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New Recommendations for Antidepressant Use in Bipolar Disorder
Antidepressant use in the treatment of bipolar disorder has become quite controversial.
Some doctors would argue that antidepressants do not improve treatment outcomes of people with bipolar and others even argue that it can worsen it. This is due to concerns over antidepressants inducing mixed states, mania, hypomania, and cycling. And if the antidepressant does induce one of these states, bipolar disorder can become even harder to treat. Because of this, doctors should avoid antidepressant monotherapy (treatment with an antidepressant alone) in bipolar disorder.
Recommendations for Antidepressant Treatment in Bipolar
In response to these and other concerns, the International Society for Bipolar Disorders (ISBD) Task Force released new recommendations in using antidepressants in bipolar treatment last month. They have recommended cases in which antidepressant treatment makes sense and cases in which it should be avoided.
When Antidepressants Can be Used in Bipolar Treatment
According to the ISBD, antidepressants may be used as adjunctive therapy (in conjunction with another medication, typically a mood stabilizer):
- In bipolar I and bipolar II in acute depressive episodes when there is a history of a positive response to antidepressants.
- In maintenance treatment when a patient relapses into a depression after the antidepressant is discontinued.
Additionally, they recommend that serotonin-norepinephrine reuptake inhibitors—SNRIs, like venlafaxine (Effexor), desvenlafaxine (Pristiq) and duloxetine (Cymbalta)) and tricyclic antidepressants (TCAs, like amatriptypline (Elavil) and imipramine (Tofranil)—only be used after other classes of antidepressants are considered and TCA usage should be closely monitored.
When Antidepressants Shouldn’t Be Used in Bipolar Treatment
The ISBD specifically states that antidepressant monotherapy should be avoided in bipolar I and according to the task force, antidepressants should not be used:
- In bipolar I or bipolar II depression when two or more manic/hypomanic symptoms are present (even adjunctively).
- In bipolar I or bipolar II depression when psychomotor agitation or rapid cycling is present (even adjunctively).
- During manic or mixed episodes.
- In patients who primarily experience mixed states.
Moreover, they recommend discontinuing antidepressants that were previously prescribed when the patient is experiencing mixed states.
(Interestingly, the task force does not explicitly say that antidepressant monotherapy should be avoided in straight bipolar II depressive episodes. I would consider this a major oversight on their part.)
Theory Behind Bipolar Treatment with Antidepressants
Basically, the idea behind treatment of bipolar disorder where depression is present is:
- First stop the cycling (or mixed state) using a mood stabilizing agent like lithium or an anticonvulsant
- If depression is present, try mood augmentation techniques that avoid the use of antidepressants
- If depression is still present, consider the use of adjunctive antidepressant treatment
Unfortunately, many people find themselves in a step-three scenario and so antidepressant use in bipolar disorder is fairly common (not to mention that many doctors prescribe antidepressants far too early in the treatment process).
Interestingly, much fewer people being treated by bipolar disorder experts are on antidepressants:
- Treated by community psychiatrists—80 percent of patients are on antidepressants
- Treated by mood disorder clinics—50 percent of patients are on antidepressants
- Treated by specialty bipolar clinics—20 percent of patients are on antidepressants
So it would seem that the more specialized the care, the more professionals recognize the concerns over antidepressants.
I would suggest this indicates that average psychiatrists far too readily prescribe antidepressants and this may be doing a disservice to patients. I’m not saying that it’s never warranted—sometimes it’s entirely appropriate—just that it may be happening too often. The new ISBD recommendations should hopefully help alleviate some of this.
(Note: this does not mean you should stop taking your antidepressants. That is never a good idea. If you have concerns about your treatment with antidepressants and want to stop them, you should discuss a tapered discontinuation schedule with your doctor.)
Image courtest of Tom Varco via Wikicommons.
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