Should Antidepressants Be Used to Treat Bipolar Disorder?
Thursday, January 6 2011 Natasha Tracy
While many people with bipolar disorder have and continue to be treated with antidepressants along with many other medications, there is a controversy in the medical community as to whether this is an appropriate approach. In bipolar disorder there is some risk of antidepressants inducing mania or perhaps worsening rapid-cycling.
But is this true? What evidence is there that antidepressants work in bipolar disorder? What evidence is there that they will make bipolar disorder worse? What do you do if you can’t take an antidepressant?
Antidepressants Cause a Switch to Mania in Bipolar Disorder
This concern came to light in the 1960’s when Tricyclic antidepressants (TCAs) were used to treat depression in bipolar disorder (bipolar I). This concern continues today and now includes concerns with bipolar II. Therefore, some doctors are very reluctant to prescribe antidepressants in cases of bipolar.
However, it is extremely difficult to ascertain (in a statistical sense) whether a switch into mania or hypomania is related to an antidepressant or simply a natural factor of the disease. It should be noted that it is thought in cases of true antidepressant-induced polarity switches, symptoms may continue even if the antidepressant is stopped.
Switching into mania or hypomania, or increasing rapid cycling is a dangerous effect that can result in worsening, or more, depressions. Recent literature suggests that about 10% - 25% of the reemergence of mania or hypomania symptoms can be attributed to antidepressant use. (Note: which antidepressant is used effects the likelihood dramatically.)
Antidepressants Don’t Work for Bipolar Depression
People fall on both sides of this argument but one thing we know for sure is that enough studies haven’t been done to draw an absolute conclusion either way. Not enough studies have been done comparing antidepressant use in bipolar vs. unipolar depression. Moreover, when you take into account bipolar II, things become even murkier.
Antidepressants with positive study data for bipolar depression include paroxetine, bupropion, and imipramine. Data on efficacy of an antidepressant combined with a mood stabilizer includes venlafaxine, sertraline, and bupropion. This evidence is not perfect though as it doesn’t account for confounding factors in a heterogeneous population. (The studies don't take into account all variables.)
Antidepressant and Bipolar Disorder Takeaways
Understanding there is controversy and limited data, here is what we know right now:
- Bipolar I has relatively high rates of switching when they are treated with a TCA or monoamine oxidase inhibitor (MAOI) alone
- In bipolar II, superior outcomes have been found when treated with venalfaxine over lithium alone, with no additional mood destabilization
- Antidepressants with positive study data and low risk of destabilization include: bupropion, sertraline, fluoxetine, tranylcypromine or venlafaxine in bipolar II depression
- If mania or hypomania appears, discontinuing the antidepressant is preferable over adding additional mood-stabilization agents
In general, antidepressants are more appropriate for:
- Bipolar II
- Depressed (non-mixed) states
- Absence of rapid-cycling
- Absence of recent mania or hypomania episodes
- Absence of substance abuse issues
- Previous favorable antidepressant response, without mood destabilization
If You Don’t Respond to Antidepressants or Switch Polarity
There is some evidence to suggest that the following are worth considering:
- n-acetyl cysteine
- adjunctive thyroid hormone
- Light therapy (if a seasonal component is evident)
- electroconvulsive therapy
The lesson, I think, is this: if you’re bipolar and only being treated with antidepressants you might not be doing yourself any favors. (This problem is often seen in cases where the bipolar isn't detected.) On the other hand, if you’re bipolar and depressed and you haven't tried an antidepressant, your doctor might be overestimating the danger.
(And keep in mind, just because your treatment isn’t listed here, that doesn’t mean anything is wrong; your doctor is just using his/her best clinical judgment and everyone is different – you are not a statistic. In all honesty, this information is just a starting point. Also remember that older drugs have more data just because, well, they’re older. Oh, and in case you forgot, I’m not a doctor; go see one if you have questions.)
The information in this article mostly comes from the journal Current Psychiatry online, article: Antidepressants in bipolar disorder: 7 myths and realities; Vol. 9, No. 5 / May 2010; but unfortunately you can’t get to the article without a subscription. You can see psychEducation.org though for lots of information on this topic.
Drug Brand Names
Bupropion • Wellbutrin
Fluoxetine • Prozac
Imipramine • Tofranil
Lithium • Lithobid, Eskalith
Modafinil • Provigil
Paroxetine • Paxil
Pramipexole • Mirapex
Riluzole • Rilutek
Sertraline • Zoloft
Tranylcypromine • Parnate
Venlafaxine • Effexor