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Link to original content: http://pubmed.ncbi.nlm.nih.gov/26459471
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. 2015 Nov;18(4):100-2.
doi: 10.1136/eb-2015-102229. Epub 2015 Oct 12.

Antidepressants in bipolar depression: yes, no, maybe?

Gin S Malhi  1
Affiliations

Antidepressants in bipolar depression: yes, no, maybe?

Gin S Malhi. Evid Based Ment Health. 2015 Nov.

Abstract

Antidepressants are widely used in the treatment of bipolar depression despite relatively meagre evidence for their efficacy and significant concerns that their prescription can precipitate an acute affective switch into mania/hypomania and that long-term administration can lead to mood instability. Therefore, the use of antidepressants to treat bipolar depression is an important but contentious issue that two recent studies, which provide important new evidence, attempt to inform. One study suggests that long-term continuation of antidepressants in patients with rapid-cycling bipolar disorder leads to a threefold increase in mood episodes during the first year of follow-up-supporting the notion that antidepressants can cause more harm than good, and that they should be used sparingly. However, this is countered by findings from the other study, which suggests that continuation antidepressant monotherapy provides patients with bipolar II disorder reasonable prophylaxis, and that the risk of switching into mania/hypomania is actually quite low. In addition to contrary findings both studies are modest in sample sizes and have significant design limitations and hence the debate remains unresolved. This brief perspective presents both views in the context of evidence and provides some key insights into the complexity of this challenging but common clinical issue.

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Figures

Figure 1
Figure 1
A treatment-emergent affective switch (TEAS) into mania. A TEAS can culminate in either mania/hypomania or depression. The figure shows a switch from euthymia or a depressed state into a state of hypomania/mania (note the duration and number of manic symptoms may not satisfy criteria for an episode of hypomania/mania—and it may be that the switch is marked solely by a few symptoms of mania lasting a relatively short period of time). The diagram also shows the key components of the process that leads to the development of TEAS beginning with a significant change to treatment some time prior to the emergence of mood symptoms. This period of time, called the Treatment-Emergence (TE) interval, is typically of 8–12 weeks duration according to an International Society for Bipolar Disorders (ISBD) taskforce. However, in practice much shorter intervals are common. The direction of the switch, the amplitude of the change and its overall duration define TEAS. The latter can be subdivided into three components: emergence, elevation and resolution. Adopting a more sophisticated approach to defining TEAS should facilitate a clearer and deeper understanding of this phenomenon to emerge. (Adapted from Malhi et al; original diagram developed with assistance from Danielle Gessler).
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