Q: "Kindling" & Antidepressants
Dear Dr. Phelps,
First of all, thank you so much for your much needed and well written book, "Why
am I still depressed?" If anyone reading this hasn't purchased it and read it
yet, it is a must read!
I'll try to make it brief. I have always been diagnosed and treated for
unipolar depression rather than bipolar depression as I never had any clear
manic or even hypomanic symptoms. Over a 12 yr period, I failed numerous SSRI
trials. The last doctor I saw put me on Effexor XR of which I titrated to 300mg
as it wasn't working terribly well either. After 4 years without full
remission, I weaned myself off.
6 months later I found myself in a new psychiatrist's office complaining of
being in an anxious, driven, ruminating state along with being somewhat
depressed. I explained that I had never had these symptoms before. She handed
me your book and I learned about "kindling."
Here's the question: Now that my brain has been "kindled" with SSRI's,
especially for the past 4 years, will it ever return to it's pre-kindled state?
Is there any research on this - even anectdotal at this point?
Thank you again,
PS Feel free to shorten this question in the interests of getting an answer. I
can not find anything anywhere on this issue!!!
Thank you for your kind words about my book. The acid
test of its value is whether you are now lead toward a more effective treatment
than the ones you have been trying so far. I hope that proves to be the case.
As for "kindling", you are correct that there is very
little research which speaks directly to this issue. For other readers, let us
review briefly: "kindling" is the idea that in some people, bipolar disorder
seems to worsen over time. The hypothesis is that this worsening is driven by
the episodes of illness themselves: each manic episode, and perhaps each
depressive episode (this is less certain, and all of this is quite uncertain),
might be the event which is making the illness worse. In this way, the illness
tends to accelerate, with each subsequent episode more severe, and more easily
triggered by such things as sleep deprivation, or alcohol, or minor stress, or
even -- over time -- finally able to occur on its own with no provocation at
The issue Kathie is referring to here is the idea that antidepressants might
actually induce episodes that served as kindling triggers. May I emphasize: this
is more like just a clinical fear, rather than a hypothesis. It would be
extremely difficult to prove from looking at clinical cases, because one can
always wonder whether the worsening might have occurred without any exposure to
antidepressants at all. The only way to deal with this would be to have a
control group which was not exposed to antidepressants, and yet that kind of a
study would have to go on for many years. We simply are not going to see that
kind of research done (it has been hard enough just to get a study looking at
whether antidepressants work better than a placebo and bipolar depression, one
such study having just been published recently after years of effort).
Eventually, one can hope that we'll have some sort of biological marker by which
to monitor the progression of bipolar disorder. Then we might be able to detect
some sort of kindling phenomenon without having to wait for years of experience
with a group of patients.
In the meantime, however, all we have to go on is the observations of astute
clinicians. In my opinion, the sharpest bipolar experts all seem to worry about
this, but I am a very biased judge in this case. I have tried to gather all of
the relevant writings on the subject that I have come across on the page on my
Antidepressant Controversies, where there is a direct link to the
Thank you for your question and your interest in this subject.
Published July, 2007