MOOD SWITCHING WITH ANTIDEPRESSANT USE

Diagnosing bipolar depression vs unipolar depression [major depression] remains difficult.  So why be concerned?  Well, there is building evidence that taking antidepressants and having a mood swing to a manic or hypomanic mood is associated with a poorer prognosis that includes more depressive mood swings [rapid cycling?], not responding as well to mood stabilizing medications, increased risk for substance abuse, more disability, and more mortality from suicide or from medical illnesses.  Also, there is a statistically higher risk of switching moods with antidepressant use in adolescents compared to adults. One explanation is that the adults are more likely to have their bipolar illness diagnosed.  There is also evidence that there are more mood swings to mania or hypomania associated with antidepressant use than those that switch spontaneously.  This could reflect how difficult it is to distinguish bipolar depression from unipolar or major depression.  In the past this switching was considered a side-effect of antidepressants and not indicative of bipolar illness.  This apparent resistance to diagnosing bipolar illness may represent the prevalence of irritability with major depression, the worse prognosis of bipolar illness, and the difficulty lifting a stable bipolar depressed mood with mood stabilizing medications.  

So, what to do?  There are a number of factors that are associated with an increased risk for switching moods on antidepressants.  These include: a family history of bipolar illness or psychosis; onset of symptoms before age 25; number of depressive episodes within several years; cyclothymic, and irritability symptoms; past post partum mood disorder symptoms; depression with psychomotor retardation, hyersomnia and increased appetite [pointing toward Bipolar Type II diagnosis]; history of excitation on mood elevating medications [basically antidepressants]; current agitated and dysphoric symptoms; possible comorbid substance abuse; and treatment with a tricyclic antidepressant or venlafaxine or duloxetine [any antidepressant known to significantly elevate more than one neurotransmitter].

After taking into consideration the above, I have found that if someone's moods are cycling it is often possible to stabilize moods, with mood stabilizing medications, without having to use antidepressants. However, if someone has symptoms suggesting bipolar depression and yet is stable [stuck] in a depressed mood, I will treat briefly with an antidepressant [often escitalopram due to quicker response] and then begin tapering it and discontinuing it after a couple of weeks of improved mood.  If the taper or discontinuation leads to return of depressive symptoms then I reinstate the antidepressant at the previous dose and then the taper and/or discontinuation is tried a couple of weeks later.  At some point I have found it is possible to stop the antidepressant and the improved mood is maintained.  Meanwhile, I have initiated a mood stabilizing medication that then will hopefully hold the improved mood.    

Comments

[Ben]

Still gathering data on the effectiveness of bipolar medication. Again, this blog is a great resource. Please keep the posts coming!