Bipolar Disorder Treatment - SSRI And SNRI Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) and other new antidepressants, such as buproprion and venlafaxine, are generally considered to be the first-line choices for the depressed phase of bipolar disease. Other medications such as tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) have also entered the bipolar treatment regimen. As discussed earlier, antidepressants alone have the potential to trigger a manic episode; therefore, they are prescribed in combination with a mood stabilizing drug.

Similar to mood stabilizers, there are studies to support the use of antidepressants in between episodes. Continuous use of both antidepressant and mood stabilization treatments may keep the severe symptoms of bipolar disorder away. Specific antidepressants may not be safe for pregnant or nursing women and should be discussed with a physician.

Bipolar Disorder Treatment - Selective Serotonin Reuptake Inhibitors (SSRIs)

When a neuron releases neurotransmitters across its synapse with another cell, the recipient cell receives the chemical signals on receptors and then releases them back into the synapse. About 90% of those neurotransmitter are taken up again (in a process called reuptake) by the original transmitter-releasing cell. It is thought that in depression, the recipient neuron does not take up neurotransmitters quickly enough, because of receptor problems.

SSRI is an acronym for "Selective Serotonin Reuptake Inhibitor". Serotonin is a neurotransmitter known to have an impact on mood. The class of SSRI bipolar medications is thought to exert their antidepressant effect in part by slowing down the process of serotonin reuptake. Serotonin is thus prevented from being taken up again and ends up staying in the synaptic gap longer than it normally would, gaining the chance to be recognized repeatedly by the receptors of the recipient cell. Over time, the administration of antidepressant medications is thought to influence recipient cells to grow additional receptors, further amplifying the effect.

Although SSRIs are effective treatments for depression, little is known about how SSRIs affect individuals with bipolar disorders. Despite this fact, they remain a commonly prescribed treatment for bipolar disorders.

Some common SSRIs are fluoxetine (Prozac), fluoxetine hydrochloride (Prozac Weekly), sertaline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). The side effects from SSRIs are relatively mild, most commonly they are nausea, headache, insomnia, sleepiness, nervousness, tremors, increased sweating, dry mouth, and loose bowel movements. These side effects usually resolve within a few weeks of bipolar treatment. One of the most bothersome side effects is that of sexual dysfunction. For males this includes delayed orgasm and for women, a decreased sex drive. SSRIs can also be responsible for serotonin syndrome, which occurs when too much serotonin is released and results in chills, headache, diarrhea, profuse sweating, confusion, and restlessness. In this case, SSRI use is discontinued as a bipolar treatment.

Bipolar Disorder Treatment - SNRI Antidepressants

This new class of antidepressants is known as SNRIs (serotonin norepinephrine reuptake inhibitors) because they affect not only serotonin, but also norepinephrine and other neurotransmitter systems. These bipolar medications are thought to work similarly to SSRIs in that they inhibit the reuptake of neurotransmitters known to have an effect on mood at the synaptic junction.

Buproprion (Wellbutrin) is sometimes used as a first-line treatment for bipolar disorder (along side mood stabilizer medications). It is as effective as comparable SSRI treatments for combating depressive episodes, and seems to have the added benefit of lessened risk of precipitating manic episodes (compared to SSRI antidepressants). The side effect profile is often perceived as milder as well. The most common side effects of buproprion are dry mouth, constipation, headaches, and insomnia. Care must be taken when using buproprion at higher doses, as it has been known to induce seizures.

Venlafaxine (Effexor) has also been rated highly for bipolar disorder treatment, but definitive studies are lacking at this time. There is some evidence that it relieves the symptoms of depression more quickly than other bipolar medications, has fewer side effects, and can be taken in combination with other medications easily. More research is needed to solidify the role of venlafaxine in bipolar disorder treatment.

Nefazodone (Serzone) is rated as a secondary choice in bipolar treatment. In addition to serotonin reuptake inhibition, it blocks a particular type of serotonin receptor as well. Although there are no published data regarding its efficacy in bipolar disorders, it has several advantages over SSRIs, notably usefulness in relieving anxiety and severe insomnia because of its sedating effect. Unfortunately, nefazodone is a strong inhibitor of liver enzymes and should be used cautiously.

Mirtazapine (Remeron) is another second-line antidepressant choice for bipolar treatment. Like nefazodone, there are few studies that can clearly demonstrate its efficacy for bipolar treatment. It has the qualities of sedation similar to nefazodone, but has the disagreeable side effect of inducing weight gain.

  • Anonymous

    My wonderful bipolar (but now ex) girlfriend was misdiagnosed for over forty years by psychiatrists, MDs and their PAs, endocrinologist, ER docs, on and on. When she was prescribed an SSRI, she went into a two-month long psychosis exhibiting disturbing psychomotor agitation, total lack of sleep, etc. I cared for her 24/7, as family and friends distanced themselves, not knowing what to do, and doctors continued judging wrongly. A little clinic finally properly diagnosed her as bipolar and helped but later she was again misprescribed then became manic, kicking me out of her life, even dragging me into court over her delusions of persecution. Another (long known) bipolar relative was recently misprescribed – doc didn’t read the medicine’s literature - an SSRI and caused a needless, destructive manic episode. I’ve come to see that most medical doctors are NOT educated enough to treat people with antidepressants. Equally deplorable are laws that allow the mentally disordered to wander the streets until they commit a crime. Every police officer told me, they don’t get proper help in prison. It’s time for serious reform of the American mental health system. I’m glad to see websites like this provide much needed information and education. And my wish is that soon everyone, the afflicted and family and friends too, receive the proper care they need to thrive.

  • Bryan

    I agree with the above comments. SSRI's are too often perscribed as the first choice. I have ADD and was perscribed an SSRI. The side effects were horrible and more than a year later I still suffer from withdrawal syndrome.

    I tihnk there are far better choices rather than jumping the gun and going for medication. Positive re-enforcement and thinking have done wonders for me and I talk about them on my site at Adder World!


  • Anonymous-1

    I am writing to ask everyone to speak out if you are concerned about your friend, spouse, SO, or family member. My boyfriend (age 39) was depressed - with thoughts of suicide - for almost 2 years. During this time I became so concerned about his health that I contacted his mother to beg her to intervene. It took a long time, but finally he reached a psychiatrist who prescribed an SSRI. There was in immediate change in his mood on the SSRI: relief of depression and suicidal thoughts, increased energy to spend hours and hours working on the house and yard, and virtually no concern for his future or finding employment. I was relieved that he wasn't depressed or suicidal I didn't understand what I was seeing. Within a few months he had started a risky relationship with a girl 15 years younger whom he didn't know, she gave him herpes, it ended our relationship. He regrets the loss of our friendship, reports continued depression and anxiety, still has no job, and is about to be homeless. I became convinced that his behavior was a result of a misdiagnosis of depression with an antidepressant prescription instead of a correct diagnosis of bi-polar. But, as he was seeing his psychiatrist once every 3 months, how would his doctor know. In the wake of a lost relationship with a man I loved very much I had to contact his mother, again, to report my concerns. Again, her response has been slow and this time I won't know what the outcome will be - I am out of his life and won't return. I have documented the history I saw and the concerns I have. I have spoken, repeatedly, to beg his family to help him. I was there when he was depressed. I was there when he started the SSRI. I was there until he became reckless and caught herpes. I know there are others out there just like me who know something is wrong with the one they love, but don't know what to do. Speak! Tell anyone. Tell everyone. I've spoken to my ex about my concerns. I've spoken to his family. If I had his psychiatrist’s number I'd call him. But, that’s all I can do. You, however, can know that there are physicians out there prescribing medication after 1 visit and checking back 3 months later - 3 months later my ex had destroyed our relationship and sent his life on a dramatically different path. If your loved-one denies a problem, don't assume s/he knows - they are ill and may not be the best judge of their mood. Don't assume a doctor is always right. I won't know what happens to my boyfriend, but I did try to help. You can try, too. And you might see the improvement.

  • Elaine

    My 15 year old daughter has had a rough life with me and my husband. She has recently experienced much emotional devastation by an abusive "relationship" which culminated somewhat in an attempted suicide. She was then diagnosed with Major Depression and was prescribed Prozac. She did not like it and was switched to Lexipro. Since then she has become increasingly agitated, violent, moody and anxious and not able to fall asleep and nightmares. She was recently admitted into a crisis unit and the admitting Dr. felt she may be bipolar and need a mood stabilizer. I read about it and was excited as it seemed to fit. Unfortunately it's a different Dr. who has to make the decision and she's going with PTSD and wants to increase her dosage from 10 mg to 20 mg. I am very concerned and am desperately trying to educate myself and advocate for her. I appreciate any suggestions/ info. Have a good day.

  • ronin

    doctors prescribe medication even off-label.

    when you have psychological problems you may receive anti-depressants, ssri's or antipsychotics.

    All are meant to change or influence the working of your brain, eventually leading to damage of the brainstructure.

    You are then bipolar as your brain is out of control and the mood changes up and down.

    When you are then getting antipsychotics, things are going worse and you may get all kinds of comorbities. These may lead to dementia, Alzheimer but also physical disorders as cardiovasculair complaints and attacks.This may end in a premature death.

    see abstract below

    The first systematic review to examine mortality data in bipolar disorder shows that affected individuals have between a 1.5- and 2-fold increased risk for premature death due to these common medical conditions.

    "It appears bipolar disorder is as big a risk factor for premature mortality as smoking. This is a major finding and drives home the message that as psychiatrists we should be regularly monitoring the physical status of our patients with chronic mental illness," principal investigator Wayne Katon, MD, from the University of Washington School of Medicine, in Seattle, said.

    With first author Babak Roshanaei-Moghaddam, MD, the study is published in the February issue of Psychiatric Services.

    Having a major mental illness such as bipolar disorder increases the likelihood of developing physical illness through a variety of factors, including poor diet, smoking, lack of exercise, substance abuse, social deprivation, and a lack of medical care, among others.

    In addition, he said, the chronic stress inherent in having a major medical illness can affect the hypothalamic pituitary adrenal axis, increasing cortisol levels and leading to heightened activity of the sympathetic nervous system, possibly leading to earlier development of medical illness.

    Medication is your last resort to go to.

    Editor's Note: I think we can agree that medications are something to respect and not something to use lightly. Most all medications do have some side effects, some substantial. When there are effective non-invasive alternative treatments it is a good idea to exhaust them first before jumping to medication treatment. But the key word here is "effective". For serious cases of bipolar disorder, psychotherapy, dietary supplements and most other non-invasive treatments have not shown promise as effective primary treatments, whereas some of the psychiatric medications, including lithium and other "mood stabilizers" have. When you have a non-mild case of bipolar disorder, your best treatment bet is frequently medication as prescribed by a knowledgable psychiatrist. The consequences of not obtaining effective treatment are also substantial, and can include suicide and secondary complications such as sexually transmitted disease, financial problems, etc.

    The abstract you quote suggests that there is an increased risk of death associated with bipolar disorder, but the authors are clearly attributing this increased cause of death to lifestyle issues associated with untreated bipolar disorder. They are not suggesting, as you seem to believe, that psychiatric medications are the cause of the increased lethality.

  • Joe

    Before I was diagnosed as bipolar, I was perscribed the antidepresant Lexapro. Very strange things started to happen to me. I didn't sleep for many days and I actually became dilusional dur ring the night. After stopping Lexapro I became very depressed for several years before I got the currage to go back to the doctor and tell them what was going on with me. At that time I was diagnosed with bipolar and perscribed Lamital. It has worked great for me until a couple of months ago when I experienced several major side effects.

    Since being diagnosed with bipolar disorder, I have spent alot of time researching and finding out everything I can about the disorder. Through my research, I have found that there is no cure or miricle drug that exists, rather people who have bipolar have to manage their disorder. I have found that I am best able to manage my bipolar disorder by talking honestly with my doctor, taking my medication as well as learing how to notice "triggers" and by learning how to relax using meditation. When times get tough, I remember that God doesn't put us through anything we can't handle.

  • babyfacemagee

    There is a huge lie being put over the american people. That lie is that antidepressants are safe. The truth is that there are hundreds of thousands if not millions of people that have had absolutely horrible experiences with antidepressants.

    Everything from delusional episodes, violence, apathy, changes of personality, brain shocks, perception changes, horrible withdrawal symptoms and syndromes and even increased depression and emotional dis-association.

    The pharmaceutical companies reluctantly add additional 'side effects' to their prescription labels when in fact they are hiding many of the most severe cases and far from being 'side effects', these are the PRIMARY EFFECTS of many of these drugs.

    The drug companies are out for one thing and one thing only. Money. They have very little regard for the well-being, emotional or otherwise of any person. Spend an hour on google and see the thousands upon thousands of lives ruined with antidepressants unnecessarily.

    The truth is there has never been a case of depression or anxiety that good old fashioned psychotherapy and hard work in figuring out your problems couldn't solve. Drugs are simply a money making machine from the drug companies. By not looking at independent research and data and blindly believing the 'labels' on drugs people are being duped.

    If you bought a car people would say you were a fool if you only looked at the brochure the car company made and that was it before buying the car. The same holds with drugs. People need independent, non-pharma financed evaluations of drugs and today we do not get that.

    the FDA is largely in the pocket of the phama companies with plum job assignments going to former fda members. Stay away from antidepressants. Even the drug companies themselves say they don't know how they work. The truth is they are no different than any other drug a person might take to 'escape' the reality of their lives. Just because the fda puts a stamp on it doesn't mean it's any better than a joint or a few drinks.

    In fact, they are better since they get out of your system after a few hours...unlike ssri's.

  • Anonymous-2

    With all due respect, your comments are sweeping, sweeping, generalizations that are lacking some factual truths. Not only that, your comments are dangerous when they are presented as the ONLY way to address depression or like diseases. Medications are not for everyone, just like all treatments are not for everyone... one size does not fit all. However, many people have found tremendous relief from symptoms of depression and anxiety with the help of medications, including SSRI's. Many people have a quality of life they never knew before starting medications. I see this everyday and have witnessed amazing, positive changes in peoples lives. Drug companies are not the true villains here, misinformation is. Your assertion that there are "millions of people that have had absolutely horrible experiences with antidepressants" is not factual and therefore you shouldn't be stating is as such.

    Not everyone experiences side effects with SSRI's depression is very real (as is suicide) and often doesn't subside with therapy alone and no two people present with the same symptoms or responses to medication, therefore sweeping, blanket statements are not applicable to everyone and could actually cause harm to someone in distress who may take your comments as the ONLY way to address depression.

  • Jay jay

    I would just like to say that some of the comments on here are terrifying to say the least. This is dangerous in itself.... now, if someone who is on the verge of commiting suicide is reading through these web-sites trying to get some very much needed advice of where to turn to reads these kinds of comments, do you actually think they are then gona go to their doctor and ask for anti-depressant help.

    Yes anti-d's do have their drawbacks but they have also prevented thousands of people from going insane and harming themselves. Doctors have to weigh up if the side effects from the tablets out weigh the potential risk from the illness. This is the case in all medicines we take... none are side-effect free!! Also each person is differernt so what works for one person may not work for another, we are all genetically different.

    The main thing is if you feel desparate for help please don't feel frightened to go see your doctor, they have seen your symtoms a thousand times before and have helped people recover a thousand times before... don't give up!!!! and have an open mind to all kinds of therapy including anti-depressants.

  • Spouse from SSRI hell

    I have told my story many times on the net.

    I had a realativly perfect life with a realtivly perfect marriage. My wife had always had OCD, and anxiety issues. I was her calming force for 12 years. When i met her she was hell bent on self destruction, doing many of the things she is now doing again. Only now they are more extreme and my 2 yr old is in her path.

    after the birth of our daughter, she became more compulsive, more bitter, and more angry. She noticed these traits and agreed to counseling. WIthout any test her LIPSW suggested shje go to her doctor and get a perscription for Prozac. At first it was great. The edge came offf and a woman that I kknew was in there for years came out. However the first sign of trouble happened when a close realative died and she said, "I can't cry. I want to cry, I should cry, but I can't."

    Then my frustratioin with her repressed libido bubbled up. It lead to her professing her undying love. Then all of the sudden her libido took off like a rocket. Then I stopped being enough to satify it.

    A woman who had been commited, loving, and the most honest person one could ask for in a relationship flipped 180 degrees. Prior to this there had never even bveen a raised voice arguement in our home. 6 months after starting this drug my wife has been indicted (would have been convicted but i talked the prosecutor out of it.) for assulting me in front of the police, filed for a divorce, left the home, has been caught having phone sex so loud my daughter could hear it, bought toys, gotten on birth control (we never used it, it made her hair fall out.), and i believe may have started a lesbian affair.

    If anybody knows a good doctor who would be decent to hire to speak of these possible affects, plesae let me know. I one dady want my daughter to know the mother that bore her.

  • Anonymous-3

    My husband became severely depressed over the loss of his business. His doctor prescribed an SSRI. Within two weeks, he'd stared an affair with someone he'd met online. Someone in normal frame of mind, he would never have even been friends with because of her lack or morality. Now he has destroyed us and all he can say is I don't know what the hell happened. Apparently, he was told long before I met him that he had bipolar and this set off a destuctive manic episoide. He dissociated so much, he doesn't even remember half of it. He is now more depressed and having panic attacks and still some manic episoides as his doctor has continued to leave him only on the SSRI. Our life together is over in two weeks treatment. Up until this he'd had a cute game called the "5 minute rule". It meant he got a kiss if we were apart for more than 5 minutes - this after ten years of marriage. Scant weeks later he'd left and moved in with another woman he'd just met.

  • steph_david18

    wow, that's crazy. I have been told i am biolar. zzi don't know how many drugs i have tried they work for me but, They make me have a problem. I am a very sexual person with my boyfriend of two years. I had my first orgasm with him. All the drugs i have tried have the side affect of me not being able to have one. Sooo.... I quit taking them i can't not have sex without having one drives me nutts. So if u know of any drug that helps this problem for bipolar people let me know. I want the help i need to notbe the bipolar person i am but i want to keep my orgasms.

  • Anonymous-4

    I have a sister who has been diagnosed with bipolar disorder. She was diagnosed many many years ago and I'm convinced, the diagnosis was questionable. She has always suffered from low self esteem which has driven her to do things that people with a healthy self image would probably not do. She never had any manic episodes (true bipolar episodes) until she started taking depression medication. She started out with just the typical depression meds ..... then she would decide that she just wasn't happy enough and either go off of them or switch to something else. She never received any psychological treatment or counseling. All these doctors did was to push the pills on her. After years of "not being happy enough", the doctors decided in their infinite wisdom that she had bipolar, so now the medication coctail is increased. She's been on every combination of drugs, literally every medication and every combination. She now has lost her balance .... she has problems with her eyesight, terrible dry mouth and cough, vision problems, shaking, rashes, etc. You name it, she's got it. In my opinion, what started out as self esteem issues, control issues, etc that could have been treated by a qualified counselor has turned into "Hotel California" with these mind bending drugs. She will never be the same again, NEVER. So I would suggest for anyone that goes to their doctor and he says "Oh, you just need a depression pill", beware. Medication just masks the problem, it solves nothing. They say that bipolar is a brain chemical imbalance, but there is no known test to validate that, not one. It's a subjective diagnosis in my opinion and one I think that can be caused by the drugs themselves. There have been times in my life when I had self esteem issues, was depressed, anxious, etc. Nobody ever promised us a rose garden. I've had periods of months where I was down because of issues in my life I was trying to cope with. Everyone feels that way at times. Everyone hurts, but you couldn't get me to take a mind altering drug if it was last option on earth. Unless I am diagnosed with Schizophrenia, I would much rather deal with the issues in my life through talk therapy and learning how to think about things differently. This is my experience with a family member who's been in a medication nightmare for more years than I can count now.

  • George Hanson

    I stumbled on this forum because I was researching the effects of SSRI's on people that are bi-polar.

    Beginning in my early 20s I started having depressive episodes a couple times per year--nothing suicidal, but feeling profoundly sad, having anxiety--often leading me to make bad decisions (i.e. briefly dropping out of school). By 27 I fulfilled a life-long dream and moved abroad. Within one year I was back in my hometown, no doubt as a result of being depressed while abroad (often times when depressed I'd think that a major change of whatever situation I was in was the answer--hence the bad decisions).

    My mother had suspected I suffered from depression for years, but I was stubborn and wouldn't hear anything about it. Finally by 30 I had hit such a low that I was ready to see a therapist. After only two sessions I was diagnosed as "dysthymic," which is basically a person who's general mood is melancholy. I liked this diagnosis because it comported with my self-perception, that I wasn't really depressed, just needed a little boost. I was told over and over again how a simple medicine--an SSRI--could easily "tweak" my moods, putting me on track. The therapist put me on Lexapro. And more problems began.

    At first I thought I was doing great. My brother joked that I was on "Sexapro" because I was, well, having sex more! One of my closest friends told me repeatedly that it changed me, making more cocky. I never received any talk therapy in all this time. Within a few years I started to feel depressed again. I was having friction with some of my good friends, all a result of my bad behavior (saying in appropriate things, generally, and usually while drunk--also it made alcohol affect me in a powerful way, exacerbating my inappropriate behavior). One person described it as giving me an ‘edge,’ although not in a good way.

    After becoming unemployed in the Great Recession a year and a half ago, I really hit rock bottom. Shortly thereafter I seriously damaged one of my longest friendships in my life. My mother convinced me to get talk therapy and consider a different medication. I finally agreed. I received talk therapy once per week, and about four months in I was prescribed Lamictal, a mood stabilizer and not an SSRI. My therapist told me I was bi-polar. I always conflated bi-polar disorder with the most extreme cases, and since I’m not an extreme case, it never occurred to me that I could be bi-polar. But now it makes sense: the depressive episodes a few times per year were the one side of the polarity.

    Since going on Lamictal last August, coupled with talk therapy, I have been told by friends and family members that I’m back to being the person they remember—and liked. It’s hard for me to tell, but if that’s what they say, then I believe them. I still have bouts of anxiety and even get sad at times, but I’ll take this over being the dick I was on Lexapro. As for the anxiety, the best way to deal with it is exercise. The anxiety isn’t entirely bad it has driven me to accomplish things, giving me a sense of urgency that I lacked under Lexapro at times.

    So, that’s my story. If you’re considered to be bi-polar, whether extreme or mild, apparently an SSRI in many cases can make things worse, not better.

  • Karen

    In my personal experience and observations of others, antidepressants do NOT help people who are bipolar but trigger mania, insomnia, and panic.

    I regret having ever taken Zoloft, and am still suffering from the damage it has caused me. I have no IDEA why doctors prescribe antidepressants to bipolar people.

    These drugs are dangerous and the public and medical community has been hoodwinked by the pharmaceutical companies claims about them.

  • ella

    I very much sympathize with whoever wrote that comment from Oct 7th. I think I TURNED bipolar I went so insane from being with someone bipolar. It's been hell ever since I met him...

    Also: venlafaxine DOES work RIGHT away (or can). First day I took it I was riding a weird high (turned very good with time). I had almost died of depression/ suicidailty/ starvation, thought there was absolutely no hope. I was shocked that it worked. However, not being on a mood stabilizer, it made me interrupt people and talk too much (VERY unusual for me, I have always been nearly silent)...

    Down side is I didn't sleep for 9 mo. on it properly, that drove me nuts. (Woke up every hour, on the hour, to the minute usually, all night, every night!) I am on bupropion now. All the way up to 450mg. Soooo depressed. But I manage now... I am used to it.... It's so stupid, I get in pits of despair and know there is NO environmental trigger (lately), and no one understands the horror of that. I feel like a broken robot that needs to be pumped with drugs.