Bipolar Disorder Medication Spotlight: Paxil (Paroxetine Hydrochloride)

By Candida Fink MD
February 20, 2009

With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. We have already covered lithium, along with anti-seizure and atypical antipsychotics commonly used as anti-manic medications or mood stabilizers in bipolar disorder. Last week, we introduced our coverage of SSRI (Selective Serotonin Reuptake Inhibitor) antidepressants with a post on Prozac (fluoxetine). This week, we continue our series on SSRI antidepressants with this post on Paxil (paroxetine hydrochloride).

As a group, the SSRI’s share many of the same potential benefits and potential negative side effects, so we encourage you to read the Prozac post first to get up to speed about general information relating to SSRI’s, including how SSRI’s work and important cautions about using any antidepressant to treat depression in bipolar. In this post, we focus on Paxil’s unique profile in treating bipolar depression and depression in general.

Potential Benefits

Paxil’s potential benefits are identical to those of all SSRI’s:

Antidepressant
Anti-anxiety (Paxil has a specific indication for treating social anxiety disorder but it is beneficial in many other anxiety disorders as well.)
Treatment of obsessive compulsive (OCD) and related disorders, often reduces irritability related to depression and anxiety

Typical Dose

Most people on Paxil take 10 to 40mg but it can be as high as 60 or 80 mg per day or up to 75 mg for Paxil CR (controlled release). Your doctor will work with you to determine an effective dosage.

Potential Side Effects

Like most medications in its class, Paxil can potentially cause any of several negative side effects. The most serious are the following:

Increased suicidality in children or teens: Clearly there is an increased risk of suicide and suicidal thinking in people with bipolar and depression as a whole. A large review of studies done on children and adolescents who were treated with antidepressants showed that there was a slight increase in the risk that these children would develop suicidal thoughts, compared to children taking placebo. Even with the increased risk, the rate of this side effect remains very, very low. These medications are far more likely to decrease the risk of suicide than to increase it. Careful monitoring and communication with the prescriber, especially early on in treatment with SSRI’s is essential in reducing this risk as much as possible.
Increased risk of mania: As mentioned earlier in this post, a person with bipolar disorder taking an antidepressant without the protection of a mood stabilizer appears to be at higher risk of shifting into mania or hypomania. While there is some indication that some antidepressants have less risk of manic switching, the risk remains present in all antidepressants. The rate of switching and the actual level of risk is not clear at this time – some researchers suspect it is very high and others feel it is actually much lower than is generally presumed.
Agitation, increased anxiety, or worsening depression or other paradoxical effects: This is not the same as a true manic switch, and can occur in people with or without bipolar disorder who take SSRI’s. In a small group of people, these medicines seem to irritate the brain wiring rather than soothe it. This appears to be more common in children and adolescents, but can occur in a subset of adults as well. Close monitoring with your prescriber will be important in detecting this.
Serotonin syndrome: When combined with medicines used to treat migraine headaches known triptans, such as sumatriptan (Imitrex), or other drugs that elevate brain levels of serotonin (including the illegal drug Ecstasy), a life-threatening condition called serotonin syndrome can occur. Symptoms include restlessness, hallucinations, loss of coordination, racing heart, increased body temperature, blood pressure fluctuations, overactive reflexes, diarrhea, nausea, vomiting, coma, and possibly death.
Persistent pulmonary hypertension of the newborn (PPHN): There are studies showing that babies born to mothers who were taking SSRI’S in the third trimester of pregnancy have an increased likelihood of this condition. Babies born with PPHN have restricted blood flow through their heart and lungs, reducing the supply of oxygen to their bodies. This can make them very ill and increase their risk of death. If you’re pregnant or planning to become pregnant, consult with the doctor who’s managing your medications.

Other less serious side effects can include the following (Note: Many of these side effects are transient and occur when first taking these medications but do not persist.):

Sweating
Sleepiness
Insomnia
Nausea
Diarrhea
Tremor
Dry mouth
Loss of strength
Headache
Weight loss or gain
Dizziness
Restlessness
Mania
Changes in sexual function

Remember: Any antidepressant can take 2-3 weeks or even longer to become fully effective; it may take several weeks to work up to a therapeutic dose. This means that your depression may not lift for several weeks. I often tell patients that however they feel in the first two weeks is unlikely to be how they feel in a month – so if they are feeling some early side effects, hold on because they will likely get better. Patience is important in getting these medications to work, but if you have any concerns about how you are feeling, you should contact your doctor. You will most likely have a follow-up visit with your doctor within a month or less of starting the medications; this is a good time frame for checking in to see if benefits have started or if side effects have faded or persisted.

Paxil has a reputation for causing more sedation and weight gain than the other SSRI’s. In my practice, I have certainly seen evidence of this, However, Paxil is a powerful and effective antidepressant and anti-anxiety medication, and I do use it frequently. Paxil has a specific FDA indication for social anxiety, and I have found it to be extremely helpful in people with this condition – even with severe symptoms. Social anxiety can co-exist with bipolar disorder.

I avoid using it first line in children, primarily because it was one of the first SSRI’s that was found to have some increased risk of suicidal thoughts in children.

For more about Paxil, visit GlaxoSmithKline’s PaxilCR page.

If you’ve taken any form of Paxil for bipolar depression or are a doctor who has prescribed it, please share your experiences, insights, and observations.

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Links to This Article

From Psych Central's Dr. Candida Fink & Joe Kraynak:
Bipolar Disorder Medication Spotlight: Effexor (Venlafaxine) | Bipolar Beat (May 19, 2009)

5 Comments to
“Bipolar Disorder Medication Spotlight: Paxil (Paroxetine Hydrochloride)”

michael at 7:07 am on February 23rd, 2009

“These medications are far more likely to decrease the risk of suicide than to increase it.”

Umm, if that were true wouldn’t the clinical trials have shown a *decrease* in suicidality in the SSRI group compared to the placebo group instead of a 50-250% *increase*?

And if that is true, exactly what was the the reasoning behind the UK MHRA decision to ban the use of Paxil for under 18s?
http://www.bmj.com/cgi/content/extract/326/7402/1282-b

Jim at 8:05 pm on February 26th, 2009

Years ago I took Paxil to treat depression and had severe anxiety attacks while taking the medicine. Once my partner helped me to recognize the anxiety attacks (I would usually black out and not remember them) I brought this to the attention of my doctor. It appears that there is not a “known” side effect of anxiety for Paxil, but I have talked to a number of other Paxil users who stopped taking it for this reason. I have since switched medications to another SSRI without the panic attacks but anytime I mention Paxil and anxiety attacks to a psychiatrist or therapist, they’ve never heard of the two. Just my two cents.

Candida Fink MD at 1:39 pm on March 6th, 2009

Hi, Michael–

When studies of SSRI’s were reviewed in a large meta-analysis, researchers found that participants who did not have suicidal thoughts at the time they started taking the medication were twice as likely to develop some type of suicidal thoughts or ideation after they started the SSRI. There are a number of important points here:

These were patients without suicidal thoughts before starting the meds.
The phenomenon that showed an increased frequency was suicidal thinking, not completed suicides.
The number of people developing new suicidal thoughts on the meds or on placebo was low in both groups, but slightly higher in the medication group.
The studies were not designed to rate frequency of suicidal thinking.
The definition of suicidal thoughts and thinking varied greatly from study to study and reviewer to reviewer.
There were no completed suicides in the studies that were reviewed.

Many people with depression and/or anxiety are already exhibiting suicidal ideas and possibly behaviors when they start these medications. These symptoms are relieved and suicide frequency is reduced for many people whose symptoms are relieved with the SSRI’s – far bigger percentages than the number of people who develop new suicidal thoughts when on these medications. The risks of under treating, based on exaggerated claims of suicidal thinking on these medications, is significant.

Jay Dennis at 12:38 am on March 7th, 2009

Is it dangerous to take Paroxetine and Lithium Orotate together? I have been on Paxil for years, but I would like to add Lithium Orotate to help my memory. I’m 77 years old.
Thanks,
Jay

Gunersonian at 11:24 am on June 1st, 2009

I have taken Paxil twice in my lifetime, when my anxiety attacks were so bad I couldn’t drive and they were ruining my life. I have to say that Paxil did wonders for me. I did gain a little bit of weight, which was a bummer, and that and being tired are the major reasons I stopped. But I had to say that the only bad side effect for me was the weight gain. Otherwise, I love Paxil.