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Bipolar Disorder

The SSRI Experience

Part 1: 30 days on psychiatric medications.

Key points

  • Psychotropic drugs can be divided into two groups: mood stabilizers and antidepressants.
  • Mood stabilizers address highs and lows; antidepressants just help with the lows.
  • Giving antidepressants to someone bipolar can make their "highs" go even higher.
Source: 123rf

Depression will affect up to 20% of people at some point in their lives. That number is tremendous! So few people seek help, and so many more suffer quietly, either not recognizing something is wrong, or not doing anything about it.

The brain is a far more complex organ than the eye, and even the eye needs help. Seventy-five percent of adults use some sort of vision correction. According to a World Health Organization study, one-half of anxiety disorders are actually recognized, and then, only one-third of the people are offered treatment. That's 1 in 6 people with anxiety who are actually treated.

Taking psych meds can unfortunately still carry unnecessary stigma these days, and some doubt whether they work altogether.

I can tell you from over a decade of practicing psychiatry, I would not be able to sleep at night, or keep doing my job, if I knew my interventions were either useless, or worse, hurting people. Placebo effect? Maybe a little. I often like to ask my patients not to tell their close friends or loved ones they are starting treatment, and ask them to check in a month or two into treatment — the results are consistently positive. Even friends who have no idea someone is being treated (in research terms they are "blinded") will report the person acts more positive, less reactive, and is overall "lighter" in their daily interactions and outlook. That makes my day.

When people report "horror stories" related to psychotropic drugs, it is often because the wrong medication was used. There are essentially two commonly used tools in psychiatry — mood stabilizers (like lithium, Depakote, Aripiprazole) and antidepressants (the SSRIs and SNRIs — like Effexor, Prozac, Zoloft, Lexapro). Mood stabilizers work on highs and lows. Antidepressants just help with the lows.

Things go wrong when bipolar people are put on antidepressants because things go "higher." By this, I mean that mood swings become more intense, rather than less. Anxiety, insomnia, agitation, and racing thoughts increase, and people can even become suicidal when they are agitated and haven't slept in days. Treatment goes wrong when bipolar people are put on antidepressants alone. We hear many horror stories in kids, often because they've not been around long enough for bipolar disorder to be recognized prior to treatment. Then, the SSRI makes things worse.

Fortunately, with careful diagnosis and review of family history, bipolar disorder can be readily recognized and treated appropriately. For the remaining patients who do not have bipolar, treatment often begins with SSRIs or SNRIs which take about a month or two to start working. While waiting, I use therapy, cognitive behavioral therapy for sleep, and some faster-acting medication to improve anxiety or mood by day and sleep quality by night.

What is it like to be treated with an antidepressant? The account below is a fictional patient, based on the key experiences of numerous real patients. We'll refer to our patient as John and look into the first several weeks of starting an SSRI, in this case, Lexapro, or escitalopram.

Let's meet (fictional, summary patient) John. John is a 35-year-old married male, working as a software engineer with a young daughter at home. Neither of his parents ever saw a psychiatrist, but his mother tended to worry often, and dad was often stressed by work and liked to drink. No one in the family was ever hospitalized, had substantial drug or alcohol problems, attempted suicide, or had any history of intense, erratic, or illegal behavior (all flags for bipolar). Personally, John also denied any history of decreased sleep or increased energy lasting more than 2-3 days (4 days is the cut-off for bipolar type 2). He would lose some sleep before big events, but would be tired and catch up in the next night or two, he was always tired when he didn't sleep.

As a child, John would lose sleep before tests, often waking too early before the alarm, and remembers praying often for the safety of his family. He would bite the skin around his fingers. He also remembers being especially sensitive as a child, easily hurt, and overly concerned for the feelings of others. He had a vivid imagination. He hated when his parents left him home alone as a child and he was homesick often through college. He did well in school but had some performance anxiety.

Since the birth of his daughter, John has been increasingly worried about being able to support his family. He noticed he would get "adrenaline jolts" from reading work emails, or prior to meetings with his boss. He was exhausted after work, and often needed a drink to cool off. He also felt burned out on weekends with less energy or desire to see friends, exercise, or do things around the home. He wanted to be left alone but often felt guilty for wanting that. He would fall asleep quickly at night, but wake easily with any noise or disturbance and have a hard time sleeping more than 6-7 hours, even on weekends. He always felt "tired, but wired," and would often be short-tempered, and slightly "mopey." He felt too much — every little thing could easily become a big deal — and this happened several times per day. One wrong email could ruin his day. He had "daymares," or dark catastrophic thoughts of how things could go bad. These scared him, and he often kept these to himself.

Decisions were always a source of stress, rumination, and often led to self-doubt. He often had "analysis paralysis," and would ruminate over decisions for days. At times he would doubt his ability. He was familiar with the term "imposter syndrome," thinking he could mess up and lose it all at any moment.

At the behest of his wife, and because of the ongoing sleep loss, he spoke with his doctor who then referred him to a psychiatrist. The diagnosis of anxiety and possible depression by history was made, bipolar disorder excluded, and treatment started with Lexapro, 5mg each morning. A lower dose, as the "full" dose of the medication, is 20mg per day.

PART 2 - Will include a week by week description of the first 30 days on lexapro. Please watch for it's release next week. A link will appear here when it is published!

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