Tricyclic Antidepressants

Use Antidepressants Cautiously for Bipolar Depression

Question:

Clinical Psychiatry News Use Antidepressants Cautiously for Bipolar Depression Carl Sherman, Contributing Writer [Clinical Psychiatry News 27(9):13, http://news.medscape.com/IMNG/ClinPsychNews/1999/v27.n09/cpn2709.13.0... ---- WASHINGTON -- The management of bipolar depression remains a thorny issue, with several "reasonable" therapeutic choices but none of unquestioned superiority for all patients. "The bedrock of pharmacotherapy -- mood-stabilizing medications -- is generally better at preventing and treating mania than depression," Dr. Gary S. Sachs said at the annual meeting of the American Psychiatric Association. Antidepressant agents, in particular, should be used cautiously and for limited periods -- days to weeks in many cases -- because of the risk of mania and rapid cycling, said Dr. Sachs, director of the bipolar clinic at Massachusetts General Hospital in Boston. Bipolar depression has received relatively little research attention, with bipolar patients excluded from most antidepressant trials. But its impact is unquestionable: Depressive episodes typically last far longer than mania and most suicides among bipolar patients occur during this phase of the illness. By 40 weeks, virtually all manic episodes have resolved, while nearly half of depressions persist for a year. Spontaneous episodes of moderate to severe depression in patients not currently on medication often respond to mood stabilizers: Eleven controlled studies have shown lithium to be effective, with one-half to three-fourths of patients recovering within 3-4 weeks. There are fewer data for carbamazepine and valproate, but response rates seem similar, Dr. Sachs said. Antidepressants alone are a poor choice for bipolar patients, in his opinion. "It's like lighting a fuse. ... Eventually you'll have an explosion." Not only is there a high risk of switching to mania (31%-70%, 20% within the first week), but the frequency of depressive episodes may increase, he said. The addition of antidepressants to mood stabilizers has achieved mixed results. Some studies have shown 40%-50% response rates, while the longest double-blind study of bipolar depression showed no significant difference among paroxetine, imipramine, or placebo when these were added to lithium. In this study, paroxetine was helpful when serum lithium levels were below 0.8 mEq/L. "The role of antidepressants may be for those who cannot tolerate a therapeutic dose of a mood stabilizer," Dr. Sachs said. Adding another mood stabilizer to the regimen of patients who have breakthrough depression while on monotherapy appears as effective as adding an antidepressant, but data are limited, and the risk of suicide counsels prudence when using this strategy. "You don't want to be months into it before giving an approved drug [for depression]," he said. As a clinical guideline, Dr. Sachs urged limiting the use of antidepressants as much as possible. These drugs should be given acutely for those who need it, for no longer than the natural course of the depressive episode. "The ‘art’ of being a psychiatrist includes estimating how long that should be," he said. While patients with unipolar depression may reasonably remain on antidepressants for 6-12 months after remission, for bipolar patients in which depression follows directly after mania, 6-12 weeks is more appropriate. And for rapid cyclers in whom mania follows depression, it is probably advisable to taper 6-12 days after the episode resolves, he said. Lamotrigine, a novel anticonvulsant, appears a promising new option for bipolar depression. A 7-week, randomized, controlled trial involving nearly 200 patients showed the drug to be effective, with no more conversion to mania than with placebo, he said. Electroconvulsive therapy remains the most effective treatment for bipolar depression, he observed.

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>Electroconvulsive therapy remains the most effective treatment for bipolar >depression, he observed.

Yep. Eric Krispy Kreme is gonna take over America…not arab terrorists. http://groups.yahoo.com/group/FactsAndFallaciesOfDepression MIBS (Minimally Invasive Brain Stimulation) http://www.musc.edu/psychiatry/fnrd/tms.htm

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>Which is  biologically and genetically totally  DIFFERENT than unipolar >depression,  which you suffer from  where ECT is more likely than not to do >REALLY bad things to you!

I dont know Linda. ECT is highly effective across the spectrum of severe psychiatric illnesses. The only psych disorder Ive read about that ECT is not effective for is OCD. And likewise Ive read ECT doesnt do too hot in cases of depression where a heavy "obsessive compulsive" component is present. But for about everything else, severe depression, mania, psychosis, psychotic depression, ECT is the best thing available. It even has off label uses for movement disorders and Parkinsons. See, ECT gets that dopamine flowing good, loosens up that rigidity  you get if you have parkinsons or a movement disorder. Its good for everything…more people should probably be choosing to have it. Eric Krispy Kreme is gonna take over America…not arab terrorists. http://groups.yahoo.com/group/FactsAndFallaciesOfDepression MIBS (Minimally Invasive Brain Stimulation) http://www.musc.edu/psychiatry/fnrd/tms.htm

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It even has off label uses for > movement disorders and Parkinsons. See, ECT gets that dopamine flowing good, > loosens up that rigidity  you get if you have parkinsons or a movement > disorder.

if i can lift weights, you kin do yoga. id still like to see some movement/relaxation therapies tried first for you. they can be unbelievably helpful. peace, anna — blackbird singin in the dead of night take these broken eyes and learn to see all your life you were only waiting for this moment to be free ~

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Then why have you resisted the good news for so long?  Jesus…er ECT will save you, Eric. – Hide quoted text — Show quoted text ->Which is  biologically and genetically totally  DIFFERENT than unipolar >depression,  which you suffer from  where ECT is more likely than not to do >REALLY bad things to you! > I dont know Linda. ECT is highly effective across the spectrum of severe > psychiatric illnesses. The only psych disorder Ive read about that ECT is not > effective for is OCD. And likewise Ive read ECT doesnt do too hot in cases of > depression where a heavy "obsessive compulsive" component is present. > But for about everything else, severe depression, mania, psychosis, psychotic > depression, ECT is the best thing available. It even has off label uses for > movement disorders and Parkinsons. See, ECT gets that dopamine flowing good, > loosens up that rigidity  you get if you have parkinsons or a movement > disorder. > Its good for everything…more people should probably be choosing to have it. > Eric > Krispy Kreme is gonna take over America…not arab terrorists. > http://groups.yahoo.com/group/FactsAndFallaciesOfDepression > MIBS (Minimally Invasive Brain Stimulation) > http://www.musc.edu/psychiatry/fnrd/tms.htm

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- Hide quoted text — Show quoted text ->I can’t take antidepressants at all, they invariably throw me into a >mixed episode, but I’m taking a large dose of Lamictal (lamotrigine), >400mg daily, and it’s the most effective treatment for my predominately >depressed mixed states that I’ve tried so far. >After 30 years of recurrent depressions and then horrific mixed episodes >my life is a wreck, so I can hardly expect anything to be 100% >effective, but my last serious predominately depressed mixed ‘episode’ >went on for four years. I think that goes beyond what could be called an >episode, but call it what you will. I was convinced that I had to >finally accept that there was no hope of ever coming out of it. As far >as I’m concerned there can be little doubt about it — lamotrigine >saved my life. >As far as side-effects are concerned, lamotrigine gets a lot of bad >press about its dangerous side-effects, but I can truthfully say that >compared to the endless array of creative combinations of nasty >side-effects I got from lithium, valproate and antidepressants, >lamotrigine has been a cool breeze.

Very true, its a well known fact that bipolars usually need to be cautious and conservative with antidepressants. Only using them when truly necessary. As antidepressants can flip bipolars into manic or hypomanic states easily. When required, the antidepressant least likely to activate mania in a bipolar is usually Wellbutrin SR. This is well established. Lamictal also has antidepressant properties, as you well know. Im glad youve found something that can fix your depression probs yet not activate mania or hypomania in you…Ive heard MANY great things about Lamictal. It appears to be a great drug for both bipolar and for depression. Eric Steroids caused my depression…prednisone should be used conservatively http://groups.yahoo.com/group/FactsAndFallaciesOfDepression MIBS (Minimally Invasive Brain Stimulation) http://www.musc.edu/psychiatry/fnrd/tms.htm

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– Hide quoted text — Show quoted text ->I can’t take antidepressants at all, they invariably throw me into a >mixed episode, but I’m taking a large dose of Lamictal (lamotrigine), >400mg daily, and it’s the most effective treatment for my predominately >depressed mixed states that I’ve tried so far. >After 30 years of recurrent depressions and then horrific mixed episodes >my life is a wreck, so I can hardly expect anything to be 100% >effective, but my last serious predominately depressed mixed ‘episode’ >went on for four years. I think that goes beyond what could be called an >episode, but call it what you will. I was convinced that I had to >finally accept that there was no hope of ever coming out of it. As far >as I’m concerned there can be little doubt about it — lamotrigine >saved my life. >As far as side-effects are concerned, lamotrigine gets a lot of bad >press about its dangerous side-effects, but I can truthfully say that >compared to the endless array of creative combinations of nasty >side-effects I got from lithium, valproate and antidepressants, >lamotrigine has been a cool breeze. >Very true, its a well known fact that bipolars usually need to be cautious and >conservative with antidepressants. Only using them when truly necessary. As >antidepressants can flip bipolars into manic or hypomanic states easily. When >required, the antidepressant least likely to activate mania in a bipolar is >usually Wellbutrin SR. This is well established.

You know your shit, this is the med my doc has just pescribed me. I get _Really_ manic on ad’s to, or at least that has been my rescent history. >Lamictal also has antidepressant properties, as you well know. Im glad youve >found something that can fix your depression probs yet not activate mania or >hypomania in you…Ive heard MANY great things about Lamictal. It appears to be >a great drug for both bipolar and for depression. >Eric >Steroids caused my depression…prednisone should be used conservatively >http://groups.yahoo.com/group/FactsAndFallaciesOfDepression >MIBS (Minimally Invasive Brain Stimulation) >http://www.musc.edu/psychiatry/fnrd/tms.htm

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>You know your shit, this is the med my doc has just pescribed me. I >get _Really_ manic on ad’s to, or at least that has been my rescent >history.

Yeah…I do know my shit. At least about some things. I am well read no doubt about it. Even my psychiatrists say Im one of the most well read patients they ever came across. I also ask a lot of questions. An educated patient is the best patient… Eric Steroids caused my depression…prednisone should be used conservatively http://groups.yahoo.com/group/FactsAndFallaciesOfDepression MIBS (Minimally Invasive Brain Stimulation) http://www.musc.edu/psychiatry/fnrd/tms.htm

Response:

Filed under: Imipramine