Considering an SSRI for Bipolar Disorder Treatment? Read This

Hear what a psychiatrist and team of psychiatric nurse practitioners have to say about the benefits and drawbacks of using an SSRI for bipolar disorder treatment.

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Bipolar disorder is a mental health condition that can impact the way you feel and function. This mood disorder results in high-highs, known as manic episodes (lasting four days or more and causing impulsive or dangerous behavioral changes), and low-lows, known as depressive episodes. Or, there may be episodes of hypomania, which is a less severe form of mania. Everyone has highs and lows, but those with bipolar disorder have highs and lows that cause significant problems in their lives.

If you’ve been diagnosed with bipolar disorder (sometimes called bipolar depression), your provider has probably suggested that you take medication to treat it –– and you might have a lot of questions about that. One class of medicine sometimes used to help treat bipolar disorder is selective serotonin reuptake inhibitors (SSRIs), which are a kind of antidepressant. 

Here’s what you need to know about how SSRIs work, their benefits and drawbacks, and other bipolar disorder treatment options. 

Using an SSRI for bipolar disorder treatment

SSRIs inhibit serotonin reuptake, meaning they make more serotonin (the brain chemical or neurotransmitter linked to mood) available in the brain. Because they affect mood, they’re commonly prescribed for depressive disorder or unipolar depression, explains Claire Streeter, PMHNP, ARNP, a Psychiatric Mental Health Nurse Practitioner with Charlie Health. 

Even though serotonin is the only neurotransmitter in the name of SSRIs, brain chemicals work together, so the medications also result in a “downstream impact” on other neurotransmitters, says Charlie Health Psychiatric Mental Health Nurse Practitioner Rebecca Holland, PMHNP-BC

So, if an SSRI is an antidepressant that can help with depression, shouldn’t it help bipolar depression? Well, it’s a little more complicated than that. According to Holland, there’s a lot of debate in the mental health community surrounding whether or not SSRIs should be used to treat bipolar I (marked by severe manic episodes and depressive episodes), bipolar II disorder (marked by depressive episodes and hypomania), or cyclothymic disorder (considered a “milder” form of bipolar disorder). In fact, SSRIs are not a first-line treatment or stand-alone treatment for this mood disorder. 

Below, we get into the potential benefits and drawbacks of using an SSRI for bipolar disorder treatment. 

What are the potential drawbacks of using SSRIs for bipolar disorder?

The main concern surrounding prescribing SSRIs for bipolar is the risk of it making symptoms worse, which could be the case regardless if you have bipolar I, bipolar II, or cyclothymic disorder.

“A standalone SSRI in bipolar disorder can potentially worsen mood dysregulation,” Streeter says. “It can worsen things like manic or hypomanic episodes or cause them more frequently.” This is very dangerous since manic episodes can cause people to engage in risky, reckless behaviors or even trigger symptoms related to psychosis.

On the flipside, Streeter says a standalone SSRI could potentially cause worsened periods of low mood, as well. “With bipolar disorder, you want to promote stability, and this could do the opposite of that,” she says. Episodes of depression are dangerous, too, as they may result in troubling suicidal thoughts.

Another concern of antidepressant treatment using SSRIs is the risk of rapid cycling, which means more frequent mood episodes, specifically four or more, in a year. There is some evidence that shows SSRIs could potentially worsen or cause rapid cycling in people with bipolar disorder.  

Separate from the bipolar-specific concerns, it’s also important to consider the potential side effects of SSRIs. Streeter says the most common side effects include gastrointestinal upset, headaches, dizziness, and fatigue. Most of the time, these side effects are temporary. If you experience significant adverse effects that you can’t tolerate, make sure to tell your prescriber so they can figure out a plan to help you feel more comfortable. 

Antidepressant treatment also runs the risk of a rare but possible medical emergency known as serotonin syndrome, which is when your body has a dangerously high level of serotonin. Fevers, irregular heartbeat, confusion, and seizures are examples of red-flag serotonin syndrome symptoms to look out for. In this case, seek medical attention immediately. Usually, this happens when you are taking multiple medications or supplements that affect serotonin levels, which is why it is always important to tell your provider all the medications you take, including supplements and vitamins.   

What are the potential benefits of using SSRIs for bipolar disorder?

Providers are typically far more likely to prescribe an SSRI as an add-on medication rather than a standalone medication, Holland says. One common combination would be prescribing an antidepressant medication (an SSRI) on top of a mood stabilizer.

“They work in different ways, so they’re going to complement each other,” says Holland. “The mood stabilizer is going to help from the top side and the bottom side, but if you’re still having a lot of depressive episodes, we can supplement what you’re already doing with a non-stimulating antidepressant.” This is the main benefit of using an SSRI for bipolar disorder: reducing residual depression symptoms that aren’t alleviated by the mood stabilizer. An SSRI for bipolar disorder on top of a mood stabilizer can potentially help with depression symptoms like low mood, lack of motivation, hopelessness, and more. There is ongoing research to understand the helpfulness of SSRIs in bipolar depression, but they do not appear to work as well for the condition as compared to unipolar depression (AKA major depressive disorder).

Another benefit is anxiety reduction, Holland adds. On top of treating depression, SSRIs are prescribed to treat anxiety disorders. It’s estimated that around 45% of people with bipolar disorder also have obsessive-compulsive disorder (OCD) or an anxiety disorder, such as panic disorder or generalized anxiety disorder –– so an SSRI can certainly come in handy here and is the most common reason an SSRI is added to a person’s medication regimen who has bipolar disorder. 

Other treatments for bipolar disorder

There are two different types of treatments for bipolar disorder: medications and psychotherapy. Usually, a combination of both is the most effective at addressing the most symptoms. 

Medication options for bipolar disorder

Mood stabilizers are the most commonly used medications for bipolar disorder. As the name suggests, mood stabilizers stabilize your mood by leveling out the high highs and low lows you experience. “You’re not stuck in a depressive episode, and you’re not in mania,” Streeter says. “You’re in that middle realm where you still can feel sad, you still can feel happy, but within a more regulated frame.” Mood stabilizers are extremely helpful for many people with bipolar I and bipolar II disorder. Examples include Lithium and Depakote.

Another class of medications your provider might prescribe is antipsychotics. They may be supplemental to or instead of mood stabilizers. Research shows that antipsychotics can help reduce the severity of both manic episodes and depressive episodes, similar to a mood stabilizer. Examples include quetiapine (Seroquel), aripiprazole (Abilify), and lurasidone (Latuda). There’s also a type of medication called an antidepressant-antipsychotic, which is a mix of an SSRI and an antipsychotic that is specifically prescribed for people with bipolar I. It combines the antipsychotic olanzapine (Zyprexa) with the SSRI fluoxetine (Prozac)

Medications work differently for every individual and take time to work, especially for depression. Most medications that help depression can take up to two months before the full effect is experienced. It can take some trial and error to see which bipolar medication or mix of medications works best for you. Your prescriber will conduct a thorough history and consider all of your symptoms related to depression, mania, or hypomania when determining your bipolar disorder treatment plan. They’ll also consider co-occurring conditions and what medications can help with those additional symptoms. 

Psychotherapy

Psychotherapy, AKA talk therapy, is also a key part of the treatment of this mood disorder. Whether you have bipolar I or bipolar II, a therapist can help you learn to manage symptoms associated with your depressive episodes, manic episodes, or hypomania. 

When you’re having a mood episode and your symptoms are flaring up, you’re likely having distorted, unhelpful thoughts or engaging in unhealthy behaviors. Therapy is an excellent tool to learn how to identify and manage these thoughts and behaviors. Your therapist may also teach you coping skills to use when you’re feeling overwhelmed, as well as emotional regulation skills to use when you’re experiencing highs or lows.

Common types of psychotherapy for bipolar disorder include:

• Cognitive-behavioral therapy (CBT)
• Dialectical behavior therapy (DBT)
• Group psychoeducation
• Family-focused therapy 
• Interpersonal and social rhythm therapy (IPSRT)

Therapy, on top of other treatments for bipolar disorder, like medications, makes for a well-rounded treatment plan that can help you feel more like yourself again. 

Medication management at Charlie Health

If you or a loved one are struggling with bipolar disorder and could benefit from therapy and medication management, Charlie Health is here to help. Charlie Health’s virtual Intensive Outpatient Program (IOP) provides more than once-weekly mental health treatment for young people and families dealing with serious mental health conditions, including bipolar disorder and other mood disorders. 

Our expert clinicians incorporate evidence-based therapies into individual counseling, family therapy, and group sessions. We also offer medication management to bipolar patients as needed. With this kind of holistic treatment, managing your bipolar disorder is possible. Fill out the form below or give us a call to start healing today.