For autistic people, caution urged in choosing to take SSRIs

I came across a literature review that looked at an issue that was at the heart of my lost 20s. In (Fredskild MU, Engell R, Kessing LV. [Bipolar affective disorder in autism spectrum disorder]. Ugeskrift for Laeger. 2022 Aug;184(33):V01220067. PMID: 36065878.), among other findings, the authors examine the intersection of autism and bipolar disorder (BD) where SSRIs are prescribed.

As an autistic person who also lives with BD (I’m BD1), I have learned firsthand about the risks of starting serotonin reuptake inhibitor (SSRI) antidepressants without awareness of my BD1 vulnerability. Though these medications are commonly prescribed for depression and anxiety, my experience reflects what experts now caution about SSRI use in autistic people who may have underlying bipolar spectrum conditions.

After two decades of coping with mood instability that I was unable to articulate clearly to providers given my language difficulties, I was eventually prescribed an SSRI. Don’t ask them how talk therapy is supposed to work when you’re an undiagnosed autistic gestalt processor (aka, non-verbal) with a very traumatic past?

At first, I was happy with the meds. I won’t say that my moods improved as much as now say that I just stopped feeling anything. Then, within a few months I rapidly cycled into a full manic episode that seemed to not end. On the SSRIs, I never felt like I could come down and rest, or even that I needed to rest (and mania in BP1 often includes reduced judgement … ouch). At a certain point, my mind realised that it wasn’t normal, trigging panic and anxiety at not being able to come down. Given the nature of SSRIs, I couldn’t just quit them cold-turkey. Because I hadn’t yet received my autism diagnosis, and because the lack of awareness around this issue with autism, BP, and SSRIs, the doctors first upped my dose (thinking that it might work) before eventually weaning me off of them entirely.

In hindsight, clear markers of BD1 were likely present earlier in my life. Now that I’ve connected with my birth parents and some of their family, I know that I have a family history of BD.

Now when SSRIs are carelessly prescribed to autistic patients like myself, without proper diagnosis and evaluation, the results can be catastrophic mood dysregulation as I endured. The medical literature indicates that for those on the autism spectrum who have (or may have) co-occurring bipolar disorder (comorbid BD), SSRIs can trigger manic or hypomanic episodes - just as is already well-documented to happen in non-autistic bipolar patients as well. This life-altering consequence of medication-induced mania, which I personally experienced from lack of proper BD assessment, is sadly avoidable. Appropriate screening procedures and diagnosis for BD before the administration of antidepressants to treat depression can prevent such medication-induced mood episodes. This underscores the need for more vigilant standards in assessing for psychiatric comorbidities like BD among autistics prior to prescribing commonly used depression medications such as SSRIs, which carry risks in this subset of patients.

In speaking out, I hope to spare other autistic people with BD (and the self-diagnosed who may not know their BD risk factors) from the anguish precipitous and uninformed SSRI prescription brought me. Our community deserves better awareness of how commonly these conditions intersect and what specialised diagnostic and treatment considerations scientists now recommend given the overlap. It is time clinical practice catches up with emerging science to prevent further harm. I urge all autistic patients to self-advocate for comprehensive evaluation, differential diagnosis, and fully informed consent regarding medications like SSRIs that bear different risks for us. Our wellbeing and safety depend on it.