ssri switch to mania

[klapmasta]

Maybe this has been covered ad nauseam in past threads, but I thought I'd try to get some discussion going. I'm an psychiatric intern, and we had a grand rounds the other day about anti-depressant switch into mania--something that was beat into my head throughout med school. He presented data from his own research, and had some anecdotal cases of the switch. After, my attending told me he was mostly full of poo, and gave me a meta-analysis from the American Journal of Psychiatry (sept 2004 161:9). The jist is that there's not enough evidence to support this theory for SSRI and MAOI's, but possibly for tricyclics. They found no increased "switch" with SSRI over placebo. They conclude that SSRI is a prudent first-line Tx for bipolar depression.

What do y'all think?

---

Members don't see this ad.

 

[Anasazi23]

We had the same discussion in rounds yesterday. The overall switch rate is small compared to what you'd think considering the hype. Around 5% in some studies.

Still, I have switched a few patients into mania in a desperate attempt to alleviate their bipolar depression. Often they didn't tolerate or failed a trial of lamotrigine. It's not pretty when it happens.

Come to think of it, there was a long-ish thread on this. I have to run but maybe someone can do a search.

 

[Faebinder]

We had the same discussion in rounds yesterday. The overall switch rate is small compared to what you'd think considering the hype. Around 5% in some studies.

Still, I have switched a few patients into mania in a desperate attempt to alleviate their bipolar depression. Often they didn't tolerate or failed a trial of lamotrigine. It's not pretty when it happens.

Come to think of it, there was a long-ish thread on this. I have to run but maybe someone can do a search.

Did you do that with SSRIs or something else?

5% is a lot considering how many people out there are on SSRI, though I bet the high rate was really because the SSRIs were given to those who shouldn't have gotten them to begin with.

 

[Shalom77]

Come to think of it, there was a long-ish thread on this. I have to run but maybe someone can do a search.

Is this the thread you were thinking of?

http://forums.studentdoctor.net/showthread.php?t=460943

 

[Anasazi23]

Yes, SSRIs were responsible. One case in particular I recall was a relatively young patient with 2 serious suicide attempts who was presenting with her third bout of major depression and SI. She was determined to have a bipolar flavor to her, though she didn't fully meet criteria. She developed a rash and acne on a slow titration of lamotrigine that was pruritic and just out of my comfort zone.

I put her on lexapro and she showed up in my office a week later, dressed in a hot pink revealing shirt, a hot pink painter's hat, pink heels, hot pink sweatpants, and pig-tails that were sticking out the sides of both her head. She did some impulsive and nearly dangerous things while "going out" (something very unusual for her) and was giggly, flirtatious, asked me to take her on a cruise. Again...all out of character for her.

She eventually improved with Abilify monotherapy, though it took a while.

 

[whopper]

Given that the STEP-BD shows no real efficacy in the use of antidepressants & treating bipolar depression, and that antidpepressants can cause a switch into mania, I'm not going to treat bipolar depression with an antidepressant unless Seroquel &/or Lamictal has been attempted first for several weeks.

I would consider giving an antidepressant (welbutrin over an SSRI) if 1-I find strong reason to believe the dx of bipolar was inaccurate (I find bipolar highly misdiagnosed) or 2-Seroquel or lamictal have been attempted for several weeks and high doses with no benefit & 3-the depression seems to not fit the subthreshold stimulation theory (e.g. the person's depressed for the same reasons a person with MDD's depressed).

Although there's no data to back it up, I theorize that Abilify may yield some benefit with bipolar depression. Abilify has been found to be effective in keeping bipolar patients stable over the long term (has an indication for it) & it can selectively raise dopamine. If only someone would do a study.

Given the data I've read, I see no reason to put a bipolar depressed person on an SNRI, especially since the data points to those meds causing mania more often, unless that patient was tried on the above for several weeks with no success--& by that time this patient must've been depressed for several months with no success.

 

[Therapist4Chnge]

I put her on lexapro and she showed up in my office a week later, dressed in a hot pink revealing shirt, a hot pink painter's hat, pink heels, hot pink sweatpants, and pig-tails that were sticking out the sides of both her head. She did some impulsive and nearly dangerous things while "going out" (something very unusual for her) and was giggly, flirtatious, asked me to take her on a cruise. Again...all out of character for her.

Don't hold us in suspense like that.....did you go?!!

 

[Anasazi23]

Don't hold us in suspense like that.....did you go?!!

We had a nice time together in the Riviera Maya.

 

[Therapist4Chnge]

We had a nice time together in the Riviera Maya.

Yet another perk for you guys.....quality of life is right!!



I've run into this, and the only thing that really caught my attention was awesome tickets to a very large sporting event. The patient wasn't even mine, but I covered for their clinician at a crucial time in treatment. After a quick talk about boundaries I had to turn it down. Too bad, my team was in the event and won that year.

The patient was quite manic around the offer, so a quick call to the psychiatrist for a consult was needed, ironically an SSRI was involved.

 

[whopper]

Most extreme thing for me was that a patient offered to have sex with me and was undressing in the room. Let's just say she undressed to the point where I could actually smell something. (Occurred during my IM rotation. They intentionally gave me a bipolar patient thinking a psyche resident was better fit to handle her).

I got myself out of that room ASAP for my own protection, and beeped the Chief, who immediately removed me from the service of that patient and gave it to another resident.

Everyday that resident saw the patient, she kept yelling "you're not that cute doctor!!!, who the hell are you!?!?!, I don't want you as my doctor, I want the other resident!"

(Not that I think I'm cute or anything but I guess she thought I was).

Good thing for me was that she was very unattractive. Had she been very attractive, I of course still would've done the same thing--but it would've been somewhat painful for me.

 

[Faebinder]

Most extreme thing for me was that a patient offered to have sex with me and was undressing in the room. Let's just say she undressed to the point where I could actually smell something. (Occurred during my IM rotation. They intentionally gave me a bipolar patient thinking a psyche resident was better fit to handle her).

I got myself out of that room ASAP for my own protection, and beeped the Chief, who immediately removed me from the service of that patient and gave it to another resident.

Everyday that resident saw the patient, she kept yelling "you're not that cute doctor!!!, who the hell are you!?!?!, I don't want you as my doctor, I want the other resident!"

(Not that I think I'm cute or anything but I guess she thought I was).

Good thing for me was that she was very unattractive. Had she been very attractive, I of course still would've done the same thing--but it would've been somewhat painful for me.

 

[billypilgrim37]

Let's just say she undressed to the point where I could actually smell something.

Dude, I just threw up a little...