ALAN EPPEL
For decades, one of the most
controversial issues within psychiatry has being whether or not antidepressants
have any role to play in the treatment of bipolar disorder.
Bipolar disorder
consists of periods of depression and periods of mood elevation. On the face of
it, it has seemed logical to many psychiatrists and researchers that
antidepressants should be used to treat depressive episodes in bipolar
disorder.
On the other
side of this debate many authors have pointed out the potential adverse effects
that antidepressants may have in bipolar disorder :
1.
antidepressants may cause switches into mania or hypomania
2. antidepressants may cause repeated cycles of depression even without
switches into mania.
3. antidepressants may induce mixed states. Mixed states consist of dark
feelings of depression and despair combined with high energy, overactivity,
racing thoughts and irritability. Mixed states pose a very high risk of suicide.
Now two articles in the
January 2016 issue of the Psychiatric Clinics of North America confirm many of
the reservations about the use of antidepressants in bipolar disorder.
Robert Post a long-time researcher and member of the Bipolar
Collaborative Network concludes that:
"Conventional treatment of bipolar depression toward the end of the twentieth century typically included
antidepressant augmentation of mood stabilizers.
However, the past decade
has seen increasing evidence that this is not only a generally ineffective treatment approach,
but one that may be counterproductive."
The article
reaffirms the primary place of lithium in the treatment of bipolar disorder and
the use of lamotrigine, valproate and carbamazepine as mood stabilizers.
Post makes the case for the
adjunctive use of several of the second-generation antipsychotic medications if
needed. [However the potential serious
adverse effects of these medications, including metabolic syndrome and tardive
dyskinesia limit their application].
In the same edition of Psychiatric Clinics , John Beyer and Richard
Weisler in discussing the risk of suicidal behavior in bipolar disorder state
that:
"Overall, the best
available evidence suggests that antidepressant use in bipolar disorder does
contribute to suicidal behaviors. In fact, the new onset of suicidal thoughts
after introduction of an antidepressant in depressed patients should raise the
clinician’s suspicion of an underlying bipolar illness".
These
articles reinforce the findings of the International Society for Bipolar
Disorders task force on the use of antidepressants in bipolar disorder:
“The evidence continues to
accumulate that antidepressants alone and in combination with mood stabilizers
have a very small role if any, in the pharmacological management of bipolar
depression. There is increasing acknowledgement that antidepressants can be
harmful. Antidepressants can lead to long-term mood instability, cycle
acceleration, mood switching, mixed states and increased risk of suicide.”
Perhaps this debate can now be put to rest.
References
Post R. Treatment of
Bipolar Depression Evolving Recommendations Psychiatric Clinics of North America
39 (2016) 11–33.
Beyer J, Weisler R. Suicide Behaviors in Bipolar Disorder: A
Review and Update for the Clinician Psychiatric Clinics of North America 39
(2016) 111–123.
The International Society for Bipolar Disorders (ISBD) task
force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013 Nov 1;170(11):1249-62.
Eppel AB: Antidepressants in the Treatment of Bipolar
Disorder: Decoding Contradictory Evidence and Opinion', Harvard Review of
Psychiatry 2008; 16:3, 205 - 209.
