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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by tom_traubert on November 10, 2004, at 20:03:28
I'm trying to find out if anyone has experienced a manic episode as a result of withdrawal from a tricyclic and benzo, or any for that matter, when bipolar disorder had not been diagnosed previously. I was taking high doses of anafranil and klonopin for ocd for a number of years, and started to drink and smoke marijuana heavily. I soon stopped taking my medication, and rocketed to the moon and came back down just as fast and strong. I went back on the medication, and a few years later did the whole damn thing again. So that's 2 manic episodes filled with every ugly symptom imaginable, followed by 2 long depressive episodes.
At heart, although diagnosed bipolar, the coincindence was too large, and I believe (but would like encouragement) that both manic episodes were preceded by med withdrawal. It's been over 5 years since I've taken any psychotropic medication at all, and it hasn't been easy. I still carry the very prominent fear of relapse, which causes me to question every very good and very bad emotion, which is something I'd like to deal better with. I'm on constant guard against another episode.
The one book I've found that discusses the withdrawal to mania link is "Your Drug May Be Your Problem" which is a good but limited book. They describe the effects of medications quite well, but I strongly disagree with their belief that no one should be on medication. (The meds saved my life at the time I started taking them, and I think that medication helps a lot of people get through a lot of difficult things. Now, this doesn't mean they shouldn't try to get off the drugs if they can, I just disagree with the idea that they should never start.)
My mind would be more at ease, and I think I would have a bit more courage in life if I thought that the manic episodes were strictly a result of the withdrawal, or in combination with marijuana and alcohol use. I would love to hear from anyone with a similar experience and how they got on with their lives. Also appreciated are observations and viewpoints from anyone on this site who'd like to respond.
Thanks.
Posted by ed_uk on November 11, 2004, at 9:47:11
In reply to Looking for similar withdrawal experiences..., posted by tom_traubert on November 10, 2004, at 20:03:28
Hello!
Mania due to antidepressant withdrawal has certainly been reported before (although I've never experienced it myself). It may occur in people with bipolar disorder, but also in people with unipolar depression. Here is a report from the journal of clinical psychiatry....
J Clin Psychiatry. 2004 Jul;65(7):987-93. Related Articles, Links
Antidepressant-withdrawal mania:a critical review and synthesis of the literature.Andrade C.
Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, India. [email protected]
BACKGROUND: Hypomania or mania have rarely been reported to develop shortly after the discontinuation of an antidepressant drug. The true incidence of this discontinuation syndrome is unknown because it may be underreported as a consequence of underrecognition or misattribution. This article examines the possible etiology, nosology, mechanisms, and other aspects of the syndrome. DATA SOURCES AND STUDY SELECTION: A PubMed search was conducted in May 2003 and repeated in January 2004 using the search terms antidepressant and mania. Relevant articles containing adequate descriptions for presentation were retrieved, and their reference lists were hand-searched for further pertinent material. Hand-searches of the indexes of leading psychiatry journals were also performed for the years 1998-2003. Twenty-three articles were identified for review. CONCLUSIONS: Antidepressant-withdrawal hypomania or mania may occur rarely with almost any antidepressant drug after sudden withdrawal, tapered discontinuation, or even merely a decrease in dose. The syndrome may be self-limiting, may abate with the reinstitution of the antidepressant drug, or may require specific anti-manic treatments; mood stabilizers do not necessarily protect against the syndrome. The true incidence of the syndrome is unknown. Narrow and broad diagnostic criteria are proposed for the syndrome, and a synthesis of literature is provided.
A few other reports.........
Can J Psychiatry. 2003 May;48(4):258-64. Related Articles, Links
Switch to mania upon discontinuation of antidepressants in patients with mood disorders: a review of the literature.Ali S, Milev R.
Queen's University, Kingston, Ontario. [email protected]
OBJECTIVE: To review the literature for reported cases of mania related to discontinuing antidepressant treatment, as well as for possible explanations of this phenomenon, and to present a case report. METHOD: We undertook a literature review through the PubMed index, using the key words mania, antidepressant withdrawal, and antidepressants in bipolar disorder. We reviewed 11 articles featuring 23 cases. Where available, we noted and tabulated certain parameters for both bipolar disorder (BD) and unipolar depression. We use a case example to illustrate the phenomenon of mania induced by antidepressant withdrawal. RESULTS: For patients with unipolar depression, we found 17 reported cases of mania induced by antidepressant withdrawal. Antidepressants implicated included tricyclic antidepressants (TCAs) (12/17), monoamine oxidase inhibitors (MAOIs) (2/17), trazodone (1/17), mirtazapine (1/17), and paroxetine (1/17). For patients with BD, we found 19 reported cases of mania induced by antidepressant withdrawal, including our own case example. Of these, selective serotonin reuptake inhibitors (SSRIs) (10/19), TCAs (4/19), MAOIs (2/19), and serotonin norepinephrine reuptake inhibitors (SNRIs) (2/19) were implicated. CONCLUSION: Our case report supports the observation of antidepressant withdrawal-induced mania in patients with BD. It is distinguishable from antidepressant-induced mania, physiological drug withdrawal, and mania as a natural course of the illness. Many theories have been put forward to explain this occurrence. Noradrenergic hyperactivity and "withdrawal-induced cholinergic overdrive and the cholinergic-monoaminergic system" are the 2 most investigated and supported models. The former is limited by poor clinical correlation and the latter by its applicability only to anticholinergic drugs.
J Clin Psychiatry. 1999 Aug;60(8):563-7; quiz 568-9. Related Articles, Links
Antidepressant discontinuation-related mania: critical prospective observation and theoretical implications in bipolar disorder.Goldstein TR, Frye MA, Denicoff KD, Smith-Jackson E, Leverich GS, Bryan AL, Ali SO, Post RM.
Department of Clinical Psychology, University of Colorado, Boulder, USA.
BACKGROUND: Development of manic symptoms on antidepressant discontinuation has primarily been reported in unipolar patients. This case series presents preliminary evidence for a similar phenomenon in bipolar patients. METHOD: Prospectively obtained life chart ratings of 73 bipolar patients at the National Institute of Mental Health were reviewed for manic episodes that emerged during antidepressant taper or discontinuation. Medical records were utilized as a corroborative resource. Six cases of antidepressant discontinuation-related mania were identified and critically evaluated. RESULTS: All patients were taking conventional mood stabilizers. The patients were on antidepressant treatment a mean of 6.5 months prior to taper, which lasted an average of 20 days (range, 1-43 days). First manic symptoms emerged, on average, 2 weeks into the taper (range, 1-23 days). These 6 cases of antidepressant discontinuation-related mania involved 3 selective serotonin reuptake inhibitors (SSRIs), 2 tricyclic antidepressants (TCAs), and 1 serotonin-norepinephrine reuptake inhibitor. Mean length of the ensuing manic episode was 27.8 days (range, 12-49 days). Potential confounds such as antidepressant induction, phenomenological misdiagnosis of agitated depression, physiologic drug withdrawal syndrome, and course of illness were carefully evaluated and determined to be noncontributory. CONCLUSION: These 6 cases suggest a paradoxical effect whereby antidepressant discontinuation actually induces mania in spite of adequate concomitant mood-stabilizing treatment. These preliminary observations, if replicated in larger and controlled prospective studies, suggest the need for further consideration of the potential biochemical mechanisms involved so that new preventive treatment approaches can be assessed.
Hope this info is helpful...
All the best,
Ed
Posted by tom_traubert on November 11, 2004, at 11:05:06
In reply to Re: Antidepressant-withdrawal mania, posted by ed_uk on November 11, 2004, at 9:47:11
> Hope this info is helpful...
> All the best,
> Ed
>
>Very helpful, thank you. The Journal looks like a great reference tool. Glad to know about it.
Thanks again,
Tom
Posted by jujube on November 11, 2004, at 11:41:56
In reply to Looking for similar withdrawal experiences..., posted by tom_traubert on November 10, 2004, at 20:03:28
I am sorry to cut into your thread, but I have some questions for you about Anafranil, if you don't mind.
My doctor recently prescribed Anafranil for me, but I haven't yet started it. I have received a lot of good and reassuring information from others on the board about it's effectiveness, which I greatly appreciate. But, I wanted to know from one other person who has taken the drug before the following: how bad the side effects were; did they subside; did you experience any cognitive impairment (e.g., memory loss, slowed thinking); did your energy levels improve; and did you experience any apathy, lethargy, or a lack of motivation? I am to start at 25 mg and a week later go up to 50 mg. I want to stop being afraid of the medicine and start taking it because I can't stand this depression anymore.
Anything you can tell me would be greatly appreciated. I know I am being neurotic about this, but I have never been on a TCA before.
Thanks, and again I apoligize for highjacking your thread with my neurotic questions.
Take care.
Tamara
Posted by tom_traubert on November 11, 2004, at 17:15:34
In reply to Re: Looking for similar withdrawal experiences... » tom_traubert, posted by jujube on November 11, 2004, at 11:41:56
It's difficult for me to give you an accurate depiction of how anafranil at those doses affects you. I was on the highest safe level (something around 200mg/day I think or maybe 275) also with 1.5mg/day Klonopin. Now, I know that a lot of the fatigue and sleepiness is probably from the Klonopin. I was tired, and no I couldn't concentrate that well, but I don't know if that was the depression or the medication. Apart from that, I had the garden-variety side effects of constipation, dry mouth, heartburn, loss of sex drive, and impaired sexual function (delayed ejaculation). I got dizzy if I stood up too quickly, and was just plain kind of sedated, which was a welcome state at that time.
Let me say again that the meds pulled me out of a terrible time in my life filled with panic attacks, deep depression and nonstop ocd symptoms. In six years I put so much medication in me and hardly ever once discussed how I was feeling or tried to consciously and energetically look my emotins and fears. Instead the doctor focused on symptoms. It's not his fault, it was his job, and I was probably too scared to talk about anything.
You didn't mention that ocd was your problem, you listed depression. I hope you know that Anafranil is mainly for ocd. I don't know if you've been on other medications, or if this is your first, but if it is I'd say try to avoid medication at all reasonable costs. Don't punish yourself, however, just explore your options. If your life is upside down, and nothing else has helped, then hopefully the meds can fill that gap.
But if you are new to the world of pschotherapy and psychiatry, again, I would really earnestly try to find a Cognitive Behavioral Therapist, one who believes that medication is only one of many possibilties, not necessarily the first and lifelong one. 99% of the people on this site are on meds for very very difficult problems and I don't fault them one bit for being on medication. For many it was a courageous act just to start. I'm just saying to try something else
if you can, because that's what I personally wished I would have done had I the knowledge or guidance.If you do start on medication, NEVER abruptly discontinue, wean yourself off. I made that mistake and paid the price, almost with my life.
Hope this helps,
Tom
p.s. every question on this site is neurotic, that's why we're here, so don't be afraid to ask.
Posted by jujube on November 11, 2004, at 17:36:01
In reply to Re: anafranil inquiry, posted by tom_traubert on November 11, 2004, at 17:15:34
Thanks for the response. I am being treated for depression and anxiety. In the past year, I have been on Paxil, Prozac, Effexor and now Celexa. None of them have seemd to help relieve the depression. My pdoc and I discussed TCAs as the next option, and I would have preferred something like Nortrityline, but he prefers Anafranil (he's been practising for probably about 30 or more years). I know that Anafranil is primarily used for OCD, but I guess he also thinks it is very effective for depression and has used it for such in his practice. I think it is approved and used for depression in other countries, but is only FDA approved for OCD. I'm very concerned about sedation and cognitive impairment, but maybe at a lose dose it won't be such a problem. If it is, I'll have to stop. Because of the work that I do, and the environment that I work in, I have to rely heavily on my memory and my ability to think fast and make decisions.
Well, thanks again. I think tonight is going to be my first dose. Actually, I am just finishing dinner, and am supposed to take it at dinner time. So, here goes nothing.
Tamara
Posted by ed_uk on November 12, 2004, at 7:43:19
In reply to Re: anafranil inquiry » tom_traubert, posted by jujube on November 11, 2004, at 17:36:01
Here in England, Anafranil has always been approved for depression as well as for OCD. There's plenty of evidence that it's effective for depression- so don't worry about that!
Ed
Posted by jujube on November 12, 2004, at 16:49:21
In reply to Re: anafranil inquiry, posted by ed_uk on November 12, 2004, at 7:43:19
Thanks Ed. I think I have been more worried (obsessed actually) with the side effects. I was just worrying that I would end up being a lethargic, brain dead person who walks around with a big, happy smile on their face.
Tamara
> Here in England, Anafranil has always been approved for depression as well as for OCD. There's plenty of evidence that it's effective for depression- so don't worry about that!
> Ed
Posted by Keith Talent on November 13, 2004, at 22:49:50
In reply to Looking for similar withdrawal experiences..., posted by tom_traubert on November 10, 2004, at 20:03:28
I experienced a dysphoric hypomanic episode upon discontinuing amitriptyline. Clomipramine might be expected to be worse, as it is more potent at blocking serotonin reuptake and its metabolite desmethylclomipramine is stronger at blocking noradrenaline reuptake, than amitriptyline. I take clomipramine now and find it better than any other antidepressant. There seems to be no problem starting at high doses, but there is a problem stopping - a slow taper is necessary.
Posted by tom_traubert on November 28, 2004, at 22:27:54
In reply to Re: Looking for similar withdrawal experiences..., posted by Keith Talent on November 13, 2004, at 22:49:50
Thanks Keith. Sorry to wait so long to respond, the page changed with the week and I neglected to look at the thread.
May I ask if you had been diagnosed bipolar before your withdrawal expierence and if you ever had another hypomanic episode?
thanks again,
tt
This is the end of the thread.
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