Antidepressant-induced Mania

It is generally recognized in antipsychiatry circles that antidepressant drugs induce manic or hypomanic episodes in some of the individuals who take them.  Psychiatry’s usual response to this is to assert that the individual must have had an underlying latent bipolar disorder that has “emerged” in response to the improvement in mood.

The problem with such a notion is that it is fundamentally unverifiable.  Psychiatry defines “bipolar disorder” by the presence of certain behaviors and feelings.  If a person meets these criteria, he/she is said to have bipolar disorder.  What immediately needs to be noted is that bipolar disorder, in common with psychiatry’s other “disorders” has no explanatory value.  To illustrate this, consider the following hypothetical conversation.

Parent:  Why does my son behave in these extreme ways?
Psychiatrists:  Because he has bipolar disorder.
Parent:  How do you know he has bipolar disorder?
Psychiatrist:  Because he behaves in these extreme ways.

The only evidence for the illness is the very behavior that it claims to explain.

As spurious as this is from a logical point of view, the notion of a latent bipolar disorder is even worse.

Why did my son become manic after starting on antidepressant drugs?
Because he had a latent bipolar disorder.
How do you know he had a latent bipolar disorder?
Because he became manic.

What psychiatry is doing here is applying their spurious explanation retrospectively Before the individual showed any signs of mania, he must have had bipolar disorder because he became manic at a later date.  But nobody could ever have verified that hypothesis, because the occurrence of a manic or hypomanic episode is the primary criterion for such a “diagnosis”.

Although the “latent bipolar disorder” is psychiatry’s usual explanation for these episodes, one occasionally encounters acknowledgement that the antidepressant was the primary causative factor, and in practice, the two conflicting theories exist side by side.

  1. The manic/hypomanic episode was caused by the antidepressant drugs.
  2. The episode was caused by the underlying latent bipolar disorder.

Theory 2 is more popular in psychiatric practice, and is routinely told to those clients who experience this kind of mood switching.  Up till now it has been difficult to challenge theory 2, because it is essentially unassailable.  One can’t prove or disprove the existence of something that is inherently latent.

. . . . . . . . . . . . . . . .

But recently some evidence has been published that favors theory 1:  that the manic/hypomanic episodes stem primarily from the antidepressant drugs.  In November 2013, Psychiatric Times published an article by Ross Baldessarini, MD, a Harvard psychiatrist, et al titled ‘Switching’ of Mood From Depression to Mania With Antidepressants.  

The article reports on, and discusses the implications of, a meta-analysis conducted by the same authors (Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: A review, Baldessarini RJ, et al, Journal of Affective Disorders, May 2013).  Here’s the opening paragraph of the Psychiatric Times article.

“Bipolar disorder often presents initially with one or more episodes of major depression, and an episode of mania or hypomania may first occur during treatment with an antidepressant, stimulant, or other agent with mood-elevating effects. Such ‘switching’ of mood into mania, a mixed-state, or psychosis can be dangerous. This switching is particularly prevalent among juveniles and young adults exposed to treatment with an antidepressant or stimulant for a depressive, anxiety, or attention disorder. Such pathological shifts of mood and behavior may represent adverse drug actions or a manifestation of undiagnosed bipolar disorder.”

The authors go on to state that they had reviewed available research on two topics:  a) antidepressant-associated mood switching; b) changes of diagnosis from unipolar depression to bipolar disorder.

They identified 51 studies involving nearly 100,000 individuals who had been diagnosed with major depressive disorder (MDD) without a history of mania or hypomania, and who had been treated with an antidepressant.  They found that mood switching (i.e. to mania or hypomania) occurred in 8.2% of participants within an average of 2.4 years of antidepressant use, or 3.4% per year.  (The rate of mood switching was 4.3 times greater among juveniles than among adults.)

The authors also reviewed 12 other studies in which individuals who were initially considered to have unipolar depression (MDD),  were assigned a new diagnosis of bipolar disorder because of the occurrence of spontaneous (i.e. no antidepressant associated) mania or hypomania.  These switches occurred in 3.3% of the individuals studied within 5.4 years, i.e. 0.6% per year.

So, manic or hypomanic episodes were 5.6 (3.4 ÷ 0.6) times more likely per year for people diagnosed with MDD who were taking antidepressants than for people with the same diagnosis who were not taking these drugs.

The authors’ comments on this difference in the Psychiatric Times article are interesting:

“A particularly intriguing finding was the large apparent excess of antidepressant-associated switching over reported spontaneous diagnostic changes to bipolar disorder. This raises questions about the diagnostic, prognostic, and therapeutic implications of antidepressant-associated reactions.”

“If the relatively low rates of new bipolar diagnoses are not due to under-reporting, their marked difference from rates of antidepressant-associated mood switching leaves open the possibility that direct pharmacological, mood-elevating actions of antidepressants may be involved in mood switching, in addition to hypothesized “uncovering” or perhaps even “causing” of bipolar disorder. Of particular concern is that these ambiguous possibilities leave specifically uncertain the potential value of long-term treatment with antimanic or putative mood-stabilizing agents.”

In the Journal of Affective Disorders article, they also state:

“An important, unresolved question is of the significance of AD-associated mood-switching. Two plausible possibilities are:  [a] responses reflecting the presence of BPD, or [b] a direct pharmacological effect of mood-elevating treatments that may be transient, relatively rapidly reversible, and not followed by a change in diagnosis…The several-fold higher proportion of patients with mood-switches among unipolar MDD patients than the rate of later re-diagnoses of BPD is consistent with the possibility that some AD-associated mood-switches may represent pharmacologic reactions (AD-induced mania).  It is also likely that AD-associated risk will be greater than spontaneous mood-elevations regardless of cause. It is important to note that the reported rates of re-diagnosis to BPD may be somewhat overestimated if some cases involve drug-related mood-elevation and not only spontaneous mania–hypomania. That is the ratio of AD-associated mood-elevations to new diagnoses of BPD may actually be even higher than we found.” [Emphasis added]

What the authors are pointing out here is that antidepressants are clearly implicated in the “excess” incidents of mania/hypomania, and they have even raised the question of a direct causal link.

Their brief reference to “diagnostic…implications” isn’t entirely clear, but is, I think, a challenge to the DSM-5 decision to allow these kinds of antidepressant-induced manic episodes to count towards a “diagnosis of bipolar disorder.”

In DSM-IV, incidents of this kind were excluded:

Note:  Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”  (p 332) [Emphasis added]

But in DSM-5, this has been changed to:

Note:  A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore, a bipolar I diagnosis. (p. 124) [Emphasis added]

So under DSM-5, the possibility that the mania was caused by the antidepressant has been eliminated in favor of the popular psychiatric notion that it “emerged” during the antidepressant use, and the manic episode can be adduced to support a “diagnosis of bipolar disorder.”  This is psychiatric spin of a very advanced order:  eliminating the DSM-IV admission that the drugs have the potential to inflict this kind of damage, while at the same time expanding the concept of bipolar disorder, which is good for business.

. . . . . . . . . . . . . . . .

But, here come Dr. Baldessarini et al collating and publishing research, some of which, incidentally, has been around since the late 60’s/early 70’s, clearly establishing a large excess of manic episodes among people taking antidepressant drugs.  And, notably, they have taken the additional step of writing up their findings in Psychiatric Times, a medical trade publication written for “psychiatrists and allied mental health professionals who treat mental disorders”, with a circulation of 40,000.

And, perhaps most significant of all, is Dr. Baldessarini et al’s reference to “prognostic and therapeutic implications.”

“Indeed, it is not even proved that drugs considered to be mood-stabilizing are highly protective against antidepressant-associated mood switching, although such protection is widely assumed.  Moreover, there is very limited evidence that prolonged antidepressant treatment provides substantial protection against recurrences of bipolar depression and that it might contribute to emotional instability or rapid cycling.”

In other words, in cases where antidepressant-associated manic episodes have occurred, continued use of antidepressants “might contribute” to instability and rapid cycling, i.e., recurrent manic episodes.

. . . . . . . . . . . . . . . . 

There has been an increasing recognition on this side of the debate that the so-called antidepressant drugs precipitate manic, and even violent, reactions, in some of the individuals who take them.  There has even been speculation that use of these products is linked to the much-publicized incidents of murder-suicide in recent years.  Brian, at AntiDepAware, has amassed a great deal of anecdotal, but compelling, information on this issue.  Joseph Glenmullen, MD, a psychiatrist, has discussed antidepressant-linked mood switching in his book Prozac Backlash  (2000).  He describes several cases from his practice, including individuals who became floridly psychotic, sometimes with graphically violent themes , after taking SSRI’s.

Psychiatry has resisted suggestions to conduct a definitive study on this matter, relying instead on repeated dogmatic assertions that the “meds” are wholesome and necessary, and that the incidents are the result of “untreated mental illness.”

But the Baldessarini et al study and, incidentally, an earlier Offidani et al study of which Dr. Baldessarini was a co-author, represent a major assault on that notion.  Tragically neither article appears to have attracted much attention in the psychiatric field, where antidepressants are still being prescribed routinely as front line “treatment” for depression and various other “disorders”, and no major alert with regards to mood-switching has been issued..  I have no inside information on this matter, but it occurs to me that Dr. Baldessarini et al have written the Psychiatric Times piece in an attempt to disrupt this complacency, and to generate some recognition among their colleagues of the enormous implications of antidepressant-induced manic episodes.  But perhaps their efforts have been in vain.  It is now 14 months since the publication of the Psychiatric Times piece, and 19 months since the original journal article, but no major change in psychiatric prescribing is evident, and psychiatrists are still telling victims of this effect that they must have had an “underlying bipolar disorder”, that the drug has activated.  As I’ve said many times, psychiatry does not take kindly to criticism.  And this appears to be true even when the criticism is from one of their own.

. . . . . . . . . . . . . . . .

Disclaimer:  In writing this post I have used terms like “bipolar disorder”, “major depressive disorder”, etc., in order to describe the journal articles being reviewed.  This was simply a reflection of the fact that the authors had used these terms, and should not be read as an indication of any endorsement on my part of the validity or usefulness of these terms.  Indeed, it is the central tenet of this site that the so-called psychiatric diagnoses have neither explanatory nor predictive validity, and are destructive, disempowering, and stigmatizing.

  • Anonymous

    It’s funny you know I’ve recruited and sourced a group of heavily neglected Russian feral children for a study I’m conducting on SSRI ‘induced’ murder suicides.

    Raised by dogs in the dog kennel while their vodka-fiend parents partied and choked back Marlboros, my sample size is now 18.

    For 9 of them, I’m crushing up some SSRIs and putting it in their dog bowl. For the other 9, the placebo group, it’s just straight up dog food.

    For the life of me, I can’t get the SSRIs to magically implant the strategic decision not to rot in prison after the murder part. I can’t even induce the murder part.

    I even took them to a casino and couldn’t get any compulsive gambling out of them. I took them to a department store, no impulse buys either.

    I keep pointing to the closet and the belt, but no dice. I even put a Likert scale questionnaire in front of them about suicidal feelings, no cigar. Not even any road rage. They just sit in the back of the car with their tongues out watching the world go by.

    I’m sure if I invented a time machine and went back to their births and taught them language and love and nurtured them into human civilization, and taught them what guns were, showed them a few thousand movies with shootings in the plots, told them they were the only animal on Earth doomed to know they were going to die one day, taught them what a leather belt was, what a casino was, what a Likert scale was, what a driver cutting them off in traffic was, and a billion other details about the collective human experience and cultural inheritance, that the SSRIs would have them behaving like the Islamic State.

    It’s just tough to get these variables right in my experiment.

    So many confounds.

  • Anonymous

    I certainly would be spinning in my grave if some simpleton wrote this about me if I decided this world of pain was too much after being ‘sectioned’ far away from my family at age 15.

  • Anonymous

    This guy is a joke! Here he is completely absolving a murderer…

  • If this field is so convinced that antidepressants “unmask” bipolar disorder, then I think they should do some serious studies examining the differences between, for example, Prozac bipolar and desipramine bipolar.

  • Phil_Hickey


    For five years of my career, I worked in the substance abuse field. I encountered a good many people who, although normally quiet and mild-mannered, became angry and violent upon consuming alcohol. I think it’s reasonable to describe these incidents as alcohol-induced episodes of anger.

    I think you’re right to point out that alcohol would not be the only factor involved. All individual human activity is influenced by a wide range of factors – historical, cultural, biological, familial, contextual, etc., and one can always adduce “reasons” for a person’s actions that focus on one set of factors and ignore others.

    But we’re still left with the fact, that of the people who take antidepressants, about 3% per year will have a manic episode, even though there has been no sign of anything like this before. Psychiatry’s defense is that the drugs didn’t induce the episode, but rather activated it.

    I will certainly concede that words are crude tools for describing the complexities and subtleties of human life. I struggle endlessly in my writing to do justice to this complexity. I think “antidepressant-induced mania” is a great deal more honest and accurate than “antidepressant-activated mania.” But I’m certainly open to suggestion for improvements.

    But whatever words we use, I think we must keep making the point that psychiatric drugs are destroying people. And that this is one of the ways that this destruction occurs.

    Please feel free to come back. This is an important topic, and I strongly
    believe that dialogue is the royal road to clarity.

  • cledwyn bulbs

    Whilst I agree that “antidepressants” (pro-depressants in my experience) can induce manic-like states (that in my opinion in no way absolve an agent for his actions), I would personally never, pace your good self, describe violence as alcohol-induced; because it implicitly denies agency. To me, that’s as meaningless as causal propositions about “mental illness” causing violence, as if one could establish empirically a causal relationship between the two as incontrovertible as between two observable phenomena in space.

    In vino veritas.

    The problem is, explanations that absolve people of responsibility for their actions will always have an advantage over those that don’t, because man is an irresponsible animal and because deterministic explanations that frame human action in terms that define out of existence the will, render a great service to those who wish to control others because, according to the assumptions built into the deterministic, scientistic theory of human behavior, people, at least when the behavior is undesirable, cannot control themselves, a theory whose proponents seem seized of the conviction that it serves the cause of justice because it involves the suspension of judgement, a conviction that takes on an ironic complexion when one realizes its truly dehumanizing character (when did dehumanization ever serve the cause of justice?).

  • Phil_Hickey


    Thanks for coming in on this. As usual, you are making compelling points. My general point is that although the vast majority of problematic behavior is not caused by damaged or impaired neurology, damaged or impaired neurology can impact thoughts, feelings, and/or behavior. If a person takes LSD, for instance, and begins to hallucinate, I think it’s realistic to describe the hallucinations as LSD-induced. Similarly, if a person consumes five or six alcoholic drinks and starts to stumble and slur his words, I think it’s reasonable to describe the discoordination as alcohol-induced.

    But, having said that, what I’m taking from your comment (and from Anonymous’ earlier comment) is that the term “alcohol-induced” (or antidepressant-induced, or whatever) is misleading in that it can be interpreted as meaning “exclusively caused by…”. I do appreciate this clarification.

    It is still my position that psychiatric drugs damage people, and I will try to find ways to express this which recognize the inherent complexity of the matter.

    Best wishes.

  • cledwyn bulbs

    Thanks for replying. You make excellent points. Absolutely agree that drugs can induce different mental states, but my experience is, having taken, LSD, amphetamine, “anti-depressants”, “anti-psychotics”, “benzodiazepines”, alcohol, marijuana, cocaine, MDMA, magic mushrooms, salvia, opiates of various types, that they never absolved me of responsibility for my behavior, even when, on prozac or on alcohol, I got in one or two fights.

    I suppose part of the problem is here is that behavior is something of an essentially contested concept (much like “illness”, as we on this site know), though I’ve never heard this mentioned. It is a polysemic term; for some people, it is inclusive of all human action, voluntary or involuntary, and for others, it presupposes intentionality, or the employment of practical reasoning, where one deliberates on what one ought to do.

    I mean the term “behavior” to denote any action that is willed, the product of our capacity for deliberative self-determination, whereas, say, involuntary movements I would describe as neurological reflexes, created by some sort of neurological perturbation; I use the term as semantically interchangeable with “action” which, by definition, implies agency, whereas I understand that the term “behavior” is used in the social sciences to refer to both actions (that is, intentional, purposive behaviors), and involuntary, reflexive movements of the body, arising either from some sort of perturbation of the brain, or habits that involve little premeditation.

    These contrasting interpretations no doubt cause a lot confusion. I’m used to hearing the word “behavior” used as a synonym of “action”, such as when people claim someone misbehaves, which is usually used to express a negative moral judgement about the person in such a way as implies agency.

    Maybe in future I should stick to the word “action” to avoid any confusion.

  • cledwyn bulbs

    Don’t know why I bracketed the word “benzodiazepines”, with scare quotes.

  • cledwyn bulbs

    There seems to be no doubt that if we define behavior so broadly as to be inclusive of any movement of the body, then much of it is automatic, specifically simple movements such as when one reflexively looks towards someone who dresses “weirdly”, or when someone taps taps their fingers, and that some behavior, according to the bipartite division of brain function into that of the automatic and the voluntary, belongs in the former category.

    Leaving aside my objections to this definition of behavior as basically semantically interchangeable with movement, the question is posed;- to what extent can people, through reflection and self-exertion, control otherwise reflexive behaviors like this?

    For example, as a child, like all children, I would stare at the “weirdo”, even though I am one myself. Yet through a mixture of reflection and empathy I have learned to abstain and to some degree control this.

    The problem is, people believe that the composite entity, human nature, of which behavior is one part, is governed by immutable laws. Much like the belief that the social world is governed by immutable laws, precluding the acting upon it by individuals, people fail to act upon themselves because, likewise, they believe their natures to be governed by similarly immutable laws, largely as a result of the successful indoctrination of the masses of determinist theories which, because of their effectiveness in providing a vehicle for what is the true function of government (namely, to control people), are understandably a integral part of the orthodox weltanschauung. This inculcates a fatalistic attitude that begets the very problem that supposedly is occasioned by this taken for granted knowledge of our own powerlessness.

    Which is not say that we are absolutely at liberty to shape ourselves as we wish, just that our latitude for self-control and self-engineering is much greater than we are led to believe, so that no matter how much we cannot overcome our a priori and a posteriori reflexes of thought and emotion, how different men react on their basis diverges so greatly precisely because of the element of choice and our capacity, in situations charged with ethical import, to choose between different alternatives, which, of course, goes against the scientistic framing of human behavior which tries to establish a set of laws obtaining under certain conditions, which ignores the variety of ways in which different actors respond under the same conditions.

    It is also true that sometimes it can seem that more complex behaviors come to seem automatic, such as stealing, as is embodied in the concept of kleptomania. Yet, insofar as such behaviors can be said to be automatic, they are only so by dint both of habit and a lack of critical self-reflection, the latter aided by dominance in the culture of theories that frame human beings as mere marionettes operated by the hands of forces beyond their control.

  • cledwyn bulbs

    That should be “WITH determinist theories….” not “of..”

  • cledwyn bulbs

    And “an integral part..”.

  • wake up

    I would define behaviour as “anything a living thing does that a dead thing doesn’t.”
    You can break it up, or break it down any way you want… You can use context and sub text, and any other type of ‘text’ to classify, or label, or separate, rationalise, justify, so on so forth, but at any time of day, behaviour is an all encompassing term…
    If you want to classify specific types of behaviour, classify the types… Physical/social/psychological/medical/conscious/unconscious etc etc…
    We ‘behave’ at a cellular level too…!!

  • cledwyn bulbs

    I’m not rationalizing anything, just stating the fact that behavior is a polysemic term, and that it is commonly used outside of the social sciences interchangeably with action, and action implies agency, not being something that merely happens, but something that people do, requiring intent.

  • wake up

    Action implies ‘activity’…
    If intent is the what you are trying to imply, then maybe you should use the word intent…
    Behaviour and action are both terms that apply to many things, and intent is not implied by either of them… You are trying to specify a certain limited interpretation of the meaning of two words that have very broad meanings…

    Say it it how you mean it… You are talking about intentional behaviour… And trying to state that certain words have specific meanings which they actually don’t…

    Behaviour and action can both be applied anything in the world that ‘does’ a thing…

  • cledwyn bulbs

    I should have specified that I was referring to “action” in the sense of something done by a willing agent. Points taken.

  • cledwyn bulbs

    My use of the term “action” as philosophers use it to denote purposive, willed activity, presupposed on the part of the reader a familiarity with the sense in which I was using it because everything I had said was clearly anchored within the context of human action, as can be inferred from the fact that I said “something PEOPLE do”, which I imagine I assumed would sufficiently disclose the fact that I was referring specifically to human action, and not non-human action. The same applies to behavior, and any confusion can be traced to my failure to specify that I was referring to human behavior like I was referring to human action, which I without justification assumed would be understood.

  • cledwyn bulbs

    You are incorrect in your definition of “behavior” as anything a living thing does that a dead thing doesn’t. Maybe you are guilty yourself of applying a too limited meaning here, and of stating that words have a specific meaning that they actually don’t, because behavior is also used to describe the movements and functioning of a machine, so your definition is also too narrow.

  • cledwyn bulbs

    This will be last comment here because I have had too much experience of engaging in arguments beyond the point at which it is productive to do so, especially with people whose only concern is to subjugate another to their own will, and your words, and the manner of their delivery, conspire to give off the impression that arguing with you won’t be productive.

    First, to forestall the possibility of hoisting yourself with your own petard again, maybe in future you should use the compound word “organic-behavior”, because as I have stated, according to your own all-inclusive definition of the word “behavior”, you are wrong to confine it simply to living matter, so that, figuratively speaking of course, you stand indicted by the rules you apply to others.

    One can ascertain the maturity of the individual one is engaged in an argument with according as to whether he/she can comport himself/herself in a manner as befits a mature individual and is consistent with the principles of civilized discourse, at least on a matter of no consequence as concerns the disputants personally, this latter qualification being made in recognition of the fact that on issues that are of personal import, and where a strong conflict of interests interposes itself between the disputants, mutual ill-will is understandably excited, though one should still try to contain it within judicial limits.

    Another means thereon is whether or not the individual can take the kind of criticisms he is wont to level at others.

    With the former in mind I would like to say I take issue with your manner, which is why, along with the reason aforementioned, I shall hereafter refrain from further correspondence with you on this matter, and with the latter in mind, I’d be interested to see whether you accept the criticism.

    You assert your opinions with the peremptoriness of a monarch issuing edicts, a pope laying down decrees ex cathedra, barking injunctions at your unfortunate interlocutor like some tyrant manque.

    Oh, and action doesn’t always imply activity. It can imply a genre of film, amongst other things. Once again, you stand indicted by your own rules. It can also be used by a film director as a command to begin.

  • all too easy

    I am slightly stunned. For once, I agree with the good doctor. Finally.
    This report proves that a non-existent disease, treated with meds that don’t address such a disease, morphs into an other new disease, which doesn’t exist, due to the side effects of the med that treats nothing. This new, terrifying and very real disease that is not a disease, (unless one expects to find diseases where they don’t exist, never could exist and will never exist), but, in fact, is exactly the same kind of disease that cause much personal, psychiatric distress, even though there is no such thing.
    Therefore, the drugs that treat these fake diseases produce the very same fake diseases (proven not to be real), unless you believe these diseases are not really real even though the meds relieving their symptomology are the very thing which cause the non-existent diseases that are.

  • all too easy

    I would add that actual “switching” is not the only clue suggesting bipolarity: antidepressant-related agitation and dysphoria (what I have called “ARAD”), in the absence of a frank “switch”, should still suggest bipolar spectrum illness, in my view. –Ron Pies MD

  • CarolineChange

    “Psychiatry’s defense is that the drugs didn’t induce the episode, but rather activated it.”

    This is not much of a defense unless it can be shown that those in whom the episodes are “activated” would have eventually manifested such episodes without exposure to antidepressants.

    Is anything known about age-of-onset for manic episodes since the arrival of antidepressants?

  • Phil_Hickey


    Thanks for coming in.

    Because we can never know what a person would have done if the circumstances were different, the “activation” defense is essentially unassailable. But by the same token, it is meaningless. It sounds convincing and is often accepted, but it is not a valid explanation.

    The age of onset question is interesting. DSM-III-R says early 20’s; DSM-5 says 18. But DSM-5 also invented the special label disruptive mood dysregulation disorder to siphon off the “epidemic” of children who had been labeled “pediatric bipolar”. So who knows?

  • CKComments

    You brought up something I’ve been wondering about–whether the signs and symptoms of AD-preceded mania are just like those in similar people whose mania arose spontaneously.

    And, Dr. Hicky, I asked about age at onset because I was thinking about all the middle-aged people who start on antidepressants and experience mania.

    Finally, I question the criterion on how long an AD-induced mania ought to last. To assume the presence of the drug is necessary for symptoms to persist requires forgetting the neurogenic and possible tissue-destroying properties of some antidepressants.


  • Phil_Hickey


    Thanks for coming in.

    You ask if the signs and symptoms of antidepressant-preceded
    mania are “just like those in similar people whose mania arose

    The problem here is that what psychiatrists call a “manic episode” is a very variable event. DSM-5 lists seven criteria, but an individual
    has to meet only three to qualify. So it’s not really possible to give a clean answer to your question.

    It is noteworthy, however, that even if the episode was antidepressant-induced, DSM still considers it a manic episode, and it can be used to support a “diagnosis of bipolar disorder”.

    I think you’re correct about long-term effects, and we’re hearing more on this topic from survivors.

    With regards to age-of-onset, DSM-III-R states; “…a sizable number of new cases appear after age 50.” DSM-5 states: “Onset occurs throughout the life cycle, including first onsets in the 60’s or 70’s.” And then, interestingly:

    “Onset of manic symptoms (e.g.,sexual or social disinhibition) in late mid-life or late life should prompt consideration of medical conditions (e.g., frontotemporal neurocognitive disorder) and of substance ingestion or withdrawal” [Emphasis added]

    So you may be onto something!

    Best wishes.

  • CKComments

    topic bipolar

    Very interesting. I am glad the authors of DSM-5 were so thoughtful. I can’t think of a non-prescribed drug that has manic-like symptoms (not agitation) in withdrawal, so they might have had ADs in mind when they added that.

    They called out two kinds of disinhibition, both social in a way, which might address my question about the features of mania in “natural” versus iatrogenic cases. More will be revealed–I hope. (This can’t be swept under the rug forever, can it? That’s a whole other blog post so please don’t try to tackle it here.)

    I am sorry to have let the thread drop for this long, by the way. I found this today…younger age of onset for BP I in the US than in Europe. I haven’t read it, but the abstract is suggestive. If it’s valid it could be due to what you mentioned, children on psych drugs, unless they’re on drugs to the same extent in Europe… World Journal of Biological Psychiatry, 2011; early online, 1–8

    Original investigation

    Age at onset in bipolar i affective disorder in the Usa and europe
    Frank Bellivier, Bruno etain, alain MalaFosse (+ others)


    Objective. to test for differences in reported age at onset (aao) of bipolar i affective disorder in clinical samples drawn from europe and the usa. Methods. admixture analysis was used to identify the model best fitting the observed aao distributions of two large samples of bipolar i patients from europe and usa (n  3616 and n  2275, respectively). theoretical aao functions were compared between the two samples. Results. the model best fitting the observed distribu- tion of aao in both samples was a mixture of three gaussian distributions. the theoretical aao functions of bipolar i disorder differed significantly between the european and usa populations, with further analyses indicating that (i) the proportion of patients belonging to the early-onset subgroup was higher in the usa sample (63 vs. 25%) and (ii) mean age at onset (sD) in the early-onset subgroup was lower for the usa sample (14.5  4.9 vs. 19  2.7 years). Conclusions. the models best describing the reported aao distributions of european and usa bipolar i patients were remarkably stable. the intermediate- and late-onset subgroups had similar characteristics in the two samples. however, the theoretical aao function differed significantly between the usa and european samples due to the higher proportion of patients in the early-onset subgroup and the lower mean age-at-onset in the usa sample.

  • all too easy

    Not one, objective, scientific test exists that provides evidence that antidepressants have ever caused mania.

  • Phil_Hickey


    Thanks for coming back, and for the link. I’ll take a look at it.

  • anon11

    There’s plenty of evidence that antidepressants precipitate manic episodes in a subset of the people put on antidepressants (though not all).


    drug therapy can precipitate mania in vulnerable individuals, but
    little is known about the effects of age on this phenomenon.


    To pharmacoepidemiologically evaluate the risk of conversion to mania by antidepressant class and patient age.

  • anon11
  • anon11

    Unless you’re being facetious.

  • all too easy

    For example?

  • anon11

    For example what?

  • anon11

    Dr. Hickey, a couple of points regarding this.

    Emil Karlsson on his website writes :

    “Let us look at the claim about bipolar disorder in particular.
    Shachar specifically claims that some individuals who are diagnosed with
    bipolar disorder have previously been diagnosed with ADHD. He implies
    that this means that ADHD medication cause bipolar disorder. In reality,
    the symptoms of ADHD resemble those of bipolar disorder to a certain
    extent, so it is more likely that those rare individuals have their
    bipolar disorder misdiagnosed as ADHD (Mayo Clinic, 2012b).” Source:

    In yet another article Emil writes: “In other words, when they write “antidepressant-associated mania or
    psychosis”, we should read that as “mania or psychosis in individuals
    who happen to be on antidepressants at the same time”. In other words,
    they are measuring a correlation. They do have another inclusion
    criteria as well: “rapid improvement following discontinuation of
    antidepressants with addition of a neuroleptic or mood-stabilizing
    regiment when clinically indicated”. Of course manic or psychotic
    symptoms will rapidly improve if you treat with neuroleptics or
    mood-stabilizers (they mention that the majority of individuals in the
    study were given these substances). Curiously, one exclusion criteria
    included “stable medication regiment prior to admission”. That means
    that they really looked at the correlation between initiation of
    antidepressants and admission of manic or psychotic symptoms, not
    long-term use. In their discussion section, the researchers point out
    that “most cases meeting inclusion criteria were known to have a
    psychotic/manic diathesis [i.e. family history of psychosis/mania – E.
    K.] by history.” and “a past history of psychosis was found in 61% (N =
    26) of our group”. Finally, the point out that “it is difficult to
    ensure that the emergence of psychotic or manic symptoms was due to the
    initiation of antidepressant treatment and not intrinsic to the disease
    course” and that their paper is not meant to study the incidence of
    antidepressant-association psychosis or mania (because they did not
    include a control group). Strike five.” Source:

    Peter Gotzche has written “One of the worst consequences is that the treatment with ADHD medications and happy pills has created an entirely new disease in about
    10% of those treated – namely bipolar disorder – which we previously
    called manic depressive illness.” Source:

    Now, I have nothing to say about the rest of Emil’s ADHD article as I do not know much about ADHD.

    But I do have something to say about antidepressant induced mania, as I have plenty of personal experience with it.

    That antidepressants cause mania in a subset of the population put on them is a FACT. These are not manic episodes that HAPPEN to occur when a person is put on antidepressants. They are DUE to them. There is a direct causal relationship between antidepressants and mania in certain individuals.

    That being said, people DO have spontaneous manias without antidepressants as well.

    I am someone who has a LOT of experience with antidepressant induced mania.

    I have tried the experiment out on myself several times with escitalopram, venlafaxine, sertraline, and fluvoxamine.

    These drugs get me “high” the same way alcohol gets me high. Of course, the highs are very different. The SSRI high is an energetic stimulant sort of high as opposed to alcohol. I also know that some people experience no mood change at all on antidepressants, and some people find benefit.

    I still take psychotropic drugs, a combination of Lamotrigine, Mirtazapine, and Escitalopram. I find them to be of some help. But they’re just to reduce the MENTAL FEELING of distress. They obviously do nothing to solve the problems in living I have. Horrible family situation, abusive father etc.

    I would like to cite a case study done by two Indian doctors S. Ramesh and Sudhir K Khandelwal. .This is a very important case study for me. My experiences with antidepressants have been similar to the person in this case study.

    There were times when I would get depressed because my father would speak shit, and I’d go to the medical shop, buy SSRIs, take them for a few days for the high, so I could go to work and function. By this time I had plenty of experience with antidepressant highs and would be careful to mind my mood and behaviour on them.

    A large scale study on this phenomenon is of course:

    My bipolar diagnosis came as a result of antidepressant induced mania. The prescribing psychiatrist was quick to recognise this and he said that they were due to the SSRIs despite my initial insistence that I created the excellent mood myself. The first time I had an antidepressant induced manic episode, I felt good after quite a long time, and I really wanted to believe that I did that myself. After that of course I made out the link between SSRI use and the “high”.

    Taking SSRIs with a mood stabilizer prevents the high.

    The bigger question is, would I, or people like me ever have experienced mania without antidepressants and thus be diagnosed bipolar?

    I have a maternal relative with a bipolar diagnosis. I asked her several times regarding her manic episodes just to be sure. She repeatedly told me that they were ALWAYS due to SSRI use.

    In my case, I have never had a spontaneous mania.

    Nasser Ghaemi, of course writes that antidepressant induced mania almost always means that the person has bipolar disorder. Source:

  • anon11

    Robert Whitaker writes (Source: :

    Next, there is substantial evidence that SSRIs increase the risk
    that an adult diagnosed with unipolar depression will turn manic and
    thus be diagnosed with bipolar disorder. Yale investigators reviewed the
    records of 87,290 patients diagnosed with depression or anxiety between
    1997 and 2001, and determined that those treated with antidepressants
    converted to bipolar at the rate of 7.7 percent per year, which was
    three times greater than for those not exposed to the drugs. This
    conversion risk was highest in teenagers.

    If you look at the gateways to bipolar, SSRI-induced mania is a
    primary one. For instance, in a survey of members of he Depressive and
    Mani-Depressive Association, 60 percent of those with a bipolar
    diagnosis had initially fallen “ill” with major depression and had
    turned bipolar after exposure to an antidepressant.

    Ross Baldessarini and Giovanni Fava recently published a paper
    on this risk in children and adolescents, through a review of reports of
    antidepressant trials for depressive and anxiety, and they concluded
    that even in the short term trials, “overall rates for mania or
    hypomania were 8.19% with [antidepressant treatment] and .17% without
    antidepressant treatment, with large drug/placebo risk ratios among
    depressive and anxiety disorder patients.”

  • all too easy

    I am in love. Comedy Central right here. Antis, who know for a fact BP doesn’t exist, swear it does too exist, when they want to blame it on psychiatric meds. Got to love these complete, unabashed, total idiots.

  • anon11

    Are you intentionally being thick? Because you’re attacking a strawman that you’ve created. I, personally, have never claimed that depression and mania don’t exist.

    And it isn’t an antipsychiatry thing (I visit a psychiatrist sometimes and take prescription pills everyday) to say that antidepressants cause mania in a subset of the population, you ignoramus.

    Psychiatrists themselves recognise this, which is why they’re careful with antidepressants sometimes.

    In my earlier posts, I linked to a large scale study and a case study from psychiatric literature itself regarding this. So, stop being an imbecile.

  • Rob Bishop

    Nobody disputes people suffer in many different ways, and that suffering is real. Upwards of 80% of thoughts are negative. Is this a disease? If I have 7,000 negative thoughts/day and Suzy has 17,000 negative thoughts/day, does that make her biologically defective? Most human misery is self-caused. When you get angry, depressed, or anxious, listen to the stories you tell yourself, in your head, and notice how repeating the stories fuels the disturbing emotions. It’s empowering to discover we are our own worst enemy, because changing ourselves is something we have within our power.

  • all too easy

    Dearest Beloved Boob aka Jimbo The Kaiser,
    Our sweet, precious, always polite-prim-and-proper, the gal who can’t explode into murderous rages, Anon11 +4-8=love and heaven, wants to tell you that yes indeed you are a complete ignoramus. So, debate with her until she cycles down into her depressive state.

  • Phil_Hickey


    This is very insightful stuff. But I’d be careful with the self-experimentation.

    You are confirming something I’ve long mentioned: that psychiatrists who prescribe SSRI’s are essentially playing Russian roulette with other people’s lives.

    Best wishes.

  • all too easy

    And you deprive the desperately injured proven safe and efficacious medications that enable them to function.

  • all too easy

    Surgeons, who perform heart bypass operations, essentially roll the dice with a sick person’s life.

  • Dell Vane

    That went well.

  • Dell Vane

    Thanks for writing all that. I am not familiar with “Emil” but he is familiar with grasping at straws, it seems. He is also unfamiliar with the behaviors that fit the diagnostic criteria for adhd produced by small number of people every decade or so.

    There used to be something called amphetamine psychosis that befell some people who took amphetamines. There are all kinds of news stories about the permanent harms that befall meth addicts. Make that methAMPHETAMNE addicts. There’s even prescription meth for ADHD which means people go to jail for not buying meth from the right dealer.

  • all too easy

    “My general point is that although the vast majority of problematic behavior is not caused by damaged or impaired neurology, damaged or impaired neurology can impact thoughts, feelings, and/or behavior. If a person takes LSD, for instance, and begins to hallucinate, I think it’s realistic to describe the hallucinations as LSD-induced” Dr. Phil Hickey
    The mechanism of action whereby LSD causes hallucinations is not known. Despite that fact, like psychiatry in general, you believe that LSD induces hallucinations. In the absence of even one, single biological test to confirm your conclusion, you have unwittingly joined forces with the majority of spurious, fraudulent, conspiratorial, selfish, greedy, money-making-driven, purposely deceitful, bunch of phonies, A.K.A. “psychiatrists”. Welcome aboard, bro. Knew you could do it.
    I am so good at this, I occasionally surprise even me.

  • all too easy

    “If you look at the gateways to bipolar, SSRI-induced mania is a
    primary one.” anon1111113
    There is no such thing as bipolar. Bipolar is not a biological disorder. You cannot create something that doesn’t exist. I certainly have sympathy for the poor slobs who experience some mood shifts, (we all know how terrible that must be) but “bipolar” itself is the spurious, greed driven creation of pharma in collusion with those drug pushers sporting white smocks, A.K.A. “shrinks”.
    I’d be happy to entertain any scientific, biologically based data that proves I’m wrong. Until then, oh well.
    My sense of humor is of super human quality as well. I’m a riot!

  • Trollolol

    Inducement doesn’t imply objective scientifically verified direct causation, you moron. Do you believe, and this is rhetorical, I don’t care what you believe, nobody does, do you believe, that situations described as alcohol fueled bar violence, are induced by alcohol? If so, do you believe that alcohol fueled violence is on par with a verified objectively demonstrable pathological organic brain disease causing seizures? You are, a moron, it is abundantly clear, you’ve been trolling this site daily for what? four or five months now? you’re utterly pathetic. The real inducement that has been proven here, is that the existence of ‘’ causes ‘all too easy’ to dedicate hours of his wasted life to trolling.

  • SS

    I had two severe manic episodes from being prescribed antidepressants. Effexor and Citroprazolam (sp?) Both times I ended up in the ER

    I’m bipolar and both my mother and sister have the same condition, The docs seem to ignore that pts experiences.

  • SS

    I also had one after being prescribed a steroid drug. I was taking St Johns Wort at the time also to make myself feel better. I think I was going through a period of depression. A psychiatrist told me that St John’s Wort cannot cause mania yet it is a prescribed drug for depression in Ireland. Herbs aren’t regulated in the US. Another doc I saw said quit taking that stuff the strength can vary widely from pill to pill.

  • SS

    The same psychiatrist told me there is no such thing as bipolar 2 you either have bipolar or you don’t.