Expert: Ivan Goldberg, M.D. - 11/11/2007

Question
QUESTION: Dear Sir,
How can SSRI induced mania be a good argument for diagnosing someone with Bipolar disorder when that person, has never had a manic reaction before medication.  When the person is taken off the medication, the manic symptoms go away. Isn't it reasonable to say that any kind of substance can lead to a bad reaction?  What if someone takes 'speed' for the fun of it and parties....they are feeling euphoric....when the effect wears off, they are free of symptoms...but that doesn't mean the person is Bipolar!!!!  And SSRI's or SNRI's are drugs..and can have an euphoric effect (or the opposite) in individuals who don't metabolize the medication as other people, or that acts on receptors that don't need any stimulating!!! therefore resulting to changes in behaviour...This is my logic...

I know some psychiatrist describe this as being Bipolar Type 2 or Bipolar Spectrum Disorer NOS.

What is your opinion on this?

ANSWER: Hi Jennifer . . .

Great question and I think I understand your position.

I disagree, and here is why. Let's say that someone takes a drug (prescribed or street) and they have a reaction that includes the symptoms of mania. If the symptoms disappear in a few hours the manic symptoms would be considered to be the direct result of the immediate effects of the drug on the neurochemistry of the brain.

BUT, lets look at another situation. Someone takes a drug that causes mania. The mania lasts for one week, the duration necessary under the DSM to make a diagnosis. In that instance rather than the mania being a manifestation of an acute intoxication it seems to have a life of its own.

In the real world, the only people in whom I have seen antidepressant-induced manias have been people with a definite family history of bipolar disorder. There is obviously no way to say if such people would have eventually had a manic episode if they hand not taken antidepressants, but it sure looks as if the antidepressants uncovered a bipolarity that was present, rather than inducing bipolarity in someone with no endogenous bipolar diathesis.

Of course, you could argue that a drug like Prozac stays in the body for weeks after it has been discontinued, but lengthy drug-induced manic episodes have been seen following the discontinuation of antidepressants with very short half-lives.

Best regards . . .
Ivan
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---------- FOLLOW-UP ----------

QUESTION: Dear Sir,
So what you are saying is that if an antidepressant causes mania for more than a week, then this probably uncovered a bipolarity that was present.....but if someone were taking street drugs and experienced mania for a week, then it's more likely an intoxication.  Both illicit drugs (marijuana) (lsd) (speed) etc... and SSRI's SNRI's MAO's affect brain chemistry.  I'm confused.

The people in whom you have seen indepressant manias, had been taking their antidepressants for a long time?  
How long after taking an antidepressant can a person experience mania?  In my logic, if mania happens after only a short time, then this is most probably a bad reaction to the med and not mania...something like a 'bad trip' even though the person might be feeling euphoric....but what if it happens after 10 years? I'd be inclined to consider this more of a probable mania because if the med has stabilized the patient for 10 years, it makes sense to say the medication rebalanced the brain chemistry to a more normal functioning and for someone to suddenly feel more euphoric for no reason, it makes more sense to me to call this a mania.   I find this subject very interesting but baffling.  It just isn't clear and I guess there is not way to be 100% certain.....I just find it sad that a person has to be taking more meds for something that has yet to be proven with 100% certainty.  

Sincerely,
Jennifer

Answer
Hi Jennifer . . .

I am sorry that my reply to your original query was not clear. What I am saying is that if someone with a street drug OR a prescribed antidepressant has a brief manic episode that is probably simply the result of the acute effects of the drug on brain neurochemistry. BUT, if the reaction lasts for a lengthy period of time, weeks or months, the mania is probably a manifestation of a bipolar diathesis that probably results for genetic factors.

As I mentioned in my initial reply the people in whom antidepressant-induced mania occur are mostly people with a strong family history of bipolarity in their families.

As you probably know, the DSM system does not allow drug-induced manic episodes to contribute toward the diagnosis of bipolar disorder. They essentially agree with your position, not mine. Many psychiatrists with extensive experience believe that the next edition of the DSM should correct what we see as this error. I have no idea how successful we will be in this.

Best regards . . .
Ivan
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