Pharmaceutical Drugs
There are many antidepressant pills on the market, of which none of them should be used without consulting your GP.
Three main types of drugs are used in manic depression: drugs to stabilize the mood; drugs to calm and lower mood in hypomania and mania; and drugs to improve and raise the mood in depression. The number of drugs available for treating manic depression increases year on year, either as new drugs are specifically developed to treat mental illnesses, or as a result of discovering mood-altering properties of existing drugs. A number of anti-epilepsy drugs have proved particularly useful in manic depression.
There are three main types of drugs used in treating manic depressive disorder, as well as other, less common ones:
- Mood stabilizing drugs
- Mood lowering, anti-psychotic drugs
- Anti-depressants
- Sleeping tablets
1. Mood stabilizing drugs
Three mood stabilizing drugs are prescribed for the majority of people with manic depression. These are lithium, valproate or depakote and carbamazepine.
These drugs are well established in treatment, relatively safe and almost certainly do not hold and unpleasant surprises for the future. Other newer drugs are constantly under development and review and can be used if a person has frequent further episodes whilst on standard treatment or the standard treatment is causing too many side effects.
Valproate, like carbamazepine is used to treat epilepsy. However, it is also a mood stabilizer as well as having anti-manic properties. As with lithium, it is not yet clear how valproate works. It can be effective when lithium has not been, either instead of, or in combination with, lithium. Side effects include weight gain and tremor.
Carbamazepine has mood-stabilizing properties and can be used together with or instead of lithium and valproate. Side effects include dizziness, intestinal upset and drowsiness, though it does have fewer side effects than most of the other drugs prescribed for manic depression. However, one rare side effect is severe skin reaction and loss of white blood cells known as Stevens Johnson syndrome.
Newer mood stabilizing drugs include lamotrigine and gabapentine. Lamotrigine and gabapentine were, like carbamazepine and valproate, originally prescribed for epilepsy and were found, like carbamazepine and valproate, to additionally reduce mood swings in patients with both epilepsy and manic depression.
2. Mood lowering, anti-psychotic drugs
There are two types of drugs that lower mood and reduce mania. The first are the group of drugs variously known as ‘major tranquilizers’, ‘anti-psychotics’ or ‘neuroleptics’. These drugs include haloperidol and chlorpromazine as well as more modern, atypical anti-psychotics, such as olanzapine and quetiapine.
Major tranquilizers work by calming and lowering the mood and reducing the delusions and hallucinations associated with mania and psychosis. Because there are fewer side effects with atypical anti-psychotics, generally people are more prepared to take them, particularly long term. However, there are two serious side effects associated with all of these groups. First, they are associated with significant weight gain, both because they increase craving for food and because they seem to have a direct effect on the metabolism, which makes people more susceptible to type 2 diabetes. It is important to be aware of this possibility and to avoid sugar and sweet foods as much as possible, whilst starting or continuing an exercise plan. Secondly, they can cause uncontrollable movements, such as chewing or facial tics. This is called ‘tardive dyskinesia’ and is extremely distressing. It may disappear when the drug is stopped but not always, so it is important to be aware of this and, if it happens, to stop the medication as soon as possible.
The second group includes all other drugs known to reduce mania. This includes lithium, valproate, and more unexpected candidates such as tamoxifen. For some people, benzodiazepine drugs such as diazepam and lorazepam help reduce mania, although benzodiazepines can equally well remove a person’s last few remaining inhibitions and make mania and hypomania worse.
3. Anti-depressants
Anti-depressants are designed to make someone feel better by improving their mood and energy levels. There are several different types of anti-depressants and if one is not helping, then it is worth trying different ones as they may become more effective. Anti-depressants take between two and six weeks to work and so patience is needed – they are not an instant cure.
There are a number of different types of anti-depressants.
- Tricyclics (TCAs)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Selective Noradrenaline Reuptake Inhibitors (SNRIs)
- Monoamine Oxidaze Inhibitors (MOIs)
- Others
Not everyone is helped by anti-depressants. In most studies forty percent of people respond to a placebo or dummy pill, whilst a larger proportion, between fifty and sixty percent, respond to the active drug. This still leaves forty percent or more of people with no benefit from anti-depressants. Some of these people will respond to a different anti-depressant, others will get better on their own and a few are extremely difficult to treat. Overall, many people do greatly benefit from anti-depressants. Other people experience significant side effects without a lot of improvement in their mood. In general terms, the best results come from a combination of drugs and psychological therapy, such as cognitive behaviour therapy.
TCAs (Tricyclic anti-depressants)
‘Tricyclic’ refers to the chemical structure of the drug. Tricyclic anti-depressants include amitriptyline, dothiepin and trimipramine.
Tricyclic anti-depressants are not often prescribed nowadays. Their main benefit is that they can be prescribed in small doses which can be helpful when someone is having a lot of side effects with SSRIs or other anti-depressants. Also, if someone has found a particular tricyclic anti-depressant helpful in the past, it can be useful to prescribe it again. In small doses at night, they can be helpful as pain killers, especially for chronic (long-standing) pain.
SRIs (Selective Serotonin Reuptake Inhibitors)
‘Selective serotonin reuptake inhibitor’ refers to the chemical activity of the drug. SSRIs block the nerve cells from taking up serotonin, thus leaving more serotonin lying around so the person feels better. Or so the theory suggests. However, the actual effect of SSRIs is now thought to be more complicated than initial studies suggested. It almost certainly depends, at least in part, on the nerve cells developing new connections and new serotonin receptors.
SSRIs include fluoxetine (Prozac), paroxetine and cipramil. SSRIs have largely replaced tricyclic anti-depressants as the first choice for the medical treatment of depression. They are more effective, safer and seem to have fewer side effects. They are prescribed at a standard dose, which ensures adequate treatment. In general terms, anti-depressant treatment is more effective if it is combined with psychotherapy or counselling rather than relying on medication.
SNRIs (Selective Noradrenaline Reuptake Inhibitors)
SNRIs include venlaflaxine and reboxetine. These are another type of anti-depressant that act in a similar but different way to SSRIs. They can work when SSRIs have not. In general terms they are thought to be of more help in people who are slowed by their depression whereas SSRIs seem to deal better where depression is combined with anxiety.
MAOIs (Monoamine Oxidase Inhibitors)
MAOIs include mianserin (which does not have food restrictions), modenclamide, phenelzine and isocarboxazid.
MAOIs, like SSRIs and SNRIs, are named after the chemical effect they are thought to have. MAOIs increase the concentration of monoamines, which like serotonin make a person feel better. Although these drugs are effective, with comparatively few side effects, they are rarely prescribed, because they react with certain foods that contain tyramine. These foods include beans, cheese, red wine, chicken livers and preserved meat products, soy sauce and chocolate.
How long should I take anti-depressants for?
This is the twenty million dollar question (or billion dollar question if you are a pharmaceutical company!). Medical teaching suggests that anti-depressants should be continued for at least six months and where depression is chronic or recurrent, for two or more years. However, in practice, a number of people who are prescribed anti-depressants probably don’t need them. Their symptoms recover spontaneously within a few weeks and there is no good reason for them to continue anti-depressant therapy once their crisis is over. For those people with significant depression who are prescribed anti-depressants for a good reason and find them helpful, continuing anti-depressants for six months is reasonable. The brain needs to regain its equilibrium and learn to stay with a normal mood. It is best to come off anti-depressants when you are feeling as well as possible and able to face the challenges that changing medication might cause, rather than at the first possible opportunity.
Stopping SSRIs
Although anti-depressants are not technically addictive, even the most hardened drug company is now prepared to admit that there is a ‘withdrawal syndrome’ or ‘anti-depressant discontinuation syndrome’ that some people experience when they stop taking anti-depressants. The ‘withdrawal syndrome’ includes dizziness, sickness, feeling faint, balance problems, tingling and strange sensations in the muscles, flu-like symptoms, hallucinations, blurred vision, irritability, vivid dreams, electric shocks, anxiety and nervousness. To all intents these symptoms can feel like a recurrence of the original depression, as well as the new problem of the person feeling completely dependent on their tablets.
It is important to realize that these symptoms are not the same as depression. The symptoms can be eased by changing to an SSRI with a longer ‘half-life’, such as fluoxetine (Prozac). Fluoxetine stays in the body longer so that there is ales abrupt jolt to the nervous system as the dose of the drug is gradually reduced. The brain gets used to drugs and when the dose is reduced, initially the brain finds the change difficult to manage. However, the brain is adaptable and gradually, with perseverance and support from your doctor, it is possible to reduce and then stop SSRI medication.
4. Sleeping tablets
Good sleep is a crucial part of self-management. Lack of sleep causes hypomania. There may be a number of reasons for not sleeping which are not all related to manic depression, for example too much caffeine, anxiety, impending exams, changing time zones and shift work (not recommended). Sleeping tablets can be invaluable, especially if sleep is the only change and there are no other sigs of impending hypomania.
However, disturbed sleep is also one of the earliest signs of impending hypomania and mania. It may be possible to avert a hypomanic episode at this stage by restoring a normal sleep pattern using sleep and other self-management strategies. The need for sleep is urgent when there are other warning signs and triggers present that threaten an imminent relapse into hypomania.
Ideally, everyone with sufficient insight into their illness should carry their own stocks of sleeping tablets and major sedatives, for use when self-management techniques alone can no longer hold back impending hypomania.
Mild non-addictive sleeping tablets are available without prescription from the pharmacy. Unfortunately, the more effective a sleeping tablet, the more addictive it is and the more reluctant doctors are to prescribe them. Doctors not infrequently fail to understand the critical importance of sleep in manic depression and do not take insomnia seriously enough. This can make it more difficult to manage the condition at this stage.
The most effective sleeping tablets for people with main depression are probably zopiclone and zolpidem. These have what is known as a short ‘half-life’, which means from a pharmacological perspective that they are metabolized quickly by the body, so causing fewer problems in the morning. Sleeping tablets are never anything other than a short term solution, as physical and psychological addiction can appear within four to six weeks. Within a very short period of time, the brain starts to think ‘Why make the effort to go to sleep when I can take a tablet that does the work for me?’ This is along the same lines as ‘Why walk when you can ride? Why stand when you can sit?’ Put simply, if you don’t keep exercising the skill of fall asleep it won’t be long before your brain is no longer bothered to do it and has reached a state of addiction.
At this point, although it is enough to try a sleeping tablet for the first night, the best plan may be to add in an antipsychotic drug such as olanzapine or even haloperidol sooner rather than later. It can be difficult, as after weeks or months of monotonous lows a little bit of high can seem like a welcome and well-earned break. It is not easy to deliberately take a tablet that will extinguish the final glimmer of hope in a desperate, dull, grey world.
