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4.4.4 Antidepressants


This article is from the Bipolar Disorder FAQ, by barry@webveranda.com (Barry Campbell) with numerous contributions by others.

4.4.4 Antidepressants


Antidepressants (ADs) are part of most people's treatment if their
disease includes severe depression. However, they must be used cautiously by
bipolars. Although ADs normally do not cause folks to get high even when
taken in larger doses than needed, for a significant number of bipolars ADs
can cause mania or hypomania and/or may trigger rapid cycling. This is most
frequently reported with the older tricyclic ADs (like nortriptylene) and
apparently least likely to occur with the AD Wellbutrin. Usually these
undesirable effects can be avoided by using an "AD + mood stabilizer" combo,
but even this does not eliminate the risk entirely. Any bipolar starting on
an antidepressant should monitor their moods carefully and stay in close
contact with their physician until it is clear that these effects do not
appear or appear only to a degree that is acceptable.

Antidepressants can take a really long time to work--six weeks or more--
and then it may take a while to find the AD which works for you, so
the hardest part about ADs is often the waiting!

Antidepressants come in several flavors:


"SSRI" means Selective Serotonin Reuptake Inhibitor.

These are the newest class of ADs and tend to be the first
drugs used these days, although there is no evidence that they
work better than tricyclics or MAOIs.

The SSRIs are: Prozac, Paxil, Zoloft, Luvox, Effexor (partly)

Side effects are: dry mouth, tremor, nausea, insomnia,
drowsiness, anxiety, hypomania, sexual dysfunction.

The SSRIs can cause rather extreme side-effects if they make
you manic (or induce rapid cycling), but they are not very
toxic so they are safest to use with a suicidal patient.


Common tricyclics include: Norpramin (desipramine),
amitriptylene, nortriptylene, Sinequan, Elavil, Anafranil,

The side-effects are the same as for SSRIs--supposedly more
severe, but your mileage may vary.

The tricyclics are generally more sedating than the SSRIs,
and are often used as sleeping pills. They also tend to
cause weight gain.

Tricyclics are quite toxic in overdose, and there is a danger
of accidental overdose, especially when used as a sleeping
pill "as needed."


"MAOI" = "Monoamine Oxidase Inhibitor."

Common MAOIs are: Nardil (phenelezine) and Parnate.

Side effects: Same as above, weight gain.

MAOIs are safer for your heart than tricyclics, so they are
safer to use with elderly patients or patients with heart problems.

MAOIs may be effective in patients who don't respond to SSRIs
or tricyclics. They are thought to be especially helpful
for people who are very tired and numb when depressed and
who can be cheered up/made more active by outside stimulation.

They may also be more effective with "atypical
depression," (more depressed late in the day rather than early,
weight gain rather than weight loss, too much sleep rather than too
little, etc.).

The main problem with MAOIs is that they interact dangerously
with foods containing tyramine (an amino acid). The
combination can lead to acute hypertension (high blood
pressure). This can be very dangerous and cause stroke,
heart attack, or death, though such a severe reaction is rare.
Symptoms of a hypertensive attack are severe headache in the back
of the head, nausea, weakness, sudden collapse.

A partial list of foods to be avoided is: cheese, yogurt, soy
sauce, avocado, ripe bananas or figs, smoked salmon, cured
ham, salami, pickled herring, broad beans.

Caffeine and chocolate should be used with caution.

There are also interactions with many drugs, and you should
not take any medication (including over-the-counter drugs)
without asking your doctor or pharmacist. Drugs to avoid
include: antihistamines, decongestants, any cold remedy,
codeine, amphetamines, Demerol and other narcotic pain
relievers, some forms of general anesthesia.

Because of these interactions with food and drugs, you should
get a Medic Alert bracelet if you are on an MAOI.

Other ADs

Some other antidepressants include:


Thought not to cause mania as much, but can make
people quite hyper and nervous. Side effects are as for the
others, with the addition of a significant risk of seizures
in extreme doses.


Desyrel (trazodone): used mainly as a sleeping pill as it is
not a very effective AD.


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