It is generally recognized in antipsychiatry circles that antidepressant drugs induce manic or hypomanic episodes in some of the individuals who take them. Psychiatry’s usual response to this is to assert that the individual must have had an underlying latent bipolar disorder that has “emerged” in response to the improvement in mood.
The problem with such a notion is that it is fundamentally unverifiable. Psychiatry defines “bipolar disorder” by the presence of certain behaviors and feelings. If a person meets these criteria, he/she is said to have bipolar disorder. What immediately needs to be noted is that bipolar disorder, in common with psychiatry’s other “disorders” has no explanatory value. To illustrate this, consider the following hypothetical conversation.
Parent: Why does my son behave in these extreme ways?
Psychiatrists: Because he has bipolar disorder.
Parent: How do you know he has bipolar disorder?
Psychiatrist: Because he behaves in these extreme ways.
The only evidence for the illness is the very behavior that it claims to explain.
As spurious as this is from a logical point of view, the notion of a latent bipolar disorder is even worse.
Why did my son become manic after starting on antidepressant drugs?
Because he had a latent bipolar disorder.
How do you know he had a latent bipolar disorder?
Because he became manic.
What psychiatry is doing here is applying their spurious explanation retrospectively. Before the individual showed any signs of mania, he must have had bipolar disorder because he became manic at a later date. But nobody could ever have verified that hypothesis, because the occurrence of a manic or hypomanic episode is the primary criterion for such a “diagnosis.”
Although the “latent bipolar disorder” is psychiatry’s usual explanation for these episodes, one occasionally encounters acknowledgement that the antidepressant was the primary causative factor, and in practice, the two conflicting theories exist side by side.
- The manic/hypomanic episode was caused by the antidepressant drugs.
- The episode was caused by the underlying latent bipolar disorder.
Theory 2 is more popular in psychiatric practice, and is routinely told to those clients who experience this kind of mood switching. Up till now it has been difficult to challenge theory 2, because it is essentially unassailable. One can’t prove or disprove the existence of something that is inherently latent.
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But recently some evidence has been published that favors theory 1: that the manic/hypomanic episodes stem primarily from the antidepressant drugs. In November 2013, Psychiatric Times published an article by Ross Baldessarini, MD, a Harvard psychiatrist, et al titled ‘Switching’ of Mood From Depression to Mania With Antidepressants.
The article reports on, and discusses the implications of, a meta-analysis conducted by the same authors (Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: A review, Baldessarini RJ, et al, Journal of Affective Disorders, May 2013). Here’s the opening paragraph of the Psychiatric Times article.
“Bipolar disorder often presents initially with one or more episodes of major depression, and an episode of mania or hypomania may first occur during treatment with an antidepressant, stimulant, or other agent with mood-elevating effects. Such ‘switching’ of mood into mania, a mixed-state, or psychosis can be dangerous. This switching is particularly prevalent among juveniles and young adults exposed to treatment with an antidepressant or stimulant for a depressive, anxiety, or attention disorder. Such pathological shifts of mood and behavior may represent adverse drug actions or a manifestation of undiagnosed bipolar disorder.”
The authors go on to state that they had reviewed available research on two topics: a) antidepressant-associated mood switching; b) changes of diagnosis from unipolar depression to bipolar disorder.
They identified 51 studies involving nearly 100,000 individuals who had been diagnosed with major depressive disorder (MDD) without a history of mania or hypomania, and who had been treated with an antidepressant. They found that mood switching (i.e. to mania or hypomania) occurred in 8.2% of participants within an average of 2.4 years of antidepressant use, or 3.4% per year. (The rate of mood switching was 4.3 times greater among juveniles than among adults.)
The authors also reviewed 12 other studies in which individuals who were initially considered to have unipolar depression (MDD), were assigned a new diagnosis of bipolar disorder because of the occurrence of spontaneous (i.e. no antidepressant associated) mania or hypomania. These switches occurred in 3.3% of the individuals studied within 5.4 years, i.e. 0.6% per year.
So, manic or hypomanic episodes were 5.6 (3.4 ÷ 0.6) times more likely per year for people diagnosed with MDD who were taking antidepressants than for people with the same diagnosis who were not taking these drugs.
The authors’ comments on this difference in the Psychiatric Times article are interesting:
“A particularly intriguing finding was the large apparent excess of antidepressant-associated switching over reported spontaneous diagnostic changes to bipolar disorder. This raises questions about the diagnostic, prognostic, and therapeutic implications of antidepressant-associated reactions.”
“If the relatively low rates of new bipolar diagnoses are not due to under-reporting, their marked difference from rates of antidepressant-associated mood switching leaves open the possibility that direct pharmacological, mood-elevating actions of antidepressants may be involved in mood switching, in addition to hypothesized “uncovering” or perhaps even “causing” of bipolar disorder. Of particular concern is that these ambiguous possibilities leave specifically uncertain the potential value of long-term treatment with antimanic or putative mood-stabilizing agents.”
In the Journal of Affective Disorders article, they also state:
“An important, unresolved question is of the significance of AD-associated mood-switching. Two plausible possibilities are: [a] responses reflecting the presence of BPD, or [b] a direct pharmacological effect of mood-elevating treatments that may be transient, relatively rapidly reversible, and not followed by a change in diagnosis…The several-fold higher proportion of patients with mood-switches among unipolar MDD patients than the rate of later re-diagnoses of BPD is consistent with the possibility that some AD-associated mood-switches may represent pharmacologic reactions (AD-induced mania). It is also likely that AD-associated risk will be greater than spontaneous mood-elevations regardless of cause. It is important to note that the reported rates of re-diagnosis to BPD may be somewhat overestimated if some cases involve drug-related mood-elevation and not only spontaneous mania–hypomania. That is the ratio of AD-associated mood-elevations to new diagnoses of BPD may actually be even higher than we found.” [Emphasis added]
What the authors are pointing out here is that antidepressants are clearly implicated in the “excess” incidents of mania/hypomania, and they have even raised the question of a direct causal link.
Their brief reference to “diagnostic … implications” isn’t entirely clear, but is, I think, a challenge to the DSM-5 decision to allow these kinds of antidepressant-induced manic episodes to count towards a “diagnosis of bipolar disorder.”
In DSM-IV, incidents of this kind were excluded:
“Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.” (p 332) [Emphasis added]
But in DSM-5, this has been changed to:
“Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore, a bipolar I diagnosis. (p. 124) [Emphasis added]
So under DSM-5, the possibility that the mania was caused by the antidepressant has been eliminated in favor of the popular psychiatric notion that it “emerged” during the antidepressant use, and the manic episode can be adduced to support a “diagnosis of bipolar disorder.” This is psychiatric spin of a very advanced order: eliminating the DSM-IV admission that the drugs have the potential to inflict this kind of damage, while at the same time expanding the concept of bipolar disorder, which is good for business.
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But, here come Dr. Baldessarini et al collating and publishing research, some of which, incidentally, has been around since the late 60’s/early 70’s, clearly establishing a large excess of manic episodes among people taking antidepressant drugs. And, notably, they have taken the additional step of writing up their findings in Psychiatric Times, a medical trade publication written for “psychiatrists and allied mental health professionals who treat mental disorders,” with a circulation of 40,000.
And, perhaps most significant of all, is Dr. Baldessarini et al’s reference to “prognostic and therapeutic implications.”
“Indeed, it is not even proved that drugs considered to be mood-stabilizing are highly protective against antidepressant-associated mood switching, although such protection is widely assumed. Moreover, there is very limited evidence that prolonged antidepressant treatment provides substantial protection against recurrences of bipolar depression and that it might contribute to emotional instability or rapid cycling.”
In other words, in cases where antidepressant-associated manic episodes have occurred, continued use of antidepressants “might contribute” to instability and rapid cycling, i.e., recurrent manic episodes.
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There has been an increasing recognition on this side of the debate that the so-called antidepressant drugs precipitate manic, and even violent, reactions, in some of the individuals who take them. There has even been speculation that use of these products is linked to the much-publicized incidents of murder-suicide in recent years. Brian, at AntiDepAware, has amassed a great deal of anecdotal, but compelling, information on this issue. Joseph Glenmullen, MD, a psychiatrist, has discussed antidepressant-linked mood switching in his book Prozac Backlash (2000). He describes several cases from his practice, including individuals who became floridly psychotic, sometimes with graphically violent themes , after taking SSRI’s.
Psychiatry has resisted suggestions to conduct a definitive study on this matter, relying instead on repeated dogmatic assertions that the “meds” are wholesome and necessary, and that the incidents are the result of “untreated mental illness.”
But the Baldessarini et al study and, incidentally, an earlier Offidani et al study of which Dr. Baldessarini was a co-author, represent a major assault on that notion. Tragically neither article appears to have attracted much attention in the psychiatric field, where antidepressants are still being prescribed routinely as front line “treatment” for depression and various other “disorders,” and no major alert with regards to mood-switching has been issued. I have no inside information on this matter, but it occurs to me that Dr. Baldessarini et al have written the Psychiatric Times piece in an attempt to disrupt this complacency, and to generate some recognition among their colleagues of the enormous implications of antidepressant-induced manic episodes. But perhaps their efforts have been in vain. It is now 14 months since the publication of the Psychiatric Times piece, and 19 months since the original journal article, but no major change in psychiatric prescribing is evident, and psychiatrists are still telling victims of this effect that they must have had an “underlying bipolar disorder,” that the drug has activated. As I’ve said many times, psychiatry does not take kindly to criticism. And this appears to be true even when the criticism is from one of their own.
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Disclaimer: In writing this post I have used terms like “bipolar disorder,” “major depressive disorder,” etc., in order to describe the journal articles being reviewed. This was simply a reflection of the fact that the authors had used these terms, and should not be read as an indication of any endorsement on my part of the validity or usefulness of these terms. Indeed, it is the central tenet of this site that the so-called psychiatric diagnoses have neither explanatory nor predictive validity, and are destructive, disempowering, and stigmatizing.
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This article also appears on Philip Hickey’s website,
Behaviorism and Mental Health
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.