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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by CK1 on March 9, 2005, at 19:54:31
Hi all,
I was given Paxil for anxiety 3 years ago and it worked great for a few years but quit working in January. I have since tried Effexor/Zoloft and they have done nothing besides make me feel worse. Has anybody ever had a really good experience on an SSRI only to have it "poop out", then you go on the SSRI "merry go round" and nothing works?
Well, this is a very good sign that you might have "Soft Bipolar Disorder" which is only improved with the addition of a mood stabilizer: depakote, lamictal, etc. In these cases, SSRI's and Stimulants can make you worse if a mood stabilizer is not added to your treatment. Hmmmmmm....It never occured to me that this could be a reason that I relapsed after feeling "soooo good" this summer.Read this:
After you try a series of antidepressants and they don't work or they do but "poop out" (which itself has been suggested represents a "soft sign" of bipolar disorder), a new strategy is worth considering anyway, namely a "consider possible bipolarity" strategy whether there are obvious symptoms to support the diagnosis, or not. Some people also think that obviously recurrent "unipolar" depression is a "bipolar" phenomenon simply missing the other pole, just as there are (about 10%, I believe Dr. Mauricio Tohen's work has shown) people with obvious manic episodes, thus clearly "bipolar", who never have depressed episodes, only the "one pole".A leading bipolar researcher, associated with Harvard, has also noted this association between "Prozac Poop-out" and bipolar disorder. He states there that transient antidepressant response ("poop-out," meaning acute improvement but later relapse) is a "soft sign" of bipolar disorder, not diagnostic in itself but suggestive. So, I think you could say there are 3 reasons to try treating you as though you have bipolar disorder: the "it's time for a new strategy" reason; the poop-out reason; and the recurrent unipolar reason above -- all even if you never had a symptom of hypomania at all. suggesting that your "recurrent unipolar" is a bit farther over toward bipolar than the pure unipolar end of the spectrum as your treatments thus far have been based upon. The good news in all this is that there may be some nifty treatment options for you when you look at mood stabilizers. Note that even old lithium has been used as an add-on to partially effective antidepressant treatment with good results in many studies -- so you don't even have to invoke "bipolar" to try that one!
Depression that doesn’t respond to antidepressants (or gets worse, or "poops out")
Many people have repeated episodes of depression. Sometimes the first several episodes respond fairly well to antidepressant medication, but after a while the medications seem to "stop working". For others, no antidepressant ever seems to work. And others find that some antidepressants seem to make them feel terrible: not just mild side effects, but severe reactions, especially severe agitation. These people feel like they’re "going crazy". Usually at this time they also very poor sleep. Many people have the odd experience of feeling the depression actually improve with antidepressants, yet overall —perhaps even months later —they somehow feel worse overall. In most cases this "worse" is due to agitation, irritability, and insomnia. In some cases, an antidepressant works extremely well at first, then "poops out". The benefits usually last several weeks, often months, and occasionally even years before this occurs. When this occurs repeatedly with different antidepressants, that may mark a "bipolar" disorder even when little else suggests the diagnosis.
Posted by Phillipa on March 9, 2005, at 20:06:56
In reply to Relapse or Poop Out -- Soft Bipolar Disorder, posted by CK1 on March 9, 2005, at 19:54:31
That's very interesting CKl. So, then, a lot of us are really bipolar and don't know it. I wonder why the pdocs don't seem to know this. In that case we all need mood stabilizers. I will be interested to see what some of our med "experts" have to day. Thanks for the info. Fondly, Phillipa
Posted by med_empowered on March 9, 2005, at 20:41:38
In reply to Re: Relapse or Poop Out -- Soft Bipolar Disorder » CK1, posted by Phillipa on March 9, 2005, at 20:06:56
Hey! As Bipolar I or NOS (depending on which shrink you ask) I found this very interesting. However, I also wanted to suggest that maybe there's another way to handle this...instead of expanding the "bipolar spectrum" to include those with prozac poop-out, perhaps psychiatrists should simply recognize that mood-stabilizers can be very beneficial to people who don't meet the criteria for Bi-polar I/II or cyclothymic disorder. I have friends with treatment-resistant depression who responded amazingly well (and, thankfully, QUICKLY) to the addition of Lamictal and Lithium to their regimines...suddenly anti-depressants that had never worked did work reasonably well, and their emotions and their lives were more balanced. These 2 people did not meet any criteria for bipolar, but still responded well to mood-stabilizers. In addition, some researchers have found that mood-stabilizers can be enormously beneficial to schizophrenics, even those (or esepcially those) labelled "treatment resistant." Here, we're dealing with hardcore, chronic schizophrenia that in the past would have been dealt with by using higher and higher doses of anti-psychotics, all in the hope that maybe something would "click" at some point. Now it seems that it may be possible to treat some cases of schizophrenia with the low-end doses of anti-psychotics and additional treatment with lithium, depakote, and/or lamictal (these are the 3 I've read about being used in schizophrenia; I imagine other mood-stabilizers could be used as well). Then of course there are people with incredible levels of anxiety that are helped by off-label mood-stabilizers...here, people who in the past might either be given huge amounts of benzos that could interfere with their quality of life, OR not given enough benzos by docs afraid of "addiction" are being treated with medication that is generally safe, reasonably well-tolerated, and effective in the long haul. Benzos, of course, could still be used, but they can be used at lower doses so there are fewer side-effects. Anyway, I think it's sad that psychiatrists seem to be neglecting potential uses for mood-stabilizers while at the same time atypical anti-psychotics are being RX'd for all kinds of conditions.
Posted by CK1 on March 9, 2005, at 20:53:35
In reply to Expanding understanding of Bipolar, posted by med_empowered on March 9, 2005, at 20:41:38
My aunt went through 5 different SSRI's and nothing worked. Her doctor put her on a mood stabilizer and Effexor at the same time and now she's "back" to being her old self. Could be coincidence, but I think the addition of the mood stabilizer improved her response to Effexor. Without the mood stabilizer, Effexor might have had no affect like all the other SSRI's she tried.
Who knows....just seems like an interesting topic for those of us not responding to SSRI's or feeling worse on them.
Posted by theo on March 11, 2005, at 9:58:20
In reply to Re: Expanding understanding of Bipolar, posted by CK1 on March 9, 2005, at 20:53:35
What mood stabilizer was she taking?
Posted by JaneB on March 11, 2005, at 12:15:29
In reply to Relapse or Poop Out -- Soft Bipolar Disorder, posted by CK1 on March 9, 2005, at 19:54:31
Posted by CK1 on March 11, 2005, at 12:40:02
In reply to Re: Expanding understanding of Bipolar » CK1, posted by theo on March 11, 2005, at 9:58:20
She's taking Depakote. Lamictal's a more widely prescribed, newer, and supposedly (better) drug with less side effects, however.
Posted by SLS on March 11, 2005, at 12:50:48
In reply to Expanding understanding of Bipolar, posted by med_empowered on March 9, 2005, at 20:41:38
I was under the impression that mood-stabilizers were of little utility in the treatment of schizophrenia.
- Scott
Posted by Ritch on March 11, 2005, at 13:24:21
In reply to Relapse or Poop Out -- Soft Bipolar Disorder, posted by CK1 on March 9, 2005, at 19:54:31
>>Hi all,
I was given Paxil for anxiety 3 years ago and it worked great for a few years but quit working in January. I have since tried Effexor/Zoloft and they have done nothing besides make me feel worse. Has anybody ever had a really good experience on an SSRI only to have it "poop out", then you go on the SSRI "merry go round" and nothing works?
Well, this is a very good sign that you might have "Soft Bipolar Disorder" which is only improved with the addition of a mood stabilizer: depakote, lamictal, etc. In these cases, SSRI's and Stimulants can make you worse if a mood stabilizer is not added to your treatment. Hmmmmmm....It never occured to me that this could be a reason that I relapsed after feeling "soooo good" this summer.Hi, interesting read. Yes, I believe there is a large group of people with affective disorders who aren't clearly bipolar.. whose experience with the newer drugs such as SSRI's *uncovers* or possibly *induces* bipolar "symptoms". I wouldn't necessarily feel certain that SSRI's could CAUSE bipolar disorder, but I definitely think that SSRI's can "turn up" bipolar in some people. Anyhow, to get to my subject line tangent.. I notice that when I get SSRI induced hypomanic symptoms (the euphoric good stuff) it seems that I find everything funny and it is like I'm stoned on weed or something and have difficulty suppressing laughter and giggling. What's really weird is that I can "hear" this particular type of giddy laughter in OTHER people that aren't "bipolar", and sure enough they have been put on an SSRI after some crisis, breakup, death in the family, whatnot, and they are still on them, and their PERSONALITY is different in that particular respect afterwords (and their personality wasn't "bad" prior). Just wondering if anyone had any comment about this type of phenomenon... Hypomania? Just a nice side effect of the SSRI? Benign? ?
Posted by CK1 on March 11, 2005, at 15:28:13
In reply to SSRI's ? giggle-pill hypomania? » CK1, posted by Ritch on March 11, 2005, at 13:24:21
Ha. Interesting. When I was put on Paxil, I never felt better in my life. I've heard that SSRI's can actually trigger "hypomania" (mild mania) in people with Bipolar that never even experienced up's or down's before. Or, it could simply be the antidepressant effect and be perfectly normal. There are obviously VERY different degrees of bipolar. Some people think they are messiah's sent from Heaven to save the human race, and there are others, like me, who just felt soo good, laughed at everything, partied all night, never got tired, etc. Heck, I always thought (until my doctors appt earlier this week) that I just had a simple case of depression/anxiety, but, now, I'm beginning to think otherwise. When someone goes to the doctor for "simple" depression, the first line of treatment is to give an SSRI. In my case, it worked (for a few years). If that SSRI doesn't work, you try another. But, after trying 3-4 different SSRI's and nothing works (or they make you more irritable and nervous), there NEEDS to be a change in strategy and many doctors are now becoming more aware of the "subsyndromal" symptoms of bipolar, meaning no clear cut symptoms. My point is, if you've tried 3-4 diff SSRI's (even if one worked for you for a long time) and they aren't cutting it anymore, think about trying mood stabilizers and adding them to whatever regime you have. In my opinion, SSRI "Poop Out" (could) be caused by a bipolar cycle you never knew existed and, if thats the case, no SSRI will work! We are all trying so hard to find "the solution" for why our beloved SSRI just "stopped working" when maybe adding a mood stabilizer to it is all we needed to keep the SSRI working indefinitely. Who knows....just food for thought!
Posted by med_empowered on March 12, 2005, at 10:45:37
In reply to Re: SSRI's ? giggle-pill hypomania? » Ritch, posted by CK1 on March 11, 2005, at 15:28:13
Hey! The anti-depressant induced mania+ other problems interest me. Apparently, there's no clear-cut answer as to whether or not anti-depressant induced mania is bipolar, a variant of bipolar, or just a drug side-effect. My old shrink (I had a number of friends with the same doc) labelled ever anti-depressant induced mania/hypomania a sign of bipolar II, and medicated accordingly. My current shrink, who is older and has been practicing longer, takes a different view. Her view seems to be that the mania/hypomania should first be regarded as an adverse drug reaction; once the initial problem has subsided, she tries to reserve judgement for a while. Sometimes, there does appear to be an underlying bipolar-ish problem, though I think she said she usually considers it cyclothymia. I don't know which approach I like more; on the one hand, you shouldn't be too cautious about DXing BP; on the other hand, calling all these reactions a sign of BP ignores the fact that antidepressants are powerful meds that are bound to have side-effects...with tricyclics, for instance, it has long been noted that some people who have never had psychosis before may well experience psychotic symptoms as a result of med exposure...since the psychosis subsides after drug withdrawal, these people are not labelled as having a "psychotic disorder,"; rather, it is considered a "drug-induced psychosis," akin to what is seen in high-dose stimulant users (and sometimes people RX'd therapeutic doses of stimulants, too).
Posted by Ritch on March 12, 2005, at 11:52:26
In reply to Re: SSRI's ? giggle-pill hypomania? » Ritch, posted by CK1 on March 11, 2005, at 15:28:13
>>.. My point is, if you've tried 3-4 diff SSRI's (even if one worked for you for a long time) and they aren't cutting it anymore, think about trying mood stabilizers and adding them to whatever regime you have. In my opinion, SSRI "Poop Out" (could) be caused by a bipolar cycle you never knew existed and, if thats the case, no SSRI will work! We are all trying so hard to find "the solution" for why our beloved SSRI just "stopped working" when maybe adding a mood stabilizer to it is all we needed to keep the SSRI working indefinitely. Who knows....just food for thought!
I agree generally with what you are saying. I definitely think that "cycling" depressions do look very suspiciously like bipolar. The cynic in me might say something like this however.. "uh oh, the new cash cow for the pharm industry.. expensive mood stabilizers for the citizenry to the rescue". Just a thought.. a lot of times where the money is happens to be where the efficacy suddenly happens. The science needs to get done and not with the carefully contrived studies the drug. mfg. can cook up. Depakote and Lamictal (i.e.) aren't cheap and both have black-box warnings. It would be nice to not have to take a drug that is not very liver-friendly or that can cause a life-threatening rash. I'm stuck.. can't take lithium and I get bad EPS from antipsychotics, so it's Depakote for me. So far no trouble with liver panels, but I still don't like that potential lingering in the background... There needs to be a couple of new ones that are effective *and* safer antimanics.
Posted by CK1 on March 12, 2005, at 12:44:32
In reply to Re: SSRI's ? giggle-pill hypomania? » CK1, posted by Ritch on March 12, 2005, at 11:52:26
I understand what you're saying. The trials these large companies have to go through for FDA approval "could" be very one-sided, in their favor.
The "life threatening rash" you mentioned IS very scary and has caused many people to stay away from it. BUT, it's extremely uncommon (1/1000) AND, if you do, however, get "the rash", there are many clear signs (flu, fever, tongue swelling) that occur before it becomes serious. If you notice these symptoms, simply stop the drug, and try something else. What's scary is 1/10 people get a "harmless rash" which looks like bug bites. For those who don't know the diff bt the harmless rash and the deadly rash, it's very scary. I'm surprised you started Depakote before Lamictal. Depakote is "supposed" to have many more side effects and you have to get liver function tests (lamictal you don't).
But, you make a good point, all this trial and error (on what's supposed to help), makes the process more complicated, and more dangerous.
Posted by Ritch on March 12, 2005, at 14:45:26
In reply to Re: SSRI's ? giggle-pill hypomania? » Ritch, posted by CK1 on March 12, 2005, at 12:44:32
> I understand what you're saying. The trials these large companies have to go through for FDA approval "could" be very one-sided, in their favor.
> The "life threatening rash" you mentioned IS very scary and has caused many people to stay away from it. BUT, it's extremely uncommon (1/1000) AND, if you do, however, get "the rash", there are many clear signs (flu, fever, tongue swelling) that occur before it becomes serious. If you notice these symptoms, simply stop the drug, and try something else. What's scary is 1/10 people get a "harmless rash" which looks like bug bites. For those who don't know the diff bt the harmless rash and the deadly rash, it's very scary. I'm surprised you started Depakote before Lamictal. Depakote is "supposed" to have many more side effects and you have to get liver function tests (lamictal you don't).
> But, you make a good point, all this trial and error (on what's supposed to help), makes the process more complicated, and more dangerous.
I started Depakote back in 1998 as a switch from lithium which (probably) triggered my hypercalcemia (high blood calcium). I don't think Lamictal was on the radar screen for bipolar just yet at that time. My pdoc is afraid of the rash more than I am, that's partly why I've never tried it. Oddly enough, I think that a combination of Depakote *and* Lamictal (at low doses) would probably work rather well, but that's the riskiest drug to combine with Lamictal unfortunately. Also, I need a STRONG antimanic agent, and Lamictal just doesn't show very strong antimanic effects for most people. Trileptal is probably the safest mood stabilizer to use for most people, but I can't handle the nausea from it without taking something else for the nausea, etc. Trileptal actually works even better for irritability than Depakote for me.To not get too far off track.. there is basically a split right now as far as opinion goes to using antidepressants in people with bipolar (or suspicious possible hidden bipolar you brought up). Some feel that you shouldn't use ANY antidepressants-they just make you worse. Others feel that if you use AD's with antimanics it's "ok". What if using *any* antidepressants is what is creating a self-sustaining relapse or self-sustaining recurrence of these type of "soft-bipolar" depressions?
This is the end of the thread.
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