Saturday, November 13, 2021

Best Medications for Depression. Or, a Tangent on Antidepressants and Bipolar Disorder

What meds are best for depression. Antidepressants, right?

Well, maybe. But only if the depression is pretty severe. Mild and moderate depression does not really separate from placebo vs. standard antidepressants. 

Also, what if the person actually has bipolar depression, rather than "regular" unipolar depression. If you give that person antidepressants, you will likely make their depression worse, not better. Wait - it gets worse! You might actually make their depression better ... for awhile. They might seem to respond and get better. So much better. In fact, they might get better than good. They might go into a hypomanic or manic phase and cause damage to their life, livelihood, and relationships. 

Or they might get somewhat better, and be really grateful for the antidepressant. But after awhile, they may shift into a bipolar mixed episode. That is, they might develop a mixture of both depressed and manic features at the same time. This feels pretty horrible to live through, which is reflected in the substantially elevated suicide risk that mixed episodes pose. 

Or maybe you give the depressed person an antidepressant and they feel better. They feel better for several months even. But after awhile, they start to cycle. What's that? Their mood starts going up and down, alternating between depressed and non-depressed more frequently. Sometimes it seems like the antidepressant helps, and sometimes it seems like it doesn't. You should probably increase the antidepressant then, right?

Actually, the correct (more helpful) treatment is to stop the antidepressant in this case. But not stop suddenly. Stopping suddenly can make the person get much more depressed very quickly. You should taper the medication down slowly over a couple of months to let their body gradually readjust to the change in medication levels. 

When a person with underlying bipolar disorder takes an antidepressant, and begins mood cycling, it's not just that their mood starts to go up and down. It may start to do so more quickly, more frequently, and more severely. It may be transformed from "normal" bipolar condition into "rapid-cycling" bipolar. This is a worsening of the person's overall condition and can be lasting or permanent. 

If the person goes into rapid cycling, which is actually a pretty common thing which happens when people with bipolar condition take antidepressants, they end up being depressed for more total time. In fact, some studies suggest that rapid cyclers end up being depressed a full three times as many days of the year as do non-rapid cyclers! Talk about iatrogenic conditions! (For our readers used to normal English rather than technical medical terms, iatrogenic means a condition caused by medical treatment.)

So, it's kind of a big deal to make sure that the person does not have bipolar disorder. But that's pretty easy, right? And bipolar disorder is super uncommon, right? 

Well, not really, and no, not really. 

In an ideal world, you could just ask a person, have you ever been awake for four straight days or more, when you weren't on drugs? Yes? Bipolar. No? Not bipolar. 

Ever since Seth tricked Osiris into laying down in that coffin and thus unleashed chaos into this world, it has been more complicated than that to diagnose bipolar. 

Bipolar One is one form of bipolar. It is the "classic" form of bipolar - bipolar in its clearest manifestation. Surely anyone who has had a manic episode in the past would know so and be immediately straightforward about it, right? Well, actually, the person might legitimately NOT remember ever having a manic episode. 

That is from state-dependent amnesia, much like in Charlie Chaplin's classic 1931 movie City Lights. If you are under 95 years old and have not seen the movie, the main character (Charlie) saves the life of a megamillionaire. The megamillionaire is then extremely grateful and lavishes gifts on Charlie whenever he sees him - as long as he (the rich guy) is very drunk. But when the rich guy is sober, he does not remember Charlie whatsoever and just runs him off. The rich guy's memory is state-dependent. 

Many times people with bipolar disorder literally cannot remember what happened during their manic episode. It can be like getting so drunk that your friends have to tell you what you did at the party last night. If you do not have people around you to tell you what you did, you might not have even any way to know what happened. 

Or, if they have "bipolar two," characterized by hypomanic episodes that are less intense than the full manic episodes of bipolar I, they may simply enjoy the high of the elevated mood. One person I interviewed recently reluctantly admitted that she has had manic or hypomanic episodes in the past but she is not interested in treating them, as she enjoys them. Her only concern is the times of depression. Thankfully she had enough trust in me (just barely) to admit this - many others choose to withhold this information. 

Another problem with diagnosing bipolar when a patient comes to you reporting depression is false positives. Sometimes (pretty frequently actually) you will meet people who will immediately tell you that they are "bpolar." "Oh yes, I have bipolar moments all the time. Just yesterday I had three manic episodes." This, of course, is a highly different definition of "manic episode" than is used in the DSM-5. "True" manic episodes need to last at least four days straight, among other diagnostic criteria. What these patients refer to is "mood lability," or mood that changes rapidly or is otherwise unstable on a moment-to-moment or hour-to-hour basis. Or they may have a good mood for a few days when something good happens and get somewhat slap-happy (a highly technical medical term.) This false self-identification is especially common with people who come from a particularly low level of formal education or have a low socioeconomic status. 

But! Sometimes people who mistakenly report these very non-bipolar "bipolar" characteristics to you actually DO have bipolar condition. It may be bipolar I, bipolar II, or bipolar NOS (not otherwise specified.) In bipolar NOS, a person may have some characteristics of bipolar, but does not meet full criteria. That is, they do not have enough symptoms to be technically considered to have "bipolar." And yet, as most mental conditions exist on a spectrum, it is not as simple as an on-off switch - they have bipolar, or they do not. Maybe they are somewhat bipolar. Their mood goes up and down. They experience significant irritability. Sometimes their thoughts seem like they are racing and they get distracted very easily. They get excited and become more prone to make risky and poor decisions that get them into trouble. And a lot of times they are just down in the dumps, feeling like life is meaningless and with no desire to do anything, even get out of bed. Maybe they meet criteria during those times for major depressive disorder (MDD). Maybe they don't check off the required symptoms on the checklist to "qualify for MDD, either. What about them?

Unfortunately, the condition that this group of persons has is not clearly defined in the DSM-5. That is not to say that this "condition" is uncommon. It is actually pretty common to find in a psychiatrist's (or other mental health prescriber's) office; it's just not currently dealt with in the DSM. 

So what do we do with people who are not quite bipolar I or II, and not fully MDD? Well, this is a very controversial subject, but the majority of consensus opinions by expert psychiatrists is, the more bipolar characteristics that a person has, the less likely antidepressants are able to help. If only a tiny bit of "bipolarity," antidepressants are more likely to help. But the more bipolarity that a person's mood symptoms suggest, the more you should try to avoid prescribing them antidepressants, and the more likely that antidepressants will end up harming them in the short or long run. 

Note that the same seems to be true for people who do meet full DSM-5 criteria for MDD, but who also have some elements of bipolarity as well. If bipolar traits are significant in this person's MDD, then antidepressants are less likely to help as well. 

So anyway, here you have this person in front of you. They have pretty bad depression right now, and you are reasonably sure for now that they do not have bipolar. However, keep in mind that a good three or four out of ten of those people who show up sitting in front of you reporting depression actually have some sort of bipolar condition. Hopefully you will identify all of them. Or even most of them. The reality is that the vast majority of people with bipolar who show up for treatment depressed do NOT get diagnosed with bipolar. Most people with bipolar actually get evaluated many times by several different doctors or other practitioners over a span of 8-10 YEARS average before they eventually get their correct bipolar diagnosis. So hopefully you do way better than the vast majority of other prescribers out there, most of whom probably have substantially more experience than you do. 

Which is another way of saying, always suspect bipolar when you see someone for "regular" depression. And always be on the alert to see if someone who you are treating for depression has a poor response to their antidepressant(s). 

Read more about this in my next post, where I may get around to actually talking about the "Best Medications for Depression."

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