Do antidepressants have any role in bipolar depression? AJP.Nov 2013

07.01.2014

The debate about safety and efficacy of  antidepresanats (ADs) in bipolar depression is a longstanding one. Good quality research evidence is lacking to make any firm conclusions. Society for Bipolar Disorder (ISBD) attempted a consensus based on available evidence and this is reported in this article by Isabella Pacchiarotti et al.

The team conducted  review of available literature and this was followed by a survey of experts (delphi method) to suggest what we could do in various clinical situations. Those items endorsed or considered essential by 80% of experts were included in the final recommendations.

Antidepressant mono therapy:There is no evidence to support use of mono therapy. This should be avoided in bipolar depression especially in those where presence of any manic symptoms along with depression is suspected or observed.

Antidepressant adjunctive therapy (acute) : Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode when there is a history of previous positive response to antidepressants. Adjunctive antidepressants should be avoided for an acute bipolar I or II depressive episode with two or more concomitant core manic symptoms in the presence of psychomotor agitation or rapid cycling.

Long-term maintenance with antidepressants:  Trials involving addition of  ADs to ongoing mood-stabilizing treatments are scant and have yielded inconclusive findings. Maintenance treatment with adjunctive ADs may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.

Mixed states: Antidepressants should be avoided during manic and depressive episodes with mixed features. Previously prescribed antidepressants should be discontinued in patients currently experiencing mixed states.

 Bipolar patients starting antidepressants should be closely monitored for signs of hypomania/mania and increased psychomotor agitation, in which case antidepressants should be discontinued. The use of antidepressants should be discouraged if there is a history of past treatment emergent  mania/ hypomania, or mixed episodes. Antidepressant use should be avoided in bipolar patients with a high mood instability (i.e., a high number of episodes) or with a history of rapid cycling. 

Which antidepressant?

The risk of mood switching is considered to be higher and more severe in bipolar I than bipolar II patients and somewhat greater with tri- and tetracyclics (and perhaps some SNRIs like  venlafaxine). Adjunctive treatment with such ADs should be considered only after other antidepressants have been tried, and should be closely monitored because of an increased risk of switch or destabilisation. Non-antidepressant treatments, including lithium, lamotrigine, olanzapine, quetiapine, and lurasidone, should be considered as monotherapy before using antidepressants in bipolar depression.

Conclusions: Avoid antidepressants if possible in bipolar depression. If required use with mood stabilisers and monitor closely.

Summary of the article:

The International Society for Bipolar Disorders (ISBDtask force report on antidepressant use in bipolar disorders. Pacchiarotti I et al Am J Psychiatry. 2013 Nov 1;170(11):1249-62.

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