly common and risky; and antidepressant-induced cycling, meaning more episodes per time, is also clearly associated with antidepressants, a second reason to avoid them if possible. He recommends using mood stabilizers with antidepressant effects, and maximizing non-medication tools like exercise and psychotherapy, before turning to antidepressants. Same as my recommendations. So this is affirming, to find an expert like Dr. Goldberg reaching the same conclusions at which I've arrived by seeing lots of patients.
However, from Australia comes a report of 10 patients with Bipolar II, some of whom seem to get a "mood stabilizer" effect from an antidepressant, used with no other mood stabilizer! This is paradoxical, quite the opposite of the effect Dr. Goldberg is writing about.
Taken together, these two articles do not shift the debate much: one is clearly warning about antidepressant risks and counseling against using them even with a mood stabilizer on board; the other is suggesting that at least for some patients, antidepressants might themselves be "mood stabilizers".
My opinion: they are probably both right. I think Dr. Parker's data from Australia are convincing, looking at the graphs: there are some patients who do indeed look more stable on an antidepressant alone -- in the short run. This leaves open the question of what will happen to them in the longer term. Meanwhile, Dr. Goldberg's review again emphasizes that for the majority of patients, the opposite holds: antidepressants can be destabilizing. He concludes with this list of factors which suggest which patients might do better on antidepressants (in other words, if you're not like this, using an antidepressant may carry more risk):
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First, a review by Dr. Joe Goldberg, well-known expert in this area, cites the latest data on the issue and arrives at conclusions very similar to mine: antidepressant-induced switching into mania is disturbingly common and risky; and antidepressant-induced cycling, meaning more episodes per time, is also clearly associated with antidepressants, a second reason to avoid them if possible. He recommends using mood stabilizers with antidepressant effects, and maximizing non-medication tools like exercise and psychotherapy, before turning to antidepressants. Same as my recommendations. So this is affirming, to find an expert like Dr. Goldberg reaching the same conclusions at which I've arrived by seeing lots of patients.
However, from Australia comes a report of 10 patients with Bipolar II, some of whom seem to get a "mood stabilizer" effect from an antidepressant, used with no other mood stabilizer! This is paradoxical, quite the opposite of the effect Dr. Goldberg is writing about.
Taken together, these two articles do not shift the debate much: one is clearly warning about antidepressant risks and counseling against using them even with a mood stabilizer on board; the other is suggesting that at least for some patients, antidepressants might themselves be "mood stabilizers".
My opinion: they are probably both right. I think Dr. Parker's data from Australia are convincing, looking at the graphs: there are some patients who do indeed look more stable on an antidepressant alone -- in the short run. This leaves open the question of what will happen to them in the longer term. Meanwhile, Dr. Goldberg's review again emphasizes that for the majority of patients, the opposite holds: antidepressants can be destabilizing. He concludes with this list of factors which suggest which patients might do better on antidepressants (in other words, if you're not like this, using an antidepressant may carry more risk):
- no previous episode of antidepressant-induced hypomania or mania
- no current or recent episode of hypomania or mania
- no rapid cycling in the past year
- Bipolar II (Bipolar I may have more risk)
- no substance use, now or even in the past
3 Comments:
The issues surrounding antidepressant use, such as cycling and suicidality, seem to stem from what seems to be a obvious fact: different people have different reactions to them. Some lucky few do very well long term on them - the "better than well" folks. Many do fine; the drugs help relieve syptoms but not much more. Others have no benefit from ADs, even differing types. And then there are the ones who go up, down, sideways, and crash on ADs. Imagine if Lipitor caused cholesterol to suddenly skyrocket in some users and you'll get a hint of the problem. ADs are not completely safe and/or effective for everyone. The general public appears to know that; doctors seem to dance around it in pratice. Unipolar and Bipolar are to some extent just labels; psychiatric nosology is not exactly concrete. Obviously, actual reactions to medication is key.
To me, one of the main problems with ADs is that general care docs hand them out like Halloween candy. Thank you HMOs. If you seem like you may be depressed to your primary care doc, you can get a year long prescription. You might do quite well on the med, or maybe not. Maybe you don't even need it that much. If you're truely insane, you have less than a half a chance of being treated for it, but that's another story. General practice doctors aren't equiped for the emotional wierdness that may happen, nor do they do much follow up which is again key. Psychiatrists often work hard to get the right prescription(s); a GP is unlikely to do as well with medication management. The FDA would do well to look more into how ADs are prescribed, dispensed, and used in actual practice - a complex and messy task for sure, but one that may result in guidelines that could improve and save lives. A black box warning is not enough - it may scare away people who would do well on the drug and yet may be ignored by those that should have read and fully understood it.
Personally, I do very well on ADs but only for a short time. I was high on Lexapro for 2 weeks but then turned into a golem. I am fortuneate to have always gone to a psychiatrist for psychiatric meds, even if they wern't always right. I know a few people on SSRIs whom have never seen a psychiatrist, or even a psychologist; at that point it's almost luck if the med works for them or one wonders just how depressed they really were. As for me, I like Seroquel now. Just my $.02 worth.
Thanks for the comments. I completely agree: some people do well on antidepressants, much better than they would without them. The trick is knowing who that is -- especially to be able to know *before* giving them an antidepressant!
I like the Lipitor analogy, very apt.
Thanks --
JP
WRT Dr. Parkers findings, it would be interesting to see if there was any relationship to SSRI half life and dosing schedule. Seeing that SSRI can act as both an anticonvulsants or pro-convulsants, through effects on GABA-stimulated Cl- uptake(PMID: 10492522,PMID: 12604672). Seeing that these effects are dose dependant it raises interesting questions. Such as could an extended release SSRI reduce or eliminate SSRI induced cycling? Should once daily dosing be discouraged?
Cheers,
Glen
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