Introduction

This page used to be entitled Breaking News: Two Psychiatrists Agree on 31 Points!  Hard enough to get agreement on anything important, let alone 31 different items. But on this issue, my colleague Tam Kelly (Fort Collins, CO) and I are in complete agreement.

Dr. Kelly evolved these 31 recommendations during 20+ years of seeing patients. Like me he has become a mood and anxiety disorders specialist, not entirely on purpose, but because we both found that some people with mood and anxiety problems were not getting better with standard approaches. (Obviously many people have gotten better with standard approaches, which is great; but for those who don’t, well, that’s where these 31 recommendations come in).

I was going to write my own page, and did publish some evidence for this approach, but Dr. Kelly’s list is more fun [with just a few explanations from me in brackets]. As you’ll see, he has a dry sense of humor and likes to speak plainly.

If you’re having trouble tapering

But if you’re having trouble tapering off an antidepressant,  a remarkable forum collects user wisdom and is moderated by a very smart soul.  See Surviving Antidepressants,  e.g. thiscollection of their most useful pages, an amazing array of how-to’s for tapering nearly every antidepressant, based on the experience of people who’ve “been there”.

Here’s Dr. Kelly –

When to stop antidepressants in people with bipolar disorder

1. If they have been on them a short time I stop them.

2. If less than 2-3 weeks and they are suffering from the antidepressant, taper quickly.

3. Less than a week, stop: two weeks then cut in ½ , a week later stop.

4. Likewise if they just increased their dose I will do the above, decreasing to their previous dose and get rid of the rest later.

5. If the pt is doing well, no mixed state symptoms or cycling, leave it.

6. If manic or severely hypomanic, get rid of them now. Usually can stop abruptly.

7. If cycling get rid of them.

8. If mixed get rid of them.

9. I usually wait until the patient is doing better to much better. Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long or even go to another psychiatrist. Even though we know the antidepressant is causing harm oft time the patient thinks either that the antidepressant is helping or that every time they try to go off they feel much worse. Waiting until they are better is usually a good thing.

10. Also waiting longer usually means that the patient is going to be more educated about bipolar in general.

11. If they are not getting better after several add on meds then slowly decrease.

12. There are more exceptions to the above rules than there are rules.

Guidelines on how to get off antidepressants

1. Educate/prepare the patient well ahead of time and repeatedly.

2. Chart GAF scores [a psychiatric standard, Global Assessment of Function, a single number summarizing how you’re doing] over time. Sometimes getting off anti-depressants isn’t the right thing to do and can be used to identify “Sweet Spot” for dosing. For example, I recently had a patient who was doing poorly on 300 Effexor XR started when she was still “unipolar”. Took two years to wean off. Retrospectively I was able to see that she was doing best around 75mg. Charting the GAF at appointments and the Lowest in between is best.

3. If the patient stops them AMA [against medical advice] abruptly and they are doing well then leave them off. Watch for manic symptoms. (Sometimes patients get better despite our best efforts.)

4. If the patient stops them AMA abruptly and they are doing worse don’t jump back up to the whole dose. The longer they were at the lower without feeling bad before felling worse, the lower dose you can return to. You can sometimes use half-lives to calculate this. Calculate the dose based on when they started feeling bad. Watch patients very closely during this time, even daily by phone or at the office.

5. Warn patients that they will have mood swings if they do this. Warn patients that they will have mood swings if theydon’t do this, probably worse. Warn them of this over and over again. The point is to try and stop them from major panic when they do have a down.

6. Slowly is best. The slower the better. I usually wait . . . at least 6 – 8 weeks between dosage decreases. Prozac/fluoxetine can be an exception to this.

7. Longer if anxiety is a major feature.

8. Faster if they feel better as they decrease dose.

9. Longer if they have difficulty with dosage decreases.

10.Longer if they are doing relatively well.

11.Never decrease before a major event or holiday.

12. Avoid decreasing during times of major stress.

13. The pt can take longer if they want to take longer for any reason.

14. Reduce in the smallest possible increments. As you approach zero then take the dose changes smaller or longer. Get out that pill cutter. If you can’t get dosage changes in small enough changes do every other day between the smaller dose and the larger dose [WARNING: the Surviving Antidepressants group is strongly against this practice. They have come up with an amazing number of ways of making small doses so that you don’t have to do this. See a summary of their wisdom.

15. You can go faster if they feel better as they decrease dose, but not too fast. Look for signs and symptoms of mania as well as depression. I have seen both hypomania and even mania in a [patient with Bipolar II] who stopped their antidepressant without taper. This has been reported in the literature as well. Going down slowly also avoids manic reactions.

Special Rules

1. Effexor XR. If the pt can tolerate doing this then this is by far the best way to do this. Open up the capsule and take one more bead out each day. Rules 11 – 13 of how to get off antidepressants apply. Pour the beads out on a creased piece of paper and count out the correct amount of beads. Then using the crease of the paper to get the beads back in the capsule. [In my town I have the advantage of a compounding pharmacist who can make small doses from the patient’s large doses. If you don’t have that you definitely need to see the Surviving Antidepressants strategies].

2. If pts can’t count beads or don’t want to do this then take out about ¼ capsule for 6 – 8 weeks and repeat.

3. For any anti-depressant you can add in 20 mg of Prozac, get them off the anti-depressant, then taper the Prozac.

4. Prozac is a special case because of its long half-life. I generally will drop of one day at a time when reducing dose, e.g. decrease to 6/7 days a week for 6- 8 weeks then decrease to 5/7 days a week. Prozac is also a good candidate for every other day decreases, e.g. from a dose of 40mg a day go to 20 alternating with 40 mgs a day [to make a 30 mg-equivalent dose].

Introduction

Anxiety can be a symptom of bipolar disorder. This was recognized by the fellow who originally described bipolar disorder as such, Dr. Emil Kraepelin, back in 1921. He described “anxious mania”, and also “excited depression”, which included a “great restlessness”. He specifically named anxiety as one of the components of this illness. All that requires saying, because “anxiety” is not generally regarded as a bipolar symptom. Yet it clearly is, as summarized in an excellent review by Freeman, Freeman and McElroy.^Freeman

The International Society for Bipolar Disorders (ISBD) further strengthened the view that anxiety can be part of bipolar disorder in a Task Force report detailed below. That ought to be enough to put any remaining controversy about this to rest.

Official word: International Task Force

The International Society for Bipolar Disorders assembled committees of bipolar specialists to prepare reports on several aspects of bipolar diagnosis.

One particular report deserves attention here: first, because the authors are very well-regarded bipolar experts. Second, because it was published in a top psychiatric journal. And most importantly, because their statements are firm and clear.^ISBD

Their paper was on “mixed states” in bipolar disorder, which is the primary setting in which anxiety makes sense as a bipolar symptom. For basics on “mixed states”, see that section of the Diagnosis page. Reviewing briefly:

• General hyper-arousal
• Inner tension
• Irritability/impatience
• Agitation
• “Frantically anxious”

can be part of bipolar disorder. In fact, the ISBD report states that anxiety is “a core symptom of mixed states”.  Here the ISBD is not alone.^{Kauer-Sant’anna}

That ought to be enough to put to rest any controversy about this. Unfortunately, however, several of the “anxiety disorders” in the diagnostic manual (the DSM) can look like  “mixed states”. So confusion is the norm. One ought to be confused. As you’ll see below, it’s almost impossible to separate some of these diagnoses.

Two ways to have anxiety with bipolar disorder

There are basically two ways you can have anxiety with bipolar disorder. First, it can be a symptom of the bipolar disorder itself. Secondly, you can have a separate anxiety condition in addition to bipolar disorder. In medical lingo, that is called a “co-morbid” condition (in case you run across that term). It means both conditions are present, and thus implies that anxiety is a separate condition, not coming from the bipolar disorder itself.

These two ways of looking at anxiety have important implications. If the symptoms are coming from bipolar disorder itself, then they should get better when the bipolar disorder gets better. But if they are coming from a separate condition, they could persist even when the bipolar disorder improves.

If your anxiety is really a separate condition, it’s going to require a separate treatment. And that really complicates things, because very often the recommended treatment for the anxiety condition could be an antidepressant medication — and antidepressant medications can make bipolar disorder worse! (see the section on treatment for details on that problem; or the controversy over use of antidepressants in bipolar disorder).

Anxiety as a symptom of Bipolar Disorder

What is the anxiety of bipolar disorder like? Patients describe it as “agitation”, and sometimes that is quite obvious: their foot bounces on the floor while we talk; they pick at their nails; sometimes they can’t even bear to sit still and will get up and pace around the office during our interview. But sometimes the agitation is only “inside”: patients experience “too much energy inside my skin”, like they’re going to “explode”, and usually their thoughts are going very fast (sometimes called “racing thoughts”). However, when this is severe, people may not experience that fast thinking, but instead just an extremely disorganized thinking — not being able to keep their mind on one thing for more than a few seconds, not being able to accomplish anything. Of course that can make “anxiety” worse as people recognize that they are really ill with something that is not obvious to anyone else, yet they are not really functioning either. How do you explain that to someone?

When this kind of anxiety is present with other manic symptoms like irritability, it can create an awful experience people feel desperate to get out of. (Very often they discover that alcohol can help settle this down for an hour or two. Unfortunately when it wears off, the symptoms come back, very often worse than before. If a person responds to that by drinking more, that can cause a worsening of the condition over several days or weeks — but because they get brief relief from drinking, they keep doing it and often have to drink more over time to keep their symptoms controlled. This is a dangerous spiral which is statistically associated with successful suicide attempts, so represents a clear reason to get help as soon as possible.) Fortunately there are very good medication approaches to this which can help within an hour.Olanzapine/Zyprexa has a special role here, in my view.

When this kind of anxiety is present with depression, this may be the worst combination of all. Anxiety is a very strong risk factor for suicide when people are depressed. The future looks hopeless and pointless because of the depression; and the present feels unbearable. Again, it’s important to know that this combination is very treatable. If you find yourself feeling and thinking like this, and you don’t have a doctor or therapist to help you manage it in the short and long term, you should take specific steps to keep yourself safe, including going to an emergency room if necessary.

Anxiety as a separate condition

Now we’ll have to be more specific about “what kind of anxiety are we talking about?”. There are several specific forms of anxiety which appear to be clearly separate from bipolar disorder (e.g. there are people with these conditions who clearly do not have any bipolar symptoms). Here’s a list, and then we’ll look at specific symptoms that identify each one. After that we’ll look at the treatment implications of having one of these. Jump to each by the link below.

• Generalized Anxiety Disorder (GAD)
• Social Phobia
• Panic Disorder (with or without Agoraphobia)
• Post-Traumatic Stress Disorder (PTSD)
• Obsessive-Compulsive Disorder (OCD)
• Specific Phobias

Most of these have been shown to occur more often than you would expect in people with bipolar disorder (more often than the percentage found when thousands of people identified at random from the phone book were interviewed). We’ll look at each one or you can use the link above to jump to the one you’re interested in.

Generalized Anxiety Disorder (GAD)

There is a lot of overlap in the diagnostic criteria for GAD and bipolar II. We need to look at this in some detail because they may be actually the same thing, at least in some people (as opposed to the rest of the list below, which are somewhat more “separate”). If you’ve read about GAD and think you have it; or if you’re curious about anxiety and bipolar disorder generally (pardon the pun); please read this essay on GAD and BPII.

Social Phobia

This condition is well described, including its treatment with a psychotherapy approach (in addition to or instead of antidepressants), on the useful HelpGuide.org site. Go there to learn much more about social phobia.

For our purposes here, you should also know that social phobia is common in people with bipolar disorder. Starting with “how many people with bipolar disorder have social phobia?”, findings range from 15% to almost 50% in one study. Looking at it the other way, “how many people with social phobia have bipolar disorder?”, one recent study found 21%. These numbers come from the review on anxiety and bipolar disorder by Freeman and colleagues.^Freeman

However, some of my patients with bipolar disorder have clearly had “cycling” in their social phobia symptoms, that goes right along with their bipolar cycling. They get much more socially anxious at some times than others. Or rather, on some occasions, which can be rare but seem always to coincide with their hypomanic phases, their social phobia virtually disappears. They can talk freely, even in a group, even with strangers. They can walk up and introduce themselves to people they have never met. They can speak up in front of others, which they normally would strictly avoid. Then, when their mood and energy cycle back down again, their social anxiety returns. They avoid social circumstances, and all the anxiety they usually get if in the center of attention, even dealing with the check-out guy in a grocery store line, comes back.

This “cycling” of social phobia symptoms along with bipolar symptoms suggests that these conditions are not just co-occurring, but are connected somehow. However, unlike the anxiety of GAD which seems to go away when bipolar cycling is controlled, some degree of social phobia symptoms seems to hang around when bipolar disorder is controlled. This is extremely frustrating for a person who knows that once in a while they don’t have to be like this.

However, the usually offered treatment for social phobia — e.g. antidepressants like paroxetine/Paxil — can make bipolar disorder worse.  But fortunately, there is an excellent treatment for social phobia that does not rely on medications at all. This therapy is described well on the HelpGuide site, here.  Usually this treatment is best done with the help of a therapist who knows “cognitive behavioral therapy”. If you can’t get such a therapist, some people have had some success on their own using a basic online anxiety treatment program (free). It works great, but very few people can do this on their own and get through it:  “e-couch” from Australia.

Panic Disorder (with or without Agoraphobia)

In my experience when people have their bipolar cycling controlled, they stop having panic attacks in almost all cases (there are surely some exceptions). So rather than focus on the panic symptoms, I almost always go after the bipolar symptoms first.

Note that if for some reason panic symptoms persisted after bipolar symptoms were treated, there is a non-medication approach that works better in most people than pills.

Post-Traumatic Stress Disorder (PTSD)

This condition too is described well by a HelpGuide page. About 40% of people with bipolar disorder also have PTSD.^Freeman The converse appears to be relevant as well: growing up in an environment of trauma appears to raise the risk of getting bipolar disorder, if one is genetically susceptible.^Post

I see these two conditions together all the time. Sometimes it’s very difficult to tell them apart from one another. This has implications for treatment, as discussed below.

Obsessive-Compulsive Disorder (OCD)

For more information on OCD, there is a comprehensive website by the OCD Foundation. Their page on “What is OCD?” is a good starting place.

OCD has a complex relationship with bipolar disorder. I’ve seen some patients start out looking like they have classic OCD and end up looking like they have definite bipolar disorder without OCD. These two conditions might be part of the same thing somehow, at least in some people. At least we know they are found together very often, much more so that one would expect. In one study, 20% of people with bipolar disorder had OCD, twice the number seen in unipolar depression (which is also higher than people with no diagnosis).^Chen

A group of researchers has looked at how OCD and bipolar relate. They found that whereas unipolar depression was “incidental”, i.e. not clearly related to the OCD (although common), by contrast bipolar disorder seemed to be more directly related to the OCD. For example, people with religious and sexual obsessions as part of their OCD were more likely than those with other obsessions to have bipolar disorder. The authors specifically recommend that bipolar disorder take precedence over the OCD in terms of which is treated first.^Perugi

Specific Phobias

These include snake, spider and height phobias, which are common. They are also extremely treatable using the “behavioral” approaches (i.e. not medications) described for some of the anxiety disorders above (success rates exceed 80%). There is no specific association with bipolar disorder, to my knowledge.

Summary: treatment implications

Antidepressants can make bipolar disorder worse. Eventhough antidepressants are a standard treatment for anxiety problems (e.g. OCD,PTSD; and to a lesser extent Social Phobia, Panic Disorder and GAD), mostexperts agree: treat the bipolar disorder first, then if anxiety symptoms remain, treat them.

I would go a bit further. If symptoms remain, “treat them” with a psychotherapy if at all possible rather than an antidepressant. There are excellent therapies with results equal to or better than medications for panic and social phobia. There are therapies which get good results, though often only with medications, for PTSD and OCD. If after the therapy has been tried, an antidepressant still must be considered, it should be added to mood stabilizers already underway (per theexpert recommendation cited above).

In my opinion, when a diagnosis of GAD is made, the patient should be informed about the extent of overlap with bipolar disorder and an effort made to determine if the patient might have bipolar disorder. (At minimum, use the screening questionnaire called the MoodCheck ). If after that the patient prefers to start with an antidepressant (versus psychotherapy, if available; or a mood stabilizer trial), don’t forget to look for hypomania or cycling of mood and energy in the first few months.

If you have anxiety symptoms, or if you have an anxiety condition in addition to your bipolar symptoms, make sure your doctor and/or therapist know about these because even with bipolar disorder they are treatable. The trick is to make sure the treatment for the one doesn’t make the other worse. That can be done.