Q:  Developed Agitation while on Antidepressants

I sent you a message very recently about my diagnosis of bp, and i apologise for writing again. I was reading the emails you have published and responded to in July and in response to a question on agitation you wrote that 'As you may have read, one of my great fear is about antidepressants is that they might be able to induce this kind of experience in some people such that it won't go away, or at least not easily.'.

I developed terrible agitation whilst on antidepressants (about six years ago) and it still comes in cycles (amongst other horrible symptoms). I didn't have that type of agitation before antidepressant treatment. I have always worried that perhaps i have suffered some form of damage from the antids. Is this possible? It really  scares me and the agitation canbe terrifying. If it was caused by antids - will mood stabilisers still make it better? Can this type of agitation be triggered in people by antids who are not bp? If you don't publish this message - please please send me a reply - i would really really appreciate it.

PS - your website really is amazing and i wish the knowledge you have would be more widely understood. Apart from my most recent psychiatrist - my other doctors didn't seem to understand at all and could do nothing to help me.
 

Dear Emily --

The fact that you have found my website "amazing" (thank you!) may suggest that you are more likely to accept my line of thought about antidepressants and their risks. I appreciate hearing that I have been found convincing, but I should caution you: most of psychiatry does not think like I do. I could be wrong about the concerns I have raised regarding antidepressants. Indeed, if I have raised significant concerns amongst a lot of people and then turn out to be wrong, I may have done significant harm.

So we should all be very cautious here and cling to whatever evidence we can find rather than accepting pronouncements of opinion. The problem is, there is just very little evidence to go on. So instead, we can ask whether there is evidence that is consistent with my fear, namely that it exposed her to antidepressants in some individuals can lead to an agitated state that may be worse than they would have experienced without the antidepressant. As you know, I have collected that evidence on my webpage about Antidepressant Controversies.

We should also ask whether there is evidence that would be consistent with the idea that antidepressants do not cause agitation or run the risk of making bipolar disorder or worse, perhaps forever. The problem there, of course, is that it is difficult to do research on "forever". At best we can to studies which watch for several years. And we can look at patients who do well on antidepressants for years, even though they clearly have bipolar disorder. I actually have quite a few of those patients in my practice, and continue to stay a relapse-free while on an antidepressant medication. So I definitely believe that it is possible to do well for years with bipolar disorder, while treated with an antidepressant.

Nevertheless, I worry that even those patients might later develop problems and I will look back and wonder if the antidepressant could have been part of the basis for that worsening. I have quite a few patients in my practice of this type as well, whose history is like yours: never the same symptoms prior to antidepressants. These patients outnumber those who are doing well on antidepressants, which may contribute to my overall impression -- even though statistically this is entirely unreliable because such patients may be much more likely to end up in my practice and those who have done well on antidepressants.

Finally then, to your questions: 
1. Will mood stabilizers make it better? Yes, that is definitely true and reflects my routine practice; in other words, that is exactly how I go about trying to address such symptoms.

2. Can this type of agitation and be triggered in people by antidepressants when they were not, prior to such medications, "bipolar"? I appreciate the question, because I too thought that if we could demonstrate even just a few people who had had this experience, it might raise the alarm levels somewhat, which would hopefully be a good thing more than a bad thing (as above, it would be bad to raise alarm if it is not warranted). So when I found a perfect case demonstration of this phenomenon, I published it as a "case report". In the article, I describe a woman's seven years of successful treatment with Zoloft, which was followed by extreme agitation (suicidal, needing hospitalization) following a minor dose increase, and resolved only one Zoloft was removed. I just saw her last week, by the way: she's doing very well on Seroquel and 150 mg of lithium, where the latter ingredient gave her back almost all of the benefits that she had experienced on Zoloft. This has been stable for about three years now.

I hope that addresses your comments and your question, at least in part. 

Dr. Phelps