New Recs for Antidepressant Use in Bipolar Patients Released

Fran Lowry

June 24, 2013

MIAMI — The International Society for Bipolar Disorders (ISBD) Task Force has released its long-anticipated recommendations on antidepressant use in bipolar disorders.

The new recommendations, which stem from an international collaboration of 70 bipolar disorder experts from around the world, were released here at the 10th International Conference on Bipolar Disorders (ICBD).

"The use of antidepressants in bipolar disorder is very controversial, and we were able to gather the best experts worldwide to do this report," Eduard Vieta, MD, PhD, professor of psychiatry at the University of Barcelona, in Spain, told Medscape Medical News.

The recommendations are the result of a review of 173 studies to assess the quality of the evidence for antidepressant use in this patient population, as well as numerous drafts and revisions.

"The take-home message is that antidepressants have a questionable benefit-risk and should only be used in certain cases in bipolar disorder," Dr. Vieta, who presented the recommendations on behalf of the ISBD Task Force, said in an interview.

"First, they shouldn't be used in mania or in mixed episodes, they should only be used in bipolar depression in patients with a history of a good response in the past to antidepressants and no history of rapid cycling or switches into mania right away," he said.

Dr. Eduard Vieta

Further, antidepressants should not be used in patients with bipolar disease with mixed features during a depressive episode or some manic symptoms during depression, Dr. Vieta said. "This condition is also now recognized in the new DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition] as a subtype of bipolar depression," he said.

The recommendations are currently in press in the American Journal of Psychiatry.


Controversy Remains

"I think it is a very important contribution that we achieved from this task force, and we are very happy with the outcome," Willem Nolen, MD, PhD, professor of psychiatry at University Medical Center Groningen, in the Netherlands, who moderated the oral session, commented to Medscape Medical News.

Dr. Willem Nolen

"It's still clear that there is a lot of controversy, but at least now we have an impression that the recommendations from this report are supported by more than 80% of the authors. This gives all of us who treat bipolar disorder and wonder where antidepressants fit in an important guide that we can rely upon."


Recommendation Highlights

The recommendations for acute treatment of a depressive episode in bipolar disorder include the following:

  • 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 2 or more concomitant core manic symptoms, in the presence of psychomotor agitation or rapid cycling.

For maintenance treatment, the following is recommended:

  • Maintenance treatment with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.

The recommendations for antidepressant monotherapy includes the following:

  • Antidepressant monotherapy should be avoided in bipolar I disorder.

  • Antidepressant monotherapy should be avoided in bipolar I and II depression with 2 or more concomitant core manic symptoms.

The recommendations for antidepressant use in mixed states include the following:

  • Antidepressants should be avoided during manic and depressive episodes with mixed features.

  • Antidepressants should be avoided in bipolar patients with predominantly mixed states.

  • Previously prescribed antidepressants should be discontinued in patients experiencing current mixed states.

The ISBD Task Force also recommended that adjunctive treatment with serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants be considered only after other antidepressants have been tried. If they are used, they should be closely monitored, owing to increased risk for switch or mood destabilization.

Dr. Vieta and Dr. Nolen report no relevant financial relationships.

10th International Conference on Bipolar Disorders (ICBD). Abstract 13. Presented June 14, 2013.


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