Garden variety bipolar disorder consists of moods that typically last weeks to months if not treated. People with bipolar experience a mood and settle in for a long ride. However, people with rapid cycling bipolar disorder experience moods that typically only last weeks. People with ultra-rapid cycling bipolar disorder have moods that only last days to weeks and people who have ultradian bipolar disorder may have moods that last from hours to days.
[It worth noting that when severe moods last only for a few hours this may be considered a mixed mood episode rather than a cycler, per se.]
So, if your mood cycles quickly and spontaneously, how do you live with it?
Would you like the short answer or the long answer? In short, if you have bipolar disorder, no, you shouldn’t be taking an antidepressant – even if you’re depressed – in many, if not most, cases.
The long answer is, naturally, more complicated.
After looking at the future treatment approaches for treatment-resistant depression, I thought I’d share a bit more depression and bipolar research. New options offer hope for everyone who run the gamut of bipolar or depression treatments.
- A new mood stabilizer
- A new, novel antidepressant
- Knowing when depression isn’t depression
Time to learn another three new things about mental health. This week we have:
- Further discussion on Antidepressant Effectiveness (vs. Placebos)
- Infographic on influential depression information sources
- Depression prognosis over 10 years
1. Antidepressants: Lifesavers—or Active Placebos?
Monday I discussed the rate at which people with depression respond to placebos (pills that do nothing). My point was not that antidepressants don’t work – far from it – it’s that some people do respond to sugar pills as if they were real medication.
Some people may have mistaken this for me suggesting that antidepressants aren’t effective, however. And it just so happens that the Psychiatric Times was considering this subject just as I was, so please check out Antidepressants: Lifesavers—or Active Placebos? for all the details on this subject.
To quote the article:
. . . the treatment of depression is an art that requires many tools—from family support, to CBT, to medication.
“We will not save lives by dismissing any of the tools we have today just because they are not effective for everyone,” he said. “But we should not be limited in the future by current treatments.”
2. Top 10 Online Influencers Making a Difference in Depression
This week ShareCare announced their list of the Top 10 Online Influencers Making a Difference in the World of Depression. ShareCare isn’t a site with which I’m overly familiar but among other things, they have subject matter experts that answer your questions on health topics.
Their top 10 depression influencers list is presented as an infographic and you can see it here. Yes, I’m at number two in a list of incredible people working for major organizations. I’m honored to have made their list.
3. Depression Prognosis Over 10 Years
I can tell you that about 75% of people respond successfully to appropriate depression treatment.* I can tell you that if you work with a doctor and a therapist you will likely experience meaningful symptom remission over time.
What I cannot tell you, however, is whether you will be depressed again in the future. It depends on a lot of variables but even knowing all of those, it’s still difficult to predict.
This study, though, followed people from the start of their treatment for major depression for 10 years. And here’s what they found:
- 77% of the follow-up months were spent non-depressed (euthymic)
- 16% of the follow-up months were spent in a sub-threshold depression (some depressive symptoms but not rising to the level of clinical depression)
- 7% in major depression
Unfortunately, I don’t have access to the full text, but the data, nonetheless, is interesting. I think knowing that you are statistically likely to spend three-quarters of your life symptom-free is a hopeful positive.
Thanks all. I’ll let you know when I learn more and do better.
* I was asked where this comes from. It is a widely-accepted number; you’ll note it’s used here.
I despise bad reporting and I don’t care if you write for a newspaper with a circulation of 3 people or the New York Times – there is no excuse to report badly on mental illness, there is quality information available everywhere.
Point in case is Depression can be treated through lifestyle changes by Danielle Faipler in West Virginia University’s student paper, The Daily Athenaeum.
Comments on Depression can be treated through lifestyle changes
This article contains some of the most widely-spread mistruths about depression and mental illness and is inexcusable. It doesn’t even pass a sanity check (even by an insane person).
Antidepressants are good for short-term treatment, but they do not facilitate with the long-term changes needed to treat the illness, and they add to the growing prescription drug abuse problem in the U.S.
That is absolutely false and I would enjoy seeing any research that indicates otherwise. As I have shown, depressed people who take antidepressants do better long-term and antidepressants are not addictive. Stating otherwise is ignorant or untruthful.
A side effect of antidepressants is hallucinations, and most of the time, different medication is prescribed to the patient.
If the number of people who experienced hallucinations from taking antidepressants alone were to get together for a party, they could fit in my freaking apartment. Yes, it can happen with some antidepressants, but it’s far from common. (And what was the second half of the sentence? What different medication?)
Further Stigmatizing Depression and Mental Illness
A walk in the park may be all it takes for someone with depression to get out of their funk.
If that isn’t one of the most stigmatizing statements, I don’t know what is. Depression is a medical illness and not a bad mood that can be cured by a stroll.
This type of reporting, even if by a student, is unacceptable. It spread lies and does so without scientific backing of any kind. This particular writer and editor should be ashamed of themselves and write a public apology for such nonsense.
It is not acceptable for a newspaper to spread mistruths and further stigma of depression and mental illness. Period.
Please view The Daily Athenaeum’s shameful response to this criticism.
Admit it – you haven’t kept up with your bipolar reading. Come on. I know it. I can barely keep up and I write the bipolar articles.
Luckily for you, I like you a lot, and I’m happy to give you a little cheat sheet on what’s been getting attention at Breaking Bipolar. We’ve got mental illness and higher education, mental illness and physical pain, how to tell if it’s a med side effect and oh so much more.
Articles Breaking Bipolar Over at HealthyPlace
- Is it a Med Side Effect? – What is a medication side effect and what isn’t a med side effect? How can you tell?
- Temperature Dysregulation – Or Why I’m So Cold – Speaking of side effects – did you know psychiatric meds can change how your body temperature feels?
- Yes, You Can Get a Higher Degree With Bipolar Disorder – So many people have written me to say how successful they have been in school. Read this for inspiration and hope. Some people have taken 10 years to get their degree – but they got it. Article includes tips on being successful at school.
- Mental Illness Means Physical Pain Too – People think mental illness is “just” in your head. They would be wrong about that.
- Is It Really Never the Psychiatrist’s Fault? – I’m tired of doctors acting like they never make a mistake.
- Being Thankful Even When Anhedonic – Even when I can’t feel pleasure I can feel grateful for the things that go right in my life.
- How to Keep Going When Medication Doesn’t Work – And for your final dose of hope and encouragement, here are some tips on continuing mental illness treatment even when everything is going wrong.
Popular Articles at the Bipolar Burble
And just in case you haven’t been glued to the Bipolar Burble, here are a few things you should read here:
- Questioning the Evidence of the Efficacy of Therapy for Depression – Interesting information on how evidence-based therapy for depression really is. Less so than I would have thought. And do you think CBT is intellectual and analytical? I do, but a commenter disagrees.
- When to Get Off Antidepressants if You’re Bipolar – The first in a three-part series on getting off of antidepressants.
- Important Safety Warnings for St. John’s Wort – Please read if you’re on or thinking about trying St John’s wort.
- Cutting Supplemental Security Income Hurts Mentally Ill Children – A guest post by Allison Gamble that garnered a lot of reads.
- Psychiatric Myths Dispelled by Doctor – Fighting Antipsychiatry – Have you read this article yet? It garnered more comments than any other at the Burble. It’s always a hot topic.
Or other bothersome antidepressants.
Generally, following the rules I wrote about last week on how to stop antidepressants while minimizing withdrawal work, and most people can successfully withdraw from antidepressants with few side effects.
Some Antidepressants Are Hard to Get Off Of
Unfortunately, some antidepressants are not so easy to get off of no matter what you do. (You can learn more about this through http://drugabuse.com/ and other similar sites.) Some antidepressants:
- Resist a taper strategy
- Have intolerable withdrawal effects anyway *
People Have Trouble Withdrawing from these Antidepressants
Any antidepressant can feel impossible to withdraw from, but the antidepressants people have most trouble withdrawing from are:
- Paroxetine (Paxil)
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor, any version)
- Desvenlafaxine (Pristiq)
But by far, venlafaxine and desvenlafaxine (Effexor and Pristiq) are the ones I hear about. In my opinion, these two drugs are a nightmare to come off of for most people. ^ (I’m not saying everyone has trouble with these antidepressants, just that many do.)
Here are tips on how to get off of horrible~ drugs like venlafaxine (Effexor) and desvenlafaxine (Pristiq).
Did I mention yet I’m not a doctor? Ah, well I’m not. None of this is to be considered medical advice; this is an informational article only. Never alter your treatment without talking to your doctor. Thanks.
It’s a bit of a short week what with the holiday and all, but still, there is time for three new things about mental health. Today’s three new things are:
- A safety warning on the atypical antipsychotic drug asenapine maleate (Saphris)
- Saffron and depression
- Multi-drug (polypharmacy) treatment of mental illness
Serious Allergic Reactions Reported with Asenapine Maleate (Saphris)
Asenapine maleate (Saphris) is an atypical antipsychotic drug recently approved for use in the treatment of bipolar type 1 mania and mixed episodes (as well as schizophrenia).
In slightly less than two years of approval, about 87,000 people have been prescribed asenapine maleate. The FDA’s Adverse Event Reporting System (AERS) has had a significant number of serious allergic (hypersensitivity) reactions reported. These serious allergic reactions were reported in 52 cases and are considered Type 1 hypersensitivity. From the FDA:
“Signs and symptoms of Type I hypersensitivity reactions may include anaphylaxis (a life-threatening allergic reaction), angioedema (swelling of the deeper layers of the skin), low blood pressure, rapid heart rate, swollen tongue, difficulty breathing, wheezing, or rash . . . Several cases reported multiple hypersensitivity reactions occurring at the same time, with some of these reactions occurring after the first dose of Saphris.”
Any such reactions require immediate medical attention.
You can report serious allergic reactions to the FDA’s MedWatch program here.
FYI, asenapine maleate’s label has been changed and updated with this new information.
Saffron (crocus sativus) is the most expensive spice by weight and is integral in French bouillabaisse. And someone asked me this week, “Can saffron help with depression?” Initially, I did a search on the Alternative Medicine Index at the University of Maryland Medical Center and turned up nothing. This alternative index lists most everything so my immediate answer to “can saffron help with depression,” was no.
However, I may have spoken slightly too soon.
Upon closer inspection I did find one study that asserts, in treating mild-to-moderate depression:
“Saffron petal was significantly more effective than placebo and was found to be equally efficacious compared to fluoxetine and saffron stigma.”
Now, hold on a minute. This is not a good, particularly scientific, study. This is just a review of studies, some of which are very questionable in nature. The above statement is premature at best. All that can really be said (in my opinion) is that saffron deserves further study and that some formulation of it might work.
Good question. This is called polypharmacy and most doctors agree it’s a bad thing. The reason polypharmacy is bad is because it greatly increases the chance, and severity, of side effects. (There are other reasons too.) People who have been through rounds of polypharmacy will tell you this is true.
However, doctors continue to prescribe many drugs simultaneously for a condition. This article explores why polypharmacy is so common.
The article may make you take a look at your drug regimen and talk to your doctor about reducing some of your medication. This isn’t always possible, but a good idea if you can get away with it.
Note on Polypharmacy
It’s worth noting some conditions do warrant polypharmacy.
According to the Psychiatric Times article, the best indications for polypharmacy are few and well established:
- Bipolar depression
- Psychotic or agitated depression
- Co-morbid conditions that require independent medications (e.g., ADD and major depression)
- When partial response to the first medication requires adding another adjunctively
- When there is a combination of psychiatric and pain problems
OK all. Until next week when I will learn more and try to do better.
While antidepressants can absolutely be life-saving medications, sometimes antidepressants aren’t the right medication at the right time for you. Or sometimes, it’s just time to try to get off of antidepressants. (For simple depression, this is often done if you have been stable for 6-12 months.)
But the key to getting off antidepressants successfully is to minimize withdrawal symptoms because otherwise you may feel like you’re trapped on the antidepressants. Additionally, the withdrawal symptoms may get mistaken for returning illness symptoms, which you do have to watch for, but if possible, it’s best not to get withdrawal and returning symptoms confused.
So, here are some tips on the best way to get off antidepressants while minimizing withdrawal.
Learn About Getting Off Antidepressants
Firstly, by reading this you are taking the first step. Learning about your antidepressant, the time it takes to get off, and what might happen, is an excellent first thing to do. Your doctor can guide you in this process.
DO NOT STOP ANTIDEPRESSANTS SUDDENLY.
DO NOT STOP THEM ON YOUR OWN.
ALWAYS TAPER ANTIDEPRESSANTS UNDER THE SUPERVISION OF A DOCTOR.
(And as always, I am not a doctor and none of this should be considered medical advice. Only your doctor can offer that.)
Taper Antidepressants More Slowly
I can’t comment on individual doctors, but I will say in studies and in the literature they take people off medication, including antidepressants, way too fast. This is likely because they don’t want to wait around to do it the right way, but still, it gives people the false sense that you can get off antidepressants quickly – you shouldn’t.
Track Your Mood During Antidepressant Decrease
I know, it seems like I’m trying to strong-arm you into tracking your mood, but during medication tapering, it’s essential. You need to track your mood every day during medication changes – this goes for all mental illness – as well as write down when you change dosages because:
- You need to know if you’re getting worse
- You need to know if you do better at a lower dose, but not off the drug completely
- You’ll have those records should you try to do it again in the future (or with another medication)
Please, please, please, even if you track your mood at no other time, do it when withdrawing from medication. (More on mood tracking here.)
(If you don’t want to track every part of your mood, then at least track the global assessment of functioning (GAF).)
Wait Six-Eight Weeks between Antidepressant Dosage Decreases
Seriously.* You are waiting so long between antidepressant dosage decreases because:
- You want to prevent withdrawal
- You do not want to induce mania, cycling or a mixed mood which is a real danger in bipolar
Changes to the Antidepressant Taper Schedule
You may want to slightly alter the antidepressant dosage decrease schedule:
- Increase speed if feeling better as dosage decreases
- Decrease speed if anxiety is a factor
- Decrease speed if feeling worse on a lower dose
- Decrease speed if feeling good at a specific dose (that might be the right dose for you)
- Decrease speed for any reason if you feel the need
Never try to decrease or get off an antidepressant when:
- You’re in a time of stress
- There is an upcoming holiday
Decrease the Antidepressant in the Lowest Dose Possible
This does not mean cutting your current pill. Some pills cannot be cut for safety reasons. This means getting a prescription for the smallest increment available and decreasing the antidepressant dosage by that much.
When you’re closing in on getting off the antidepressant completely, slow down even more. Cut the pill if you can. If you can’t, alternate on the higher dose for one day and then the lower dose for one day.
Exceptions to the Antidepressant Withdrawal Rules Above
As with all things in life, there are exceptions:
- If you’ve been on the antidepressant a very short time you may be able to get off of it quickly
- Fluoxetine (Prozac) may sometimes be tapered more quickly
- Venlafaxine (Effexor), desvenlafaxine (Pristiq) (and sometimes other antidepressants) can be too hard to get off of using this method (see next article in series)
Getting Off an Antidepressant Takes Too Long
Look, you are getting off a medication that has altered the chemicals in your brain. This is not a minor event. While this method is slow, it gives you the very best chance of successfully getting off the medication without inducing withdrawal or worsening illness symptoms.
Don’t Freak Out When Coming Off Antidepressants
Remember not to freak out. Some withdrawal symptoms and some bipolar/depression symptom fluctuation may occur and you’ll still be all right. Just maintain a close relationship with your doctor to make sure it isn’t the start of something more serious
How to Get Off of Antidepressants with Minimal Withdrawal Series
Previously we saw:
Up next is:
If Your Doctor Doesn’t Get This, Send Them to Psycheducation.org for Their Own Education
* This information (and other information in this article) is provided by psycheducation.org and Dr. Jim Phelps.
This week’s three new things include:
- A new supplement that may help brain health and mental illness: l-theanine
- A poor comparison between rapid cycling bipolar disorder and the financial markets
- A new discussion of antipsychiatry
1. New to Me: L-Theanine as an Antidepressant
Maurya, a commenter, asked if I knew anything about l-theanine. Well, I didn’t. Every once in a while even I run across something of which I haven’t heard.
So, for those of you in my boat, here’s a bit about l-theanine:
- L-theanine is derived from green tea although we’re not sure of the best way to extract it.
- L-theanine has been studied on mice and seems to exert antipsychotic- or even antidepressant-like qualities.
- L-theanine is a glutamate derivative and loyal readers will know that I think glutamate will be a big player in mental illness treatment in the next few years. (N-acetylcysteine (NAC) also works with glutamate.)
- There is very little conclusive research on l-theanine, we really just have ideas about what it does; it may possibly be a stress-reducer
- L-theanine may improve cognitive impairment (a human study)
As always, as this is a supplement it is not FDA-controlled and there is no guarantee as to what you will get in the bottle and you should never take any supplement without first checking with your doctor.
More studies on l-theanine can be found here.
I’m a writer so questionable metaphors irk me. And rapid cycling bipolar disorder as a metaphor for the financial marketplace? Really? That’s a whole new level of irk.
If you really want to make that comparison then the bulk of the article should be on the markets and not mental illness, and not the other way around like Lloyd I. Sederer M. D. did in Rapid Cycling Bipolar Disorder: In the Office and On ‘The Street.’
Comments of Mental Illness Stigma
All this poorly-written article did was confuse people and elicit a bunch of anti-bipolar comments like:
“The foundation of the Bi-Polar epidemic is based in suppressed biochemistry, outdated understanding of genetics and a complete misunderstanding of our true spiritual nature.”
“So how exactly is this different from saying some people dramatically over-react to external circumstances?
Sorry folks, but this one goes into the notebook for the next philosophical discussion of “medicalization” as a way of discussing deviance.”
Seems to me he just wanted to use mental illness as an eyeball-grabber, tricking readers onto a topic they would never otherwise read – with the extra bonus of eliciting remarks of stigma.
3. What I Find Interesting – New Discussion of Antipsychiatry
As you might know, I’m not a fan of antipsychiatry folks. I have written a lot on this topic and I’m sure I will write much more in times to come. But I can across this article, Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry which has an interesting discussion of antipsychiatry viewpoints.
Two Sides to Antipsychiatry
It astutely notes there are two sides of antipsychiatry – those who feel that nothing can be defined and thus no mental illness can be defined; and those who feel illness is rigidly defined and mental illness doesn’t meet that definition.
Both sides, as the author says,
“. . . have had the effect of discrediting and marginalizing psychiatry and of delegitimizing psychiatric diagnosis and nosology.”
It’s a very intelligent view of antipsychiatry criticism that is elevated far beyond what we normally see online. Check it out.
Until next week: Smarter and Better.
I try not to give medical advice here because I am not a doctor. But so many people ask me about this I felt I had to address getting off antidepressants without withdrawal. So many people with bipolar disorder (depression and others) need information about getting off psych meds and they are not getting it from their doctors.
This is the first in a three-part series:
- When to Stop Antidepressants in Bipolar Disorder
- How to Stop Antidepressants in Bipolar Disorder While Minimizing Withdrawal
- How to Stop Taking venlafaxine (Effexor) and Desvenlafaxine (Pristiq) – as they are particularly nasty to get off
This is an informational article only and should not be considered a recommendation. Talk to your doctor before any and all changes to your treatment. I’m not kidding about this.
Bipolars Shouldn’t Take Antidepressants
Some doctors are on the fence about this, but more and more bipolar specialists are recommending people with bipolar disorder not take antidepressants. There are lots of reasons for this, and I have to tell you, they are compelling.
Why Shouldn’t People with Bipolar Disorder Take Antidepressants?
Some reasons people with bipolar shouldn’t take antidepressants:
- Antidepressants may not work in bipolar disorder – believe it or not, the literature is mixed on how well antidepressants even work for bipolar depression.
- Antidepressants can induce mania or hypomania (known as switching) – most of us have seen this and it happens all the time to bipolars who are prescribe antidepressants by non-psychiatrists because they just don’t understand the danger. And it is very dangerous because once switched, this type of mania or hypomania can be treatment resistant.
- Antidepressants can induce rapid-cycling or mixed moods – same as above, this cycling can be treatment-resistant.
- Antidepressants can worsen a bipolar’s illness overall – this is more controversial and I suspect varies case by case.
To be clear some people with bipolar disorder will always need antidepressants temporarily, or long term, for their mood, but more and more, doctors are saying to avoid them whenever possible. (Alternatives will be presented in a future article.)
When to Stop Taking Antidepressants
Here are some guidelines from Dr. Phelps about when to stop taking antidepressants in bipolar disorder:
- If they have been on antidepressants a short time, I stop them.
- Less than a week, stop; two weeks, cut in ½, a week later stop.
- Likewise, if they just increased their antidepressants dose I will do the above, decreasing to their previous dose and get rid of the rest later.
- If manic or severely hypomanic, get rid of antidepressants now. Usually can stop abruptly.
- If cycling or mixed get rid of the antidepressants.
- If they are not getting better after several add-on meds then slowly decrease.
- There are more exceptions to the above rules than there are rules.
When to Stay On an Antidepressant if You’re Bipolar
More guidelines from Dr. Phelps: When a bipolar should stay on an antidepressant:
- If the patient is doing well, no mixed state symptoms or cycling, leave it.
- I usually wait until the patient is doing better to much betterto stop an antidepressant; why:
- Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long and may not even go to another psychiatrist.
- Even though we know the antidepressant is causing harm often time the patient thinks either the antidepressant is helping or every time they try to go off they feel much worse.
- Waiting until they are better is usually a good thing.
- Also waiting longer usually means that the patient is going to be more educated about bipolar in general.
When to Get Off an Antidepressant Recommendations
I think Dr. Phelps’ recommendations are good ones, otherwise I wouldn’t have them here, but note where he says there are more exceptions than he has listed, so keep in mind, you might fall into one of the unlisted exceptions.
And I think the part above where Dr. Phelps talks about trust and making sure the patient is better before messing around with their cocktail is key. It shows he’s respecting the patient and their health, not to mention the doctor-patient relationship which is very important.
Talking to Your Doctor about Getting off Antidepressants is Scary
I know it’s scary to think about going off antidepressants, even if you do think they are causing problems. But think about it, discuss it with your doctor and make the right decision for you. And don’t do anything until you read the next part about how to get off antidepressants without withdrawal.
Bipolar Disorder – Getting off Antidepressant Series
- Bipolar Disorder – When Not to Take Antidepressants