Antidepressant side effects?

February 24, 2007 7:24 AM

How frequently do antidepressants create behavioral abnormalities like OCD, low impulse control, or mania? How does that work? Is it due to misdiagnosis, drug interaction, or abnormal drug tolerances?

I've had a number of students and a couple of friends claim that a period of unusually bad behavior was due to weird side-effects from antidepressants: sometimes they seem to become drunk after a single beer, other times they say they became unable to control themselves and started engaging in really risky behaviors. One guy said, "It was like the moment I considered something I was already doing it." In his case, 'it' was heroin, and a disaster.... I'm curious about how this works from the neurological perspective. Are some drugs (SSRIs, for instance) more likely to create this problem than others? Perhaps related is the FDA study that showed teenagers were more likely to commit suicide when prescribed antidepressants.

I'd be satisfied with some sense of what this is called or how to google for it. I haven't been able to find anything in the morass of mental health information and advertisements, but I'm guessing this is due to over-broad search terms.

posted by anotherpanacea to science & nature (26 comments total)

We'll take antidepressants here to mean SSRIs, as they're the most commonly prescribed agents nowadays.

They're used as treatments for OCD, often with good effect, so I believe we can lay that to one side. I'm not familiar with the idea that they would be thought of as a cause that syndrome.

Disinhibition and clinical mania are not uncommon side effects from these agents, I believe you'll probably find those effects listed under those names in the package inserts and PDR. I tend to view the one as just an extension of the other.

SSRIs are chemical mimics of the monoamines, which include serotonin as well as dopamine and norepinphrine. We should like to believe that the drugs were specific for the serotonin reuptake transporter on a certain subclass of serotonergic neurons, but that is known to be untrue; the drugs have various degrees of affinities for various receptors of all three mononamines, and there are a couple dozen of these receptors.

Serotonin is important to mood; dopamine affects initiation and maintenence of muscular movement, as well as pleasure and reinforcement; norepinephrine is important in arousal, wakefulness, and level of activity. The medicines affect all these things.

Because different people are differently constituted, the meds affect them differently - I wish we had better ways of understanding this, as do most folks who prescribe these. We do think that if a person has bipolar disorder, or a predisposition towards same, that an SSRI has a higher-than-usual chance of inducing mania; but a few moments' reflection on this will reveal the semi-circularity of that proposition.
posted by ikkyu2 at 7:56 AM on February 24, 2007 [1 favorite]

One helpful term for googling is "treatment-emergent mania." This is sometimes a problem for patients with bipolar disorder, especially if they are can be misdiagnosed with unipolar depression (easy to do, since they generally spend much more time in the depressive state than in the manic state) and are not taking concurrent mood stabilizers. I'm not sure of the incidence of treatment-emergent mania in correctly diagnosed depressed patients, though.

(on preview, listen to the good doctor)
posted by twoporedomain at 8:04 AM on February 24, 2007 [1 favorite]

The search terms you're looking for are "SSRI side efffect profile". You'll still have to do some manual sorting however.
posted by tkolar at 8:04 AM on February 24, 2007

Different SSRIs do have different profiles and affect different people differently.

Sertraline/Zoloft triggers OCD in some people, but has nothing like that effect in me.

When I was taking Paxil/paroxetine I slept most of the time, but when I was awake my moral compass was gone. I could do anything I felt like just by deciding to. Even if I knew intellectually it was a bad idea, that didn't translate into feeling bad about doing it. (That year I had an affair with my boss. My boss was a man. I was a lesbian. And the paroxetine had *totally killed my libido* and eliminated the possibility of orgasm. At the beginning of the affair I told him that he would fire me when the affair was over. He said that was ridiculous, but did just that when the time came.)

Other people who take paroxetine have no such problems. Nothing like them at all.

If you read the patient inserts for SSRIs you get a list of possible side effects like sweating and rash and headache and sleepiness, but sleeping with your boss is not on the list. That's why I reccommend only accepting prescriptions from psychiatrists - not family physicians - because they see a lot of this stuff and have a feel for it.

As mentioned above, people who are bipolar are more likely to become manic when taking antidepressants, and bipolar people are often misdiagnosed as depressive. This is not just because bipolar people spend more time depressed than manic, it's also because the depression feels bad and the mania doesn't. So people present for treatment of depression, and when asked if they are ever manic they say no - because manic is what they feel they should be all the time.

So that's another reason to see a psychiatrist even for something as easy to treat as depression, even for something as easy to prescribe as an SSRI. A psychiatrist is more likely to pick up on signs of mania and to prescribe a mood stabiliser instead of or together with an antidepressant if warranted. (When I say 'mania' I'm also including hypomania, which is the version of mania where you can be highly functional and effective. Mania is neither. People with bipolar II have full-blown suicidal depressions alternating with truly great hypomanic periods.)

And yes, SSRIs can make people more sensitive to alcohol. I personally don't notice that effect because I've always been a cheap drunk anyway and I don't drink that much to begin with. So maybe sertraline affects me that way, maybe it doesn't. But it definitely affects some people that way.
posted by kika at 9:42 AM on February 24, 2007

The only thing I can offer is my own personal experience. When I was 13, I was prescribed Prozac. I don't remember how long I took it, but I got nothing from it. It didn't do what it was supposed to, and there weren't any side effects either.

About two years later, I was prescribed Zoloft for anxiety. It didn't seem to do much either, but this time something did happen. It was around that time that I started exhibiting OCD symptoms. Coincidence? I don't know. Possibly, since I still have symptoms of OCD. Back in those days, I also suspected that I was possibly bipolar. The more mild form with hypomania as opposed to full blown mania. I no longer take Zoloft, and I no longer exhibit hypomania. At least I don't think so. And one last bizarre side effect, though it's not really what you're asking for, from time to time I would get this.. zap feeling in my head. Very odd feeling. And thankfully, it went away as soon as I stopped Zoloft.

So I'm quite suspicious of SSRIs these days.

I'm glad you asked this question because it's something I've been quite curious about.
posted by VegaValmont at 10:02 AM on February 24, 2007

"Disinhibition and clinical mania... I tend to view the one as just an extension of the other."

Speaking from personal experience, I believe you're mistaken in that view. They can occur separately, even while taking an SSRI.

(General question for all: has anyone else noticed Wellbutrin/Zyban or Cymbalta causing/aggravating migraines? I had to go back to the SSRI Lexapro, despite its side-effects.)

On preview, VegaValmont, if you mean a physical "zap" feeling, almost like a small electrical shock, I got that when I was on a high dose of Zoloft too; I'd also hear a high-pitched "ka-ching" kind of noise when I turned my head quickly.
posted by davy at 10:21 AM on February 24, 2007

I'm a psych RN and can tell you that it's hit or miss. Our docs try drugs with the fewest side effects first, then if not effective or SE aren't tolerable they taper off and onto the next... I've seen patients go through ten or more different meds before finding the one that works. Of course this is done in a hospital, with close monitoring and alot of lab work. Basically you can't tell what will work for any one person or their specific problem (s). Especially with psychiatric drugs.
posted by bkiddo at 10:22 AM on February 24, 2007

Psych drugs do not mix with alcohol. Someone who needs psych meds should not take recreational drugs, or drink. SSRIs don't cause OCD/ impulsivity. The personality/ chemical imbalance that already exists (hence the need for the meds) can be less obvious if that person is depressed- so yeah if someone is naturally inclined to risky behavior, and takes SSRIs, feels great and goes on a bender, their behavior can ... get them in trouble. People with mental illness struggle even when properly medicated.
posted by bkiddo at 10:29 AM on February 24, 2007

Oh and personally I don't mind a little hypomania myself, so it took 'em a while to peg me as "Bipolar II". In the past several years I haven't been made to get treatment for the upswings, though a few docs have recommended "stabilizers" like Depakote -- I just don't want to.

And about the non-SSRI Bupropion (Wellbutrin/Zyban), I have noticed though that kept me awake and made me grumpier and quicker to take offense than usual.
posted by davy at 10:32 AM on February 24, 2007

Another bipolar 2 here, who takes Lamictal

Occasionally I will have a small bit of scuppernong wine at my folks' house. I get mildly fuzzy after a few sips. Which is why I plan to only have a few sips if any.

Any real drinking is verboten for me, obviously.
posted by konolia at 10:55 AM on February 24, 2007

Oh, and when I first started my med journey (on zoloft) life was wonderful all the time until the panic attacks started a few months later. Which is how my diagnosis changed...
posted by konolia at 10:56 AM on February 24, 2007

There is a very large collection of people's accounts of their experience with psychoactive substances of a rather disturbingly wide range of kinds at the Vaults of Erowid. Many of the stories are very detailed and compelling; almost all are interesting. I've spent hours and hours looking at these narratives and trying to understand what they could mean.

Here is a link to the section of the site devoted to psychoactive pharmaceuticals; it includes general information such as chemical formulas and prescribed uses, and selected external links as well as user's renditions of their experiences. The introductory paragraph:

Psychoactive Pharmaceuticals are over-the-counter or prescription chemicals approved for human medicinal use. The inclusion of chemicals in this list is not intended to suggest that they are necessarily used recreationally. The substances described have mind- or emotion-altering properties or may be listed because they have possible interactions with recreationally used chemicals.

posted by jamjam at 11:49 AM on February 24, 2007

Mixing Bupropion, Lexapro, booze and pot was fun. For me at least.
posted by davy at 11:53 AM on February 24, 2007

davy: To be more clear, I mean to say that clinical mania is an extreme point on a spectrum that also contains disinhibition. One can certainly be disinhibited without being manic, but I find it hard to imagine that the reverse can be true.
posted by ikkyu2 at 12:03 PM on February 24, 2007

SSRI antidepressants are a scandal. They help many, but play a big role in destroying many lives as well. Everyone is different. I highly recommend the books of Joseph Glenmullen, M.D. He also has a website at ProzacBacklash.com
From that site:
Harvard psychiatrist Joseph Glenmullen's new book The Antidepressant Solution: A Step-by-Step Guide to Safely Overcoming Antidepressant Withdrawal, Dependence, and "Addiction," can now be ordered online. The Antidepressant Solution is a menu, or cookbook-style program, for tapering safely and comfortably off antidepressants. In a series of historic warnings in 2004, the FDA has asserted that "adult and pediatric patients" on antidepressants can develop an array of side effects, including "anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia (severe restlessness), hypomania, and mania" that may make them suicidal "when the dose either increases or decreases," that is whenever the dose changes. The Antidepressant Solution includes a chapter on how changing the dose of antidepressants up or down may make patients suicidal. The Antidepressant Solution provides the information you and your doctor need to ensure your comfort and safety whenever you start an antidepressant, change the dose, or go off the drug. A reassuring book from one of the leading experts on antidepressant side effects, The Antidepressant Solution is the antidote to the recent alarming news about these drugs.

Good luck!
posted by Gerard Sorme at 12:11 PM on February 24, 2007

Thanks all. The search term I needed was 'disinhibition,' but please feel free to continue discussing this. My own interest stems from attempts to model of the brain's role in happiness. ikkyu2's point, that antidepressants still haven't managed to isolate serotonin the way we would like, is particularly helpful. I've also read that there are more than one sort of serotonin receptor, which complicates the matter of re-uptake inhibition still further.

The three-neurotransmitter model gives an extremely interesting model of the brain and of psychopathology, since it gives us ways to understand the interactions of mood, 'gumption,' and alertness. It sounds like the problem in these cases is tied to SSRIs interacting with dopamine in troubling ways, such that patients receive both an elevated mood and troubling pleasure/patterning effects, which shade over into anxiety and sleeplessness as well. Sadly, I suspect that there is insufficient warning given to depressed patients about the interaction of alcohol and SSRIs, let alone admissions of possible misdiagnosis to monitor. Scary stuff.
posted by anotherpanacea at 1:31 PM on February 24, 2007

Sadly, I suspect that there is insufficient warning given to depressed patients about the interaction of alcohol and SSRIs

Dunno. Every SSRI prescription bottle I have ever received has had a bright yellow warning sticker specifically about alcohol interactions.

I suspect patient error and/or "warning fatigue".
posted by tkolar at 1:46 PM on February 24, 2007

"One can certainly be disinhibited without being manic, but I find it hard to imagine that the reverse can be true."

Ah, okay. I thought back and realized that I was not inhibited about complaining to my friends and family that I was inhibited about doing all kinds of things because the CIA was out to get me. (Is it still "hypomania" when there's sleeplessness and rampant paranoia?)
posted by davy at 2:06 PM on February 24, 2007

Oh, that "CIA-victimization" episode was before I was prescribed an SSRI; the only meds I was on then were aspirin and caffeine, and less of those given the anxiety and stomach acidity. Since going on SSRIs I've been spared from undue paranoia, and on a high enough dose I forget anybody might object to me for any reason. (Yay disinihibition!)
posted by davy at 2:10 PM on February 24, 2007

davy, that's exactly right. It did feel like an electric shock. I didn't get high-pitched noises. I'd never heard of that before, but it's not surprising. It was alarming because I was 15 and I should've been starting to learn how to drive. And you know.. what if I was out driving and "the zap" happened? I was always afraid that if that happened I would get into an accident. No worries about that anymore..

Anyway... I mentioned before that I'm suspicious of these SSRIs, but I'm not entirely against them. I know they do a world of good for others. Including some of my family. I don't think they ever worked for me because I don't think they're what I need, but that's an entirely different discussion.. But something to keep in mind I guess would be that this is all still relatively new territory. I wonder how things will progress. I hope someone can make progress and bring forth better medications/treatments.
posted by VegaValmont at 3:59 PM on February 24, 2007

well, i never had any problems with SSRIs (i took several, to no effect, really), but, for awhile, i was taking clonazepam (sold as klonopin, sometimes), a benzodiazepine antianxiety/sleeping pill. i mean, on the one hand, shit was fantastic, but, in addition to developing a bit of an addiction to the stuff, i seemed to lose most inhibition while i was taking it. this culminated in my threatening to stab a particularly assholish fellow student in the middle of a painting critique... wish a screwdriver. the alcohol thing certainly sounds in keeping with antidepressants.
posted by wreckingball at 7:39 PM on February 24, 2007

I've heard about the potential for addiction with anxiolytics like Xanax and Klonopin endlessly. I don't doubt that at all, but I've personally known two people who take Xanax with no addiction problems whatsoever.

That's another thing I find interesting. Mostly because I suffer from anxiety, and I know that's a potential treatment.
posted by VegaValmont at 9:55 PM on February 24, 2007

Of course, another possibility is that the specific bad behavior in question is utterly unrelated to the SSRIs, but that pushing their bad behavior onto an external cause is an attractive, easy out.

How you would tell the difference, lacking the ability to observe alternate timelines, is a corker of a problem.
posted by ROU_Xenophobe at 10:04 PM on February 24, 2007

Anecdotally, I asked a question about a friend's apparently manic behavior while taking Zoloft last year. There were a number of anecdotes in the comments about the bad effects of antidepressants on bipolar-predisposed people.
posted by LobsterMitten at 11:26 PM on February 24, 2007

Starting off a course of anti-depressants can be very dangerous, and it seems SSRI's maybe moreso than others in shooting people into mania.

As noted above, lots of bipolars spend most of their time in depressed state or mixed state with depressed mood and energy, throw an SSRI on them without a mood stabilizer and they launch into mania. It's very dangerous, you've got to watch very close, and the patient themselves are not always the best to watch it, as they are too close to see what is happening to them.

Alternately, everyone knows about giving anti-depressants to people who are deeply depressed and suicidal and the anti-depressants giving them the lift of energy they lacked to finally go on and wax themselves. Again, very dangerous.

These things are great medications, awesome, actually, but people need to be very closely monitored at the start and/or any time they up the dose. Seems to me that these drugs are handed out like breath mints, not really a wise course of action imo...
posted by dancestoblue at 11:31 PM on February 24, 2007

dancestoblue, SSRIs definitely are too easily handed out. That's one of my.. irritations with doctors/psychiatrists.
posted by VegaValmont at 11:21 AM on February 25, 2007