With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. Over the past weeks, we covered several commonly used atypical antipsychotics, including Zyprexa (olanzapine), Risperdal (risperidone), and Seroquel (quetiapine). This week, we turn our attention to antidepressants, specifically the SSRI (Selective Serotonin Reuptake Inhibitor) variety. Medications in this class include:
Although each of these medications has unique properties and may be more or less effective in the treatment of a particular individual, they have similar profiles in terms of potential benefits and drawbacks:
First released in 1987, Prozac (fluoxetine is the generic) is the “granddaddy” of the SSRI’s. It has a long history of use and a solid track record of safety and efficacy. It is often my first choice when we have decided to use an SSRI for depression and/or anxiety symptoms. On a practical level, it is easy to dose – there aren’t a lot of in-between dose changes to make, and it is generally quite well-tolerated. The biggest potential downside is that is takes longer to work. But it also stays in your system longer because it has a longer “half life” in the blood, so there tend to be few withdrawal effects from either missing a dose or stopping the medicine altogether. Depressive symptoms can recur when a person stops taking fluoxetine or any other SSRI, but that is not the same as withdrawal.
Although mania grabs all the headlines, the recurrent and severe depressive episodes experienced by people with bipolar disorder are typically the most devastating and dangerous of the cycles. Mania and hypomania don’t typically trigger a visit to the doctor, while depression will more likely generate help-seeking behaviors., This often means that antidepressants will be the first medications considered.
Unfortunately, if bipolar is involved, an antidepressant taken without the protection of a mood stabilizer can induce mania and worsen the course of the illness. Because of this, if you (or your doctor) have any suspicions that your depression is actually part of a bipolar disorder, , you and your doctor will discuss the possibility of taking a mood stabilizer first (preferably one that controls depression as well as mania, such as lithium or Lamictal). If the mood stabilizer controls the depression, you’re in luck. If not, antidepressants may be added to the mix, with less risk of “manic switching.”
Several recent studies have suggested that it is not clear whether antidepressants work very well in bipolar depression. If someone is placed on antidepressants for bipolar depression, it is not clear at all how long they should stay on these meds. Some studies have indicated that long-term use of antidepressants in bipolar disorder makes things worse. But none of these findings are iron clad, because the studies often don’t distinguish between Bipolar I and Bipolar II; people with Bipolar I may respond very differently to antidepressants than do people with Bipolar II. In everyday practice antidepressants are used frequently in people with Bipolar II but less often in people with clear Bipolar I.
How does an SSRI work?
Serotonin is a neurotransmitter – a chemical in the brain that carries signals between synapses (gaps between nerve endings or brain cells). Neurotransmitters are sort of like email, enabling cells inside the body to communicate with one another.
The human brain has many different neurotransmitters, each of which specializes in certain operations, including cognition, memory, physical movement, immunity, and mood. Serotonin helps regulate mood, anxiety, sleep/wake cycles, sexual behaviors, and other brain functions.
Neurotransmitters work by moving from one brain cell (neuron) to another – through a space called the synapse. After the transmitter is used by the second neuron, the first neuron sucks it back up and breaks it down. SSRIs prevent the first neuron from absorbing and breaking down serotonin after its use, thus increasing its concentration in the synapse between neurons. This increased level of serotonin lessens symptoms of depression and anxiety for many people, although how that actually happens is still not clear.
Most people on Prozac take 20 to 80 mg once a day. Your doctor will work with you to determine an effective dosage.
Like most medications in its class, Prozac can potentially cause any of several negative side effects. The most serious are the following:
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.)
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.
For more about Prozac, visit Eli Lilly’s Prozac page.
If you’ve taken any form of Prozac for bipolar depression or are a doctor who has prescribed it, please share your experiences, insights, and observations.
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Thank you so much for sharing your expertise. My daughter was diagnosed with bipolar a few years ago and after over 15 combinations of medications she is stable and enjoying her life. We are writing a book together on her experience (and mine as a mother). At one point in the midst of a huge suicidal ideation and hospitalization she told me that illegal drugs seemed to be a better choice because the drugs the doctors were giving her had twice almost killed her. It takes immense strength and support for a young person to make it through this maze when diagnosis and treatment so often takes awhile. Her doctors hung in there as did family and friends. Thank you to your profession! I teach about mental health conditions to graduate students but living it is a different matter. MH doctors are the best!
Cinda (www.lineacinda.com)
Great information regarding medication treatment for depression. It is good to know that these drugs are given to manage depression. But it is also sad to know that abuse and long term use may have a side effects to our body. That’s why many researchers now conduct studies for natural remedies for depression management.
I have Bipolar II, and I can’t take Prozac or Wellbutrin. Both meds throw me into hypomania, but I tolerate other SSRIs fairly well.
After recovering from a bone marrow transplant for leukemia, I kept getting pneumonia. When I asked why I was so tired all the time, I was put on Prozac. I called it Cleanzac, since I was up at 3 a.m. cleaning night after night. I went off it but still had the lack of energy so I was put on Paxil. When I stopped sleeping and had hand tremors, the doctor doubled the dose. I became extremely manic. I checked myself in to the hospital and was put on lithium for bipolar. Eventually I was diagnosed with pulmonary fibrosis caused by chemo.
Mania triggered by anti-depressants is not the same as mania. Physical depression cause by disease in not the same as depresssion. It is easier to write a prescription that ask a few questions.
Hope no one else has to go through this.
The cocktail of meds that has worked best for me personally (and the one I am on currently) is a combination of lamictal, prozac, and adderall (I’m ADHD as well). It’s difficult finding medications that will work well together when you have bipolar disorder and ADHD, because certain medications by themselves will treat one disorder, and amplify the other, and totally throw me off balance. It took a long time to find stuff that worked well, but I think lamictal is probably what helped me the most.
I have a significant other who was taking Prozac through a bipolar study program. He has recently either been removed from the program or quit it and has abruptly stopped taking his meds without consult of a doctor. I can tell his depression has relapsed back in and he seems incapable of functioning well. I was wondering what some of the side effects of abruptly quitting Prozac were. I would like to know all I can about how to deal with this.
i have bipolar I with rapid cycling..i take prozac and lithuim..i seem to be doing ok…is there anyone else who takes a combination like this..my new doctor is afraid to keep me on this..
hey i have bipolar as well im only 17 and i got diagnosed 15 months ago.. I am on a combination of lithium, serquel, imovane and now they want to add prozac due to panic attacks will this help