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,
Kathie

PS  Feel free to shorten this question in the interests of getting an answer.  I can not find anything anywhere on this issue!!!


Dear Kathie --

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 all.

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 website entitled Antidepressant Controversies, where there is a direct link to the section on kindling.

Thank you for your question and your interest in this subject.

Dr. Phelps