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Bipolar Disorder

UNDERSTAND AND PREVENT BIPOLAR DISORDER

 

This course is about a mood disorder that is so commonly discussed in the media of late-bipolar disorder. Although this disorder is not as common as depression, the number of bipolar disorder diagnoses appears to be rising, mainly because of new research and consideration of symptoms that do not meet the full criteria for bipolar but do have many similar symptoms that cause significant impairment. Such symptomatology may comprise other bipolar categories that are considered part of the “bipolar disorder spectrum.” 

(36) Bipolar Disorder

Bipolar Overview

BIPOLAR DISORDER AND SEX ADDICTION

BD35

Will I become addicted to the medication?

The one major concern for many patients who take psychotropic medications for years is the fear that they will become addicted to or dependent on their medication. Addiction is a complicated and controversial issue that bears some explaining. From a psychopathological  or medical standpoint, addiction is defined as the pursuit of a substance in such a manner that the pursuit and use of it consumes so much time and energy for the person that he or she excludes the majority of, if not all, other important activities in his or her life. By that definition, anything that gives pleasure causing pursuit of it with abandon is potentially addictive-from gambling to sex to drugs to even the Internet and all variations on those themes. By that simple definition, no medication for the treatment of bipolar disorder other than the rare possibility of benzodiazepines, which are generally limited in use for that reason, has proven to be addictive.

Many people do, however, become physiologically dependent on various prescription medications, and this is where confusion reigns. Dependency has many definitions, which further confuses the picture. It is seen as a pejorative term, akin to addiction. But one confuses the concept of dependency as defined by the DSM-IV-TR with two other concepts, one being the dependency one has on any medication to treat achronic illness that will flare up if the medication is stopped (e.g., diabetes, heart disease, or epilepsy as well as bipolar disorder); the other being that if one takes a medication chronically, then suddenly stops it and experiences withdrawal symptoms, he or she must be dependent on the medication. Dependency, instead, is more strictly defined in the DSM-IV-TR and is more akin to the previous description of addiction than the misunderstanding of the lay concept. There are two major criteria, the first being an emphasis on ever-increasing use in order to achieve a desired effect, known as tolerance; the second being that the concept of withdrawal includes both physiological and behavioral manifestations and is important in terms of the maintenance of the addictive behavior. This definition is very specific and as a result any physiological withdrawal symptoms that develop from the immediate cessation of a medication do not meet the definitional requirements of substance dependence unless they are accompanied by the other definitional criteria. This causes no end of confusion to both clinicians and the general public.

For example, the most obvious drug that people think about in terms of dependency includes most of the prescription pain medications that are called opiates (heroin is an opiate and was developed because it was thought to be nonaddictive). Everyone who takes these medications on a regular basis will develop some amount of withdrawal symptoms if they stop them abruptly. However, not everyone escalates their use of these medications over time, nor do they engage in reckless behavior in pursuit of the drug as the result of experiencing withdrawal symptoms. Because a druglike an opiate can make one high, is often pursued with abandon, and does cause dependency, people often mistake these two very different notions as one and the same.

Additionally, many medications that do not lead to addiction can cause physiological withdrawal. Many anticonvulsant medications, antihypertensive medications, and all steroid medications cause withdrawal, but no one would ever consider these drugs addictive. In stark contrast, many hallucinogens and stimulants do not cause any measurable physiologic changes in the body that one could absolutely label withdrawal, and nevertheless these are some of the most highly addictive substances known to humans. Where do antimanic agents, antidepressants, and other psychiatric medications fit on this continuum? Some antimanic agents are associated with various withdrawal syndromes, such as the possibility of a withdrawal dyskinesia, a transient movement disorder, associated with the abrupt withdrawal of a typical antipsychotic agent. Most antidepressants cause some level of physiologic dependency, especially the tricyclic antidepressants. Any drug, whether prescription medication or street drug, that causes a withdrawal syndrome must be tapered over time, or one risks developing withdrawal. In fact, three types of discontinuation syndromes can occur when you stop a medication that you have been taking regularly for a significant period of time: withdrawal, rebound, and recurrence. Withdrawal occurs when a drug or medication is abruptly stopped. It is accompanied by clear physiologically measurable changes, including vital sign changes, skin color and temperature changes, and psychological distress. For some drugs, such as benzodiazepines, this can be a life-threatening emergency. For this reason, you must always consult a physician when deciding to discontinue a medication to see whether such a withdrawal could occur. Rebound occurs when the symptoms for which one was receiving the medication become transiently worse than the symptoms one had before treatment. This is a potential risk for any sleep medication from which rebound insomnia can be very severe. However, this is a transient effect and abates within days. Unfortunately, most people do not realize that rebound is expected and transient, and they immediately go back on their sleeping medications.

Rebound generally is not accompanied by any physiologic changes. Recurrence is simply the return of symptoms for which one originally received the medication. Recurrence is more delayed in the timeline after stopping a medication than either withdrawal or rebound. Typically, if you begin to experience symptoms as early as a few days after stopping antidepressant medications, these actually represent rebound or minor withdrawal (no measurable physiologic changes) that is commonly known as a discontinuation  syndrome. Rarely is it caused by recurrence. This is why it is a good idea to taper the medications. When the medications are appropriately tapered, any symptoms that return can properly be attributed to recurrence, and thus increasing the medication back to a therapeutic dose may be a wise choice. In summary, clearly, although many psychotropic medications can cause various discontinuation syndromes, they are not addictive. I know that I am not physically addicted to my medication, although I also know that if I were to go off of any of it I would have to do it slowly so that my brain chemistry could adjust to the changes. I do, however, know that I am dependent on the medication and it is frightening to think what might happen and how I would end up feeling if I didn’t take it for a prolonged period of time. That fear makes me dependent but I also believe that being on the medication is like treating any other biologically-based illness: It is necessary to remain healthy.

Terms:

Addiction - continued use of a mood-altering substance despite physical, psychological, or social harm. It is characterized by lack of control in the amount and frequency of use, cravings, continued use in the presence of adverse effects, denial of negative consequences, and tendency to abuse other mood-altering substances.

Dependence - the body’s reliance on a drug to function normally. Physical dependence results in withdrawal when the drug is stopped suddenly. Dependence should be contrasted with addiction.

Dyskinesia - an impairment in the ability to control movements

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(37) Bipolar Disorder

My Story: Bipolar Disorder

 BD351

Will I gain weight from the medication?

Weight gain is a very real concern for most patients. Unfortunately, the majority of medications used to treat bipolar disorder have some degree of weight gain associated with them. Both lithium and Depakote (valproate) are associated with weight gain, the mechanism of which is not understood. The weight gain from Depakote (valproate) may be associated with polycystic ovarian syndrome, but mostly it occurs independently of the condition. Weight gain from the anticonvulsants may not occur in everyone, so it need not immediately rule out a potentially effective treatment. It is important to maintain good nutrition and healthy eating habits, as well as partake in regular exercise, to help offset the weight gain risks. Being cognizant of any appetite-inducing effects of the medicine can help you resist urges to eat more as well. Of the atypical antipsychotics, Geodon (ziprasidone) and Abilify (aripiprazole) appear to have the least overall risk for weight gain, while Clozaril (clozapine) and Zyprexa (olanzapine) appear to have the highest risk. Aside from obesity, there is the associated risk of metabolic syndrome with atypical antipsychotics as well. Anticonvulsants with lower risk for weight gain include Lamictal (lamotrigine) and Topamax (topiramate), although topiramate does not have FDA approval for bipolar disorder. Topamax (topiramate) has also been studied independently as a potential weight loss agent and has been reported to reverse the weight gain caused by other agents.

In terms of the antidepressants, the older antidepressants have been classically associated with weight gain (tricyclics, monoamine oxidase inhibitors).When the SSRIs first entered the market, they were believed to have no associated weight gain as a group, and some even were found to cause weight loss (e.g., Sarafem [fluoxetine]). Keep in mind that side-effect profiles are typically developed from the early studies of medications, which are conducted over the short term (i.e., several weeks). In clinical practice, however, many physicians have found that SSRIs can be associated with weight gain over the long term. Although clinical trials have typically found that weight gain does not differ significantly from placebo, uncontrolled studies have noted weight gain over the long term. Paxil (paroxetine) appears to be more associated with weight gain clinically than the other SSRIs. Celexa (citalopram) has been reported to have early weight gain. There may be an increase in carbohydrate craving associated with SSRIs as a possible mechanism.

Bupropion is one antidepressant that does not have weight gain associated with it and can be considered as one treatment option. More long-term controlled studies are needed to compare weight gain over time between antidepressant users and those who are not. Keeping in mind the potential for weight gain, good nutrition and exercise should be part of the treatment with antidepressants as well.

Ultimately, the risk for weight gain needs to be balanced against the risk for untreated bipolar disorder. Close monitoring of weight and vigilant efforts to prevent the initial weight gain can be very effective in limiting the amount that is gained. Weight gain on one agent does not necessitate the same on another agent, so different trials may be needed as well.

How long will I have to stay on medication?

It is important to understand that medications for bipolar disorder are used for treatment of the acute illness as well as to maintain remission of the illness. Remission may be partial or full, full remission occurring when there are no longer any symptoms. An acute manic episode is typically brought under control more quickly than an acute depressive episode. Full remission of symptoms, however, does not mean it is time to stop the medication. Many people stop their treatment prematurely because they either feel better or are experiencing side effects. It may be thought that the medication is not needed anymore or even questioned whether the medication had anything to do at all with the improvement (particularly if there were no side effects). Close monitoring by your doctor can help to address questions of efficacy as well as to provide the feedback as to level of improvement. When medication is discontinued prematurely, a relapse or recurrence is likely to occur soon thereafter. A relapse occurs if there is a return of symptoms of your previous episode within the period of time known as remission, which is within six months of resolution of symptoms.

Recurrence occurs if the symptoms of either depression or mania return during the period of recovery, which is after six months of remission. Statistically speaking, after remission of either a manic or depressive episode, there is highest risk for recurrence within the first year.While the standard recommendation following one major depressive episode (unipolar) is to continue pharmacologic therapy for at least one year after remission, maintenance therapy will more likely be indefinite for bipolar disorder. The more episodes of either mania or depression you have over time increases the risk for future episodes. Bipolar disorder tends to worsen with time, particularly if left untreated, which is why indefinite treatment with a mood stabilizer is recommended. If an antidepressant is used, many clinicians recommend it be discontinued as soon as depressive symptoms have remitted, to reduce risk for a manic switch. Long-term management, however, will be guided by the frequency, severity, and consequences of past episodes.

Are both medication and therapy necessary in the treatment of bipolar disorder?

Both medication and therapy are necessary and effective treatments for both the depression and manic phases of bipolar disorder. In contrast to unipolar depression, therapy alone would not be adequate for the treatment of bipolar I disorder. And while medication is likely a necessary part of treatment for bipolar disorder, therapy too is usually a necessary adjunctive treatment to address the multitude of issues that can arise in treatment. Therapy can focus on potential precipitating stressors. In developing coping mechanisms and problem-solving abilities, the risk of recurrence under stressful circumstances in the future can be minimized.

There may be situations when medication needs to be avoided during the depressed phase of the illness-the use of therapy, in particular cognitive behavioral or interpersonal therapy, can sometimes make this possible.

The most important factor in determining a positive outcome from either modality is that both forms of treatment require commitment to the treatment in order for it to work. Therapy requires regular attendance to appointments; communication with the therapist during the session; and for some forms of therapy, work on assignments between sessions. The process of therapy is not easy. It can be anxiety provoking and one does not necessarily feel relief after each individual session. Relief comes over time with hard work on the issues. It may feel easier to cancel sessions or to terminate treatment prematurely, but then the therapy is not given a chance to be effective.

As for medication, its use requires daily compliance and regular communication with your doctor. It is often difficult for many people to remember to take a medication daily, twice a day, or more. Doses may be skipped. Missing doses regularly results in reduced efficacy of the medication. Sometimes a medication doesn’t work right away. It becomes frustrating, and the medication treatment is abandoned prematurely.

Often, when a person has a list of “ineffective” medications, many of them did not get adequate trials.

Term:

Remission - complete cessation of all symptoms associated with a specific mental illness. This occurs within the first six months of treatment, after which the term used is recovery.

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(38) Bipolar Disorder

MAYO CLINIC - BIPOLAR DISORDER

NATIONAL INSTITUTE OF MENTAL HEALTH

Bipolar Overview

BD36

My doctor thinks I should have ECT. I thought that was no longer used. What is it and what does it do?

There are many myths surrounding the use of electroconvulsive therapy (ECT). ECT is a procedure that induces a seizure in the brain through an application of electric current through the scalp. ECT is not a first line treatment (and is typically offered only after several failed medication trials or repeated hospitalizations), but it is a very effective treatment. It is very safe and is not painful. The patient is given anesthesia and a muscle relaxant for the procedure. For some patients, ECT is safer than medications, particularly for those with serious medical conditions for whom medication can be contraindicated, and for pregnant woman, who may not want to expose the fetus to certain medications (e.g., lithium). ECT is growing in use in elderly depressed patients because of higher rates of concurrent medical illness and risks of toxicity from medication.

Psychotic depressions are often refractory to medication, and thus ECT may be considered early in the treatment to avoid a prolonged course of medication trials. ECT is an effective treatment for acute mania when it is unsafe to utilize medication.

The risk of serious complication from ECT is 1/1000. Cardiac complications are the most common adverse effects, which is why a pre-ECT evaluation includes evaluation of the cardiac system. Most potential cardiovascular complications can be avoided with the use of appropriate medications. Confusion and/or memory loss is also common. Confusion is usually transient.

Memory deficits may be for events preceding or following the procedure. Memory deficits usually resolve over weeks to months after, although occasionally there are more persistent memory difficulties.

Although ECT provides rapid improvement in symptoms of depression and mania, there is a high rate of relapse-up to 50% within six months, so continuation/ maintenance ECT or medication is recommended following the treatment course. Continuation ECT is usually provided only if continuation medication has not successfully prevented relapse or recurrence of symptoms in the past.

ECT is usually done in a hospital setting as an inpatient (outpatient ECT may be provided for maintenance ECT). Medications are typically tapered off and discontinued prior to the treatment, and this process may need to occur in a hospital setting because of the risk for worsening depression and/or suicidality. ECT providers have received specialized training and certification.

While protocols may vary from state to state, usually more than one physician needs to evaluate the patient and determine that ECT is clinically appropriate. Unfortunately, due to a negative portrayal of ECT by the media over the years, even with the safety features in place, this very effective procedure is highly stigmatized and even illegal in some jurisdictions.

Are there any natural remedies for bipolar disorder?

“Natural” or alternative treatments describe any treatment that has not been scientifically documented or identified as safe or effective for a certain medical condition.

Examples of alternative treatments are acupuncture, yoga, herbal remedies, aromatherapy, biofeedback, and many others. In considering an alternative treatment, as with any scientifically documented treatment, you should consider the risks versus the benefits of such a treatment. If a particular procedure has no specific, direct risks associated with it, an important risk is potentially delayed treatment of the condition in question. For a mild depression, this risk may not be too great, but for a more severe depression with suicidal thoughts and certainly for an acute manic episode, it could be a fatal risk. Other risks include loss of money on an ineffective treatment, use of a treatment that is not standardized nor required to conform to specific regulations, and frustration when hopes of a unique treatment are not realized.

A number of dietary supplements have been touted to have effectiveness for depression, bipolar disorder, or mood lability in general, including St. John’s wort, SAM-E, omega-3 fatty acids, folic acids and other B vitamins, magnesium, phenylalanine, and taurine. Although there is some promising, albeit early, evidence for efficacy or utility of some of these interventions, the evidence is too limited in scope to consider such treatments safe and/or effective.

Herbal remedies are a popular “natural” choice for treatment of many other conditions. A common assumption about these “natural” treatment choices is that they are safe because they are natural. While herbs are found in nature, as with manmade chemicals, herbs have a specific chemical structure that also alters the body chemistry. As such, there can be significant side effects from such compounds as well.

Some of these side effects can be life threatening. For example, there have been many cases of liver failure from use of kava supplements around the world. In many cases, the problem per se is not that there are side effects; it is that the herbal treatments are not regulated as to either their safety or efficacy.

If a specific treatment is known to be effective, there may be certain risks one is willing to take for relief.

But without known efficacy it is not possible to make an informed decision as to the risks from exposure. Lack of regulation also means supplements available in the store are not rigorously tested for purity or quantity of the active compound in question.

Individuals who sell these treatments may pose as experts but have not necessarily obtained any specialized training or certification. Keep these issues in mind if you choose to undertake an alternative treatment so that you can make fully informed decisions about treatment

Will diet or exercise help with my mood?

Bipolar disorder is not caused by problems with diet, although some believe that a balanced diet would leave one less predisposed to difficulties handling stress and thus possibly any mood conditions that result from that stress. Sleep, on the other hand, has a stronger association with bipolar disorder. During a manic episode, a person has a decreased need for sleep. Although poor sleep will not cause bipolar disorder, lack of sleep can precipitate a manic episode in a bipolar individual.

Problems with sleep can predispose someone to depressive symptoms when chronically under-rested as well. Persons who sleep less than six hours per night have reduced concentration and irritability. In the management of bipolar disorder, development of good sleep hygiene is an important component of treatment for these reasons. Recent research has focused on the effects of exercise on mood and anxiety. Although the medical benefits of exercise are well known, the psychological benefits are less understood. Adults who exercise regularly report lower rates of depression and anxiety than the general population. Studies of the effect of exercise on depression have demonstrated positive results. Many theories exist as to how exercise improves mental health. Exercise causes changes in levels of serotonin, norepinephrine, and dopamine and causes the release of endorphins (which masks pain). It may reduce muscle tension, and adrenaline is released, which counteracts effects of stress. Psychologically too, exercise improves self-esteem, provides structure and routine, increases social contacts, and distracts from daily stress. Although the degree of impact that exercise has on mood disorders needs more research, there are many good reasons for including regular exercise as part of a treatment plan for bipolar disorder.

Term:

Alternative treatment - a treatment for a medical condition that has not undergone scientific studies to demonstrate its efficacy.

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(39) Bipolar Disorder

Living With Bipolar Disorder- Anger State

Bipolar Anger

Bipolar Disorder and Anger

BD37

Why did my doctor recommend therapy if I am already taking medication?

Although therapy alone may be adequate for mild cases of depression, it is most optimal to be in therapy when taking medication for bipolar disorder. Studies on depression have shown that therapy and medication together have the best efficacy. Medication can treat your depression and mania independently of therapy, but it will not change environmental circumstances, will not change your coping skills, and will not change your personality or improve your self-esteem. Keeping in mind that depressive and manic episodes are typically due to a culmination of biological, psychological, and social factors, addressing the psychological and social underpinnings of your mood states is warranted. You cannot change your “biology” or genes, but you can use therapy to change other contributors to relapse. Ideally, the risk of future episodes can be reduced, as medication is generally not considered 100% effective in preventing recurrences of depression and mania. In fact, therapy may help minimize the use of antidepressant medication and thus reduce risk for switches into mania.

My mood stabilizer isn’t helping. What happens next?

It can be disheartening when you do not feel better after a medication has been started. The reality is that the response rate to any given medication tends to be approximately 60% to 70% in clinical trials. This means that a good portion of individuals (more than 30 %!) would not be expected to see improvement on the first medication tried. If a medication is not working, several factors first need to be considered: How long has the medicine been taken? Is the dose high enough? Is the medication being taken as prescribed?

Although antimanic medications for acute mania begin to work within days, it takes from four to six weeks (sometimes up to eight weeks) for the full effect of most psychotropic medications to work (after an adequate dose has been prescribed). Often the dose of medication has not been optimized. As long as there are few or tolerable side effects, the dose can be pushed to the maximum recommended dosage. Your doctor may want to go past the typical maximum dose on some medications (those that do not require blood tests to establish a therapeutic range) if you have no side effects and have partially responded to the treatment. In general, however, once the maximum dose has been prescribed for up to six weeks, and you have been taking it as prescribed, an adequate medication trial has occurred. If there is no improvement, your doctor should switch you to another medication.

The change can even be within a class; for example, a lack of response to one antimanic agent does not mean the same will be true for another antimanic agent. If you have a partial response, your doctor may want to augment with another medication. Augmentation strategies generally involve using a medication with another mechanism of action so that different neurotransmitter systems can come into play to help, similar to what cardiologists do when they prescribe a second antihypertensive medication to patients whose blood pressure remains elevated after an initial antihypertensive has been prescribed. Thus, if treatment with a given agent fails, management techniques include switches within a class, switches to another class, augmentation, the use of medications other than those commonly prescribed, and finally ECT for more refractory episodes.

You must be open with your doctor about your level of adherence with a given medication. It is not unusual for people to forget doses or skip doses for specific reasons. People often do not want to admit this to their doctor, as they think he or she will become upset with them. If you are having problems with taking your medication, it is extremely important for your doctor to know so that the two of you can discuss some of the barriers to taking it, such as side effects. A lack of efficacy is often due to regularly missed doses, and without this knowledge, other medication trials may be suggested unnecessarily.

Will the medication turn me into a zombie or make me look drugged up?

Looking “medicated” is often a reason some people shun treatment with various psychotropic medications. As a rule antidepressants do not typically cause such an effect. Medications that tend to be more sedating can make a person appear robotic or slow, but often these effects can be minimized or eliminated by changing the timing of the dosing or by switching to another agent. Traditional antipsychotic agents have a higher propensity for a certain type of side effect that can cause a robotic appearance. These medications are used less often in the treatment of bipolar disorder, but when they are utilized such side effects can be minimized with other types of medication. Some manic individuals feel as if they are overly slowed because they are used to and enjoy their highly energetic states when manic or hypomanic. In fact, their presentation usually appears more normal once the mania is under control. In the case of untreated depression, because of decreased energy, fatigue, and poor concentration, treatment is more likely to make you look less “robotic.” Some people worry their personality will be changed by medication. Medication does not change a personality. For someone who has been depressed for years (such as in dysthymic disorder) or hypomanic for years (such as in cyclothymia), it may seem as if the mood is just a part of his or her personality. Thus once your depression or hypomania is treated, you might wonder if your personality has changed. Similarly, some people believe they will no longer experience sadness or joy and thus not feel human. Normal ups and downs, however, are not eliminated by antidepressant use.

Scott’s comments:

I was afraid of this. Would I still be myself? A walking zombie? As I began my prescription, I felt no side effects. I was actually a bit leery of the efficacy of the medication, right up until the point that my wife said something to me that would have absolutely tripped my trigger in the past. This time, nothing happened. The physiological response was simply gone. Like water off a duck’s back, her comment came and went, with no reaction from me. It was weird-normally I would have gone ballistic. This lack of sensitivity to stimuli that would have sent me into a manic state was simply amazing. Not having any other noticeable side effects was even more incredible. I look the same, I feel great.

Leslie’s comments:

I was never afraid that the medication I was prescribed would turn me into a zombie, most likely because I had spent so much of my life being depressed that I welcomed any relief that I might get. I know that many people worry that taking medication will change their personality but again, I never had that fear. I quickly learned that medication allows my “real” personality to come out, rather than having the personality that is created as a result of the bipolar disorder; a personality that I believe is not my “real” self. I am concerned, however, when changes in my mood occur (for example, becoming depressed and sluggish) because I never know if it is a function of my medication, life’s normal ups and downs, or the beginning of another bipolar episode.

Terms:

Augmentation - in pharmacotherapy, a strategy of using a second medication to enhance the positive effects of an existing medication in the regimen.

Dysthymic - the presence of chronic, mild depressive symptoms.

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(40) Bipolar Disorder

Bipolar video diary - hypersexuality & me (Video)

Bipolar Hypersexuality

Bipolar Disorder and Sex Addiction

Bipolar Hypersexuality or Sex Addiction?

Bipolar38

My antidepressant is helping, but I have sexual side effects. What can I do?

Many antidepressants can have sexual side effects, which range from decreased interest in sex to difficulty having an orgasm. Many individuals are too embarrassed to ask their doctor about these problems, but it’s important to discuss such side effects and learn your options. Depression itself can be a cause of reduced interest in sex, so first a determination needs to be made as to whether the depression has remitted on the medication. If depressive symptoms are gone, then other considerations should also be made, such as what the baseline sexual functioning was prior to becoming depressed or prior to the treatment. As a group, SSRIs do have a very high incidence of sexual side effects associated with them. These side effects can result in reduced compliance and thus reduced efficacy of the medication. Several options address these effects.

Sometimes a “wait-and-see” approach is effective, as the negative effect may wane with time. Another option is to try another SSRI, which may not have the same effect for you personally, or to switch to a different class of antidepressant that does not typically cause sexual side effects. Antidepressants not typically associated with sexual side effects are bupropion, mirtazapine, and nefazodone. Nefazodone however, has been implicated in some cases of liver failure, and thus is not routinely prescribed unless other options have been exhausted. If the medication currently being taken is working, however, rather than take the risk of switching to another medication that may not be as effective, other types of medications may be prescribed in addition to the antidepressant that can counteract the effect SSRIs have on sexual functioning. The different options should be discussed with your doctor, but current approaches include the use of sildenafil (Viagra), bupropion, and herbal remedies.

I have episodes of hypomania without depressive episodes. I am considering not getting treatment.

Hypomanic symptoms by definition are not severe enough to cause marked distress or disability. To some degree, they may improve your general well-being and level of functioning. At the same time, however, such episodes can adversely impact your social relationships.

Bipolar symptoms occur in cycles, and if you wait long enough, many symptoms may in fact remit even without treatment or you may cycle downward into a more depressive state. The real concern is whether or not someone will switch into a depressive state, which can be more debilitating. No one can predict with any degree of accuracy whether this will happen to you.

Most studies of bipolar disorder have demonstrated that, on average, for every day one experiences hypomania, one will experience thirty-seven days of depression. The risks of a significant depression leading to disability are great: a loss of productivity in school or work, impaired relationships, family conflicts, financial problems, developmental delays in children, and most significantly, suicide. Research suggests that bipolar disorder itself can have harmful effects on the brain that render the cycles more frequent, intense, and prolonged with time. These effects may make you more susceptible to future depressive episodes, possibly more severe, in the future.

Can I take other medicines while I am on an antidepressant?

It is always important to inform any doctor you see of all medications you are taking, including any herbal or over-the-counter supplements. Although many medications can be taken concurrently, there is potential for reactions between many medications as well, thus consideration must be given for this. Sometimes, the potential reaction is minimal and may be due to additive side effects (e.g., sedating effects may combine).

Other times, the presence of one medication can influence the elimination of the other medicine from the body, either allowing excessive accumulation or causing too-rapid depletion. Consequences can thus be toxicity or lack of efficacy. The SSRIs have specific enzyme groups that metabolize the medication. Each SSRI has a different profile as to the enzymes involved in its own metabolism. MAOIs are generally contraindicated in combination with all other antidepressants due to the risk for serotonin syndrome, which can be fatal (although there are certain combinations that skilled clinicians can prescribe in a methodical way to minimize the risks). Serotonin syndrome occurs when there is excess serotonin in the central nervous system.

Symptoms include tremor, confusion, incoordination, sweating, shivering, and agitation. Most SSRIs are contraindicated in combination with thioridazine (Mellaril) as well, due to risk of cardiac toxicity. SSRIs should be used cautiously in combination with sibutramine (Imitrex), commonly prescribed for migraine, also due to risk for serotonin syndrome. St. John’s wort, an herbal preparation used for depression, should be avoided when on a prescribed antidepressant, also due to potential risk for serotonin syndrome. Again, there are some circumstances when a psychiatrist will combine two SSRIs, for example, but this is typically done cautiously and under his or her guidance.

Terms:

Metabolize - the process of breaking down a drug in the blood.

Serotonin – syndrome an extremely rare but life-threatening syndrome associated with the direct physiological effects of serotonin overload on the body. Symptoms include flushing, high fever, tachycardia, and seizures.

Cardiac toxicity - damage that occurs to the heart or coronary arteries as a result of medication side effects.

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