Bipolar disorder actually refers to a group of mental health conditions that feature alternating and unpredictable mood states. These conditions are sometimes referred to in terms of the “bipolar spectrum.” Mania, an intensely elevated or euphoric mood, and depression are the mental states typically associated with bipolar disorder. Doctors classify the various subtypes of this disease based upon the severity and occurrence pattern of mania and depression. Bipolar II disorder, for example, entails a higher rate of major depressive episodes, with relatively few instances of mania. Appropriate treatment for all forms of bipolar disorder involves regular cognitive therapy sessions and mood stabilization via pharmaceutical interventions. Doctors may prescribe an indefinite course of psychotropic medications to prevent a patient from lapsing into either depression or mania.

The antidepressant medication Prozac (fluoxetine) is part of a typical treatment plan for those suffering from bipolar II disorder. Prozac works by altering the ratio of certain chemicals within the brain. Rigorous testing has confirmed that this medication is both safe and effective, with relatively minor side effects in most patients. The current guidelines for bipolar II treatment recommend discontinuing Prozac within several weeks of depression remission, because clinicians suspect that prolonged antidepressant therapy may trigger a manic state. The mood stabilizer lithium is therefore preferred for long-term maintenance therapy. A team of clinical investigators set out to challenge the notion of Prozac’s danger, testing Prozac against lithium in a double-blind, placebo-controlled study in a group of individuals with bipolar II disorder.

All participants in the study had recently recovered from a depressive episode with the assistance of Prozac. One group was switched to lithium, one to placebo, and one continued on Prozac. Participants were blind to their treatment condition, and the study moved forward for 50 weeks. Psychiatric interviews and patient self-reporting helped pinpoint relapse events and overall mental health status. The results of the study were surprising even to the researchers. Those taking lithium were 2.5 times more likely to relapse than those taking Prozac. Similarly, the time to relapse, when it did occur, was far longer with Prozac than lithium. Most importantly, episodes of mania in the Prozac group were not significantly greater than either the placebo or lithium group.

Conventional wisdom argues against maintenance treatment with antidepressants for bipolar individuals. However, recent study results have challenged that wisdom, at least in the case of bipolar II disorder. For those suffering from this variety of the disease, long-term treatment with Prozac appears to be safe and effective for both preventing relapse and staving off manic episodes.

References

1. Amsterdam, J.D. & Shults, J. (2010). Efficacy and safety of long-term fluoxetine versus lithium monotherapy of bipolar II disorder: a randomized, double-blind, placebo-substitution study. American Journal of Psychiatry, 167, (7), 792-800.
2. Fluoxetine – PubMed Health. (n.d.). National Center for Biotechnology Information. Retrieved April 11, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000885/

Major depressive disorder (MDD) is more prevalent in the pediatric population than previously believed. According to some estimates, between 2% and 8% of children and adolescents have mood disorders. Depression in childhood often predicts recurrent episodes of depression later in life. This population is also at heightened risk of psychiatric disorders, substance abuse, social maladjustment, homelessness, and criminality. Clearly, depression in young people is not a problem that can be safely ignored. Early therapeutic intervention is essential and usually consists of cognitive-behavioral therapy and medication. Currently, the only antidepressant medication approved for use in children and adolescents is Prozac (fluoxetine). However, the lasting effects of Prozac exposure during youth are still not completely known. Conventional wisdom suggests that the benefits of treatment likely outweigh long-term risks, particularly in cases of MDD.

The adolescent brain, just like the adolescent body, experiences profound and rapid development. Chemicals in the brain called neurotransmitters direct cellular and structural growth throughout the brain, and this process gives rise to the adult brain: a well-regulated, stable organ that manages consciousness and the central nervous system. During the period of rapid growth, any disruptions or chemical stimuli can lead to functional changes later in life. For this reason, antidepressant use in childhood has come under great scrutiny. Prozac alters the balance of neurotransmitters in the brain. Some have argued that Prozac exposure during adolescence may result in lasting, even permanent behavioral changes. Researchers conducted a controlled experiment with adolescent rats to address some of these issues.

Rats given Prozac during adolescence displayed significant behavioral changes when tested as adults. For example, they showed less response in a forced-swim test and more response to anxiety-producing situations, such as a new environment. The increased anxiety was reduced by a second exposure to Prozac. Most disturbingly, sexual behavior in adulthood was impaired by Prozac taken during adolescence. This finding was completely unexpected. However, the researchers cautioned that the relationship between brain development and behavior is enormously complicated, and the current study only highlights this complexity. How much of these results translate to humans is also an open question. Rats are typically used in these studies because they mimic human physiology and neurobiology. Still, the underlying mechanisms of behavior are not well understood.

The adolescent rat study, among others, adds powerful evidence to the argument that Prozac initiates profound changes in the brain. These changes manifest themselves as behavioral and mood alterations. Human research is necessary to determine the scope of these alterations. As it stands, prescription of this antidepressant for children with MDD is still warranted.

References

1. PubMed Health. [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Fluoxetine. Retrieved April 11, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000885/
2. Iniguez, S. D., Warren, B. L., Bolanos-Guzman, C. (2010). Short- and long-term functional consequences of fluoxetine exposure during adolescence in male rats. Biological Psychiatry, 67(11), 1057-1066.

Since my last blog, Depression Medications: How Can You Get Your Libido Back? a number of you have asked for more information about possible sexual side effects caused by antidepressants. Before I say more—a cautionary word—I’m a psychotherapist/counselor, not a medical doctor/psychiatrist. So what I write in this blog is drawn from my (extensive) experience working with people who have challenges and/or difficulties with sex—I’m a sexologist, not a psychopharmacologist!

Some of the worst culprits, or libido smashers, are the selective serotonin reuptake inhibitors (SSRIs) such as Effexor, Paxil, Prozac, and Zoloft. Unfortunately, these are all heavily prescribed. I mentioned last month that many folks can benefit from a so-called “drug holiday,” when they forgo their medication for a few days. Be aware that this intervention does not work for Prozac. This is due to the much longer period of time that Prozac remains in the bloodstream, compared to the other shorter-acting SSRIs, like Zoloft.

Several types of antidepressants have virtually no side effects. The most common ones that I hear about are Wellbutrin, Xanax, and Klonopin. I’ll often suggest, to the new people I see, substituting (with the agreement of their medical doctor, of course) Xanax or Klonopin for Wellbutrin because the latter can exacerbate anxiety or “agitated depression,” as it’s called by psychiatrists.

Wellbutrin is also infamous for causing insomnia and headaches, which tend to make most of us anxious, and it certainly doesn’t contribute to an enjoyable sexual connection! Wellbutrin is pharmacologically distinct from the SSRIs, as it enhances the neurotransmitter dopamine, which has the opposite effect on libido and orgasm of serotonin. Xanax and Klonopin are usually prescribed to combat anxiety, not serotonin, so they tend to have very few sexual side effects.

I will often recommend that people who are leery about psychotropics try St. John’s Wort, which is most effective, I’ve found, for Type A blood types (remember, I’m not prescribing, just using anecdotal experience to make these suggestions!). Because it’s not regulated as a pharmaceutical substance, I’m told that efficacy can vary widely.

[fat_widget_left] The individuals I see in my office have reported that Viagra is effective for SSRI-induced absence of orgasm, and I’ve known people of both genders who swear by the botanical preparation ginkgo biloba to reverse libido, arousal, and/or orgasm problems. One sex therapist colleague tells me that Viagra can be helpful for women as well, but no one I work with has directly reported this to me.

If switching to an alternative psychotropic is not clinically appropriate or effective, some doctors might recommend adding another medication on a daily or as-needed basis. Many people are hesitant about taking one drug, let alone two! But for those who are comfortable with it, a second medication can often offer an antidote to the side effects of an otherwise helpful medication.

Most commonly, a sexual-savvy psychiatrist will prescribe a single low dose of Wellbutrin for people complaining of sexual side effects from other antidepressants—employing lower does of Wellbutrin than would be necessary to treat depression alone. These small doses can restore the serotonin-dopamine balance that I mentioned earlier, alleviating sexual side effects.

People starting out with me often ask if I suspect that their sexual problems are relationship issues or caused by medication. I always ask them how long the sexual challenges have been occurring. SSRI-induced sexual dysfunction follows a fairly typical pattern: it begins within days or weeks of starting the new psychotropic medication. For example, a woman may report that she can no longer reach orgasm with her husband within weeks of beginning Prozac for obsessive compulsive disorder.

Women rarely volunteer this immediately, but I ask LOTS of questions, which makes it easier to discuss sexual concerns. Men usually have less hesitation talking about such problems, and as one man said to me recently, “that’s why we came to a sex therapist and not the marriage therapist down the street!” The fact that I coach by phone also seems to help, especially for men, who might have difficulty opening up “when the plumbing doesn’t work!”

Don’t forget—if you have questions about your medications, make sure to discuss them with your medical doctor or psychiatrist.