More than just a lift: Off label use for Antidepressants

A brief history of antidepressants

Antidepressants were accidentally discovered by chance in the 1950’s.(1) While seeking out a medication for schizophrenia, the main diagnosis at the time, drugs were found that could “tweak” the balance of the brains neurotransmitters (even though they didn’t really know how it worked at that time) Patients that weren’t schizophrenic got worse, but other patients, depressed (“neurotic”) had bouts of euphoria.

In 1955, the miracle cure Tofranil (imipramine) was patented, and others started coming up with similar tricyclic(2) antidepressants. Relief came to 60-80% of the patients, but there were terrible side effects and tricyclics can cause heart problems, much moreso than many other psychiatric drugs. In 1987, Prozac, the first SSRI(3) was created, with the same effectiveness and less side effects.

Wellbutrin (Buproprion)

Wellbutrin was created as an atypical antidepressant but they found it helped aid people in quitting smoking, in which it is called Zyban. (When I took it, I got so anxious, I started smoking again after 6 months smoke free!) It is a mild stimulant and is the fourth most prescribed antidepressant in the USA.(4) It is very effective and can be an add-on drug to an antidepressant without worrying about serotonin syndrome, a dangerous syndrome caused when there is too much serotonin in the brain. Often, it is prescribed because SSRI’s can effect sexual functions, and this can help get them back, as well as lose some weight while you’re at it!

Zoloft (Sertaline)

Zoloft is used to treat depression, obsessive compulsive disorder, panic disorder and social anxiety. It is the second highest selling antidepressant in the USA(5) and is approved for children and adults. It works in a similar fashion to tricyclic antidepressants and some say it helps control urges, such as binging and purging. I took it for bulimia, but it made me incredibly violent and agitated, so I was taken off it ASAP.

Off-label Uses 

Off label uses of antidepressants are on the rise. One in five doctors prescribing antidepressants are not psychiatrists(6) and aren’t being used for psychiatric purposes. They can help with: fatigue, non-specific pain, smoking cessation, headaches, abnormal sensations and premenstrual tension.

 Prozac, Zoloft and Paxil are approved for premenstrual tension. Wellbutrin for smoking cessation and Cymbalta for diabetic neuropathy, chronic musculoskeletal pain and fibromyalgia. Some antidepressants control menopause symptoms as well as hormones do, and if you switch it around, beta-blockers help anxiety. Many medications for schizophrenia were used off-label for bipolar disorder or to augment an antidepressant, and are now on the market, FDA approved for both, such as Abilify, Seroquel and Zyprexa. Many antidepressants can help with pain (migraines, for example) such as Elavil (amitriptyline).

 Hell, Viagara is even prescribed to some women to improve their sex lives too!

1. http://www.time.com/time/health/article/0,8599,1952143,00.html

2. Three-ring chemical structure

3. Selective Serotonin Reuptake Inhibitor

4. http://en.wikipedia.org/wiki/Bupropion

5. http://en.wikipedia.org/wiki/Zoloft

6. http://depression.about.com/b/2011/08/09/off-label-antidepressant-use-on-the-rise.htm

7. http://www.consumerreports.org/cro/2012/05/off-label-drug-prescribing-what-does-it-mean-for-you/index.htm

8. *Note: Off-label does not mean illegal. It is generally not FDA approved for that specific condition. Also, antidepressants don’t have the abuse potential of many other meds.

Scary Side Effects Part 3 – Antidepressant Induced Mania?

In the 1980’s, bipolar disorder was called manic depression and was a feared word. It was changed to bipolar (two poles) later in the 1980’s and diagnosed more and more. But often, the patient will present with depression symptoms, and get prescribed an antidepressant, which can cause horrible hypomanic, mixed, and even full blown manic episodes. This can be because we go to the doctor when we feel down, not up. After years and years of being bipolar, I know when to see a doctor for mania. (Also called “insight”)

 Mania can feel great, but it can also be dangerous. Impulsivity, people giving away all their money. Then comes the inevitable crash. Many bipolar suicides are accidental during a mixed or manic state. Some may say that antidepressant induced mania is just a side effect, it isn’t indicative of bipolar disorder. There are a lot of controversies about it.

 Some people put on antidepressants are bipolar, but it can have the same effect on somebody who isn’t bipolar. Their moods start cycling(1) and they start showing clinical features and meeting the diagnostic criteria of bipolar disorder. Is this a lasting effect? It can be. The criteria for bipolar disorder is one manic episode, although most have several.

 “The findings of this study confirm that treatment-induced mania is a clinical phenomenon that belongs within the bipolar spectrum rather than a coincidental treatment complication, and that it should be placed under ‘bipolar disorders’ in future classification systems.” (1)

Statistics

Thirty-five percent of the patients had a manic episode rated as likely to have been antidepressant-induced. No variable was a predictor of vulnerability to antidepressant-induced mania. Cycle acceleration was likely to be associated with antidepressant treatment in 26% of the patients assessed. Younger age at first treatment was a predictor of vulnerability to antidepressant-induced cycle acceleration. Forty-six percent of patients with antidepressant-induced mania, but only 14% of those without, also showed antidepressant-induced cycle acceleration at some point in their illness. (2)

 Antidepressants can be devastating to someone with bipolar disorder. It can send the patient into a mixed or manic state. Some people are able to tolerate antidepressants such as tricyclics, MAOI’s, or Wellbutrin, but SSRI’s and SNRI’s have a tendency to push you over the edge. However, this may not be true at all!

 

Myth or Mania? Controversy

Sometimes the myth is just an incorrect use of language. Many people have detected a temporal association between the use of tricyclic antidepressants and mania in patients with bipolar disorder, but no mechanism is indicated. There is an assumption the association could extend to all antidepressants despite chemical and pharmacological transformations.(3) 

This association between mania and SSRI’s hasn’t been found. Studies find that the switch rate is no different than that of normal bipolar disorder when the patient is on an SSRI or SNRI.

 Revisiting the Controversy

“Mania is likely to be antidepressant-induced and not attributable to the expected course of illness in one-third of treatment-refractory bipolar patients, and rapid cycling is induced in one-fourth. Antidepressant-induced mania may be a marker for increased vulnerability to antidepressant-induced cycle acceleration. Antidepressant-induced cycle acceleration (but not antidepressant- induced mania) is associated with younger age at first treatment and may be more likely to occur in women and in bipolar II patients.”(4)

 

Conclusion

Antidepessants can make a bipolar patient exhibit signs of mania. When the antidepressant is stopped, the mania generally goes away. Antidepressants are often prescribed for those that are bipolar, for the symptoms during depression. (I take Luvox for Pure-O OCD). However, a mood stabilizer with an antidepressant effect such as Lamictal or Lithium would be more effective than adding on antidepressants.

 

There are controversies, so keep that in mind. Also, with any medication and diagnosis: YMMV (your mileage may vary)

 

 

1. http://psychcentral.com/news/2011/10/13/antidepressant-induced-mania-similar-to-bipolar-disorder/30300.html

2. http://www.ncbi.nlm.nih.gov/pubmed/7625459

3. http://thelastpsychiatrist.com/2005/07/do_antidepressants_induce_mani.html

4. http://ajp.psychiatryonline.org/article.aspx?articleID=171161