Let's say that you're at your buddy's house. You're watching a crappy prime-time network program (the episode where Jack Bauer goes down on Madam President). Suddenly, your friend stands up, goes to the fridge, and takes out a diet-coke in a black can (d-bags call it Coke Zero). Before opening the can, he methodically taps his index and middle fingers on top of the can.
When you hear the tapping, you casually turn your head toward your friend and ask, "Are you retarded?"
"No," says your soon to be former friend, "I'm knocking loose the bubbles from the bottom of the can so they float to the top, so it won't foam when opened."
If you haven't tried this technique, you have certainly seen someone do it, despite the fact that it doesn't work (1). It's simply just not true, yet people all over the world perform this little trick and proudly profess their discovery to others, who then spread this good news to even more people. After enough time, a myth is transformed into a fact.
Another myth that has been accepted as fact is antidepressant induced mania, which is the topic of study in this pointless investigation (2). The study is titled, "Correlates of Treatment-Emergent Mania Associated With Antidepressant Treatment in Bipolar Depression." The stated goal of the study is to examine "the correlates associated with treatment-emergent mania in patients receiving adjunctive antidepressant treatment for bipolar depression."
Hidden beneath these words is the assumption that antidepressant induced mania is a real phenomenon with legitimate scientific backing. Moreover, it means the authors (all 13 of them) cited research studies that support this assumption.
"While antidepressants may be effective in some individuals with bipolar disorder, they can precipitate a rapid mood switch from depression to mania (8, 14, 15), a phenomenon also known as treatment-emergent mania." (2). According to this sentence, studies 8, 14, 15 are studies that utilize the scientific method to provide nearly conclusive evidences that "treatment-emergent mania" is a real phenomenon.
Reference 8 is a letter to the editor (3). It's in reference to a study published in 2005, in which antidepressants were found not to induce mania. I'll repeat that, because it sounds mildly important. The study found that antidepressants did not induce mania, yet, this letter was referenced as evidence in support of antidepressant induced mania. Drater spelled backwards is what?
Reference 14 is titled, "A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression" (4). First, modafinil is an arousal promoting agent (that's pharma speak for stimulant), not an antidepressant*. Secondly, the study found this, "there was no difference between groups in treatment-emergent hypomania or mania." They're 0 for 2.
Reference 15 is here (5). This study actually looked at the phenomenon of treatment emergent mania; however, it was a meta-analysis that found this, "In bipolar depressives, manic switch occurs substantially more often with TCAs (11.2%) than with SSRIs (3.7%) or placebo (4.2%)". The SSRI rate was lower than the placebo rate. Since this study (2) looked at the antidepressants sertraline, venlafaxine, and bupropion (SSRI, SNRI, & DNRI) and not TCAs**, that's strike three.
I vaguely recall myself complaining about not reading references before citing them (6, 7). What exactly to peer reviewers do anyway?
I had to re-read this study. When I found out that the authors cited 3 studies in support of their assertion that countered their assertion, I blacked out, only to wake-up 7 days later in Butte, Montana digging for copper in a pair of crotchless panties.
However, I should have stayed in Butte. When I picked-up where I left off, I read this, "more than 40% of patients enrolled in STEP-BD self-reported manic or hypomanic switch associated with antidepressant use." Self-reported? Parents self-reported that vaccines caused autism in their children. I'm suppose to accept patient self-reports as proof when patients cannot remember if they were hospitalized for a mood episode (8, I know the book has 1,200 pages; I'm too lazy to find the reference, but trust me it's in there, somewhere, I think..., don't quote me on that).
Here is where the researchers exhibit that special kind of stupid that I mentioned briefly in this post (9). The study found "that minimal manic symptoms at baseline coexisting with otherwise full syndromal bipolar depression are associated with antidepressant treatment-emergent mania or hypomania." Some could argue that the switch (as evidence by minimal manic symptoms) was already in progress, before the antidepressant was on board. Bipolar disorder is, after all, a highly recurrent disorder.
I could say more about this study, but my head hurts. I may have just popped an aneurysm. You can read more about this study and still learn nothing by going here (10).
You can read more about antidepressant induced mania here (11).
* Technically, "antidepressant" is a meaningless term. The FDA regulates what drug companies can advertise their drugs as treating. There are many classes of drugs (e.g., TCA, SSRI, NASSA), all of which have different mechanisms of action and are all equal in efficacy (roughly). A drug can have antidepressant properties and not be labeled as an antidepressant. Just because one subclass of antidepressant might increase switch rates does not mean all antidepressants increase switch rates. Modafinil works by stimulating the tuberomammillary nucleus of the hypothalamus, thus increasing arousal (in case you cared to know).
** Although the proposed mechanism of action for TCAs is through serotonin-norepinephrine re-uptake (SNRI), they are dirty drugs. They also block histamine receptors, muscarine receptors, and alpha adrenergic receptors. Those additional properties might explain the differences between TCA and SSRI in that one study.
M. A. Frye, G. Helleman, S. L. McElroy, L. L. Altshuler, D. O. Black, P. E. Keck, W. A. Nolen, R. Kupka, G. S. Leverich, H. Grunze, J. Mintz, R. M. Post, T. Suppes (2009). Correlates of Treatment-Emergent Mania Associated With Antidepressant Treatment in Bipolar Depression American Journal of Psychiatry, 166 (2), 164-172 DOI: 10.1176/appi.ajp.2008.08030322