COMMENTARY

Should Antidepressants Ever Be Used in Bipolar Disorder?

W. Wolfgang Fleischhacker, MD

Disclosures

February 04, 2015

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Hello. This is Wolfgang Fleischhacker from the Department of Psychiatry and Psychotherapy of the Medical University of Innsbruck in Austria, speaking for Medscape.

One of the burning treatment questions in psychiatry is whether or not to use antidepressants to treat people with bipolar disorder who have a depressive episode and, if yes, whether to use antidepressant monotherapy or antidepressants in conjunction with mood stabilizers. In this context, I want to briefly recapitulate findings from a paper[1] published in the October 2014 issue of the American Journal of Psychiatry by Alexander Viktorin from the Karolinska Institutet in Stockholm, Sweden, and colleagues in Sweden and the United States.

To shed more light on this important question, the authors evaluated pharmacoepidemiologic study data from two Swedish registries. From these registries, they identified more than 3000 patients who had been treated with an antidepressant during a depressive episode. The methods of this study and the selection of patients are well described and were rigorously defined in this article.

They found that the risk for a switch to mania was considerably enhanced in people who were treated with antidepressant monotherapy, whereas patients who received antidepressants and mood stabilizers in combination did not have an increased risk for a switch to mania and even demonstrated a reduced risk in the longer-term outcome evaluation.

The authors also critically noted that 35% of the patients identified by the pharmacoepidemiologic studies were treated with antidepressant monotherapy, which is clearly against recommendations made by most clinical trial guidelines and also counter to clinical experience accrued since the introduction of tricyclic antidepressants.

Study Findings Underscored by Other Recommendations

In an editorial[2] in the same issue of the journal, Dr Eduard Vieta put these results into perspective in light of a recent task force report of the International Society for Bipolar Disorders, which also strongly cautioned against using antidepressant monotherapy in people with bipolar disorder. Dr Vieta also emphasized that we have little evidence that antidepressants work at all to treat depressive episodes in people with bipolar disorder. Indeed, very few studies have evaluated this important question. This also led him to conclude that we need to be very cautious and base our treatment decisions on individualized patient profiles, with respect to using antidepressants.

Dr Vieta suggested that we should consider using antidepressants, albeit always with mood stabilizers, for patients in whom polarity is dominated by depressive symptoms, in patients with bipolar II disorders, and in patients who have shown good response to antidepressant treatments in the past. We should avoid using antidepressants in patients who have experienced switches to mania during past treatments and in other high-risk populations with little evidence to support the use of antidepressants.

In summary, these two articles bring forward the fact that in patients who have a depressive episode in the context of bipolar disorder, if antidepressants are considered at all, they should always be combined with a mood stabilizer.

Thank you very much for listening in. This is Wolfgang Fleischhacker for Medscape.

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