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Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 28-29

Anti-depressants in bipolar disorder: Quo vadimus?

Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India

Date of Web Publication13-Jun-2014

Correspondence Address:
Dr. Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2349-4220.134448

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How to cite this article:
Menon V. Anti-depressants in bipolar disorder: Quo vadimus?. Int J Adv Med Health Res 2014;1:28-9

How to cite this URL:
Menon V. Anti-depressants in bipolar disorder: Quo vadimus?. Int J Adv Med Health Res [serial online] 2014 [cited 2022 Aug 11];1:28-9. Available from: https://www.ijamhrjournal.org/text.asp?2014/1/1/28/134448


The use of anti-depressants in bipolar depression remains a controversial and emotive issue among mental health clinicians and practitioners. Despite the lack of a strong evidence base for treatment benefits with anti-depressants for bipolar depression, [1] the reality is that most of us continue to recommend these agents for our patients. There are a number of issues that seem to cloud our judgment in this matter. On the one hand, there is evidence about a subset of individuals with bipolar disorder who may derive definite benefit from being put on anti-depressants when they are experiencing symptoms of depression, and on the other hand there are enduring concerns about their 'mood-destabilizing properties' - short-term switching from depression to hypomania or mania, and paucity of evidence of their long-term efficacy in treating bipolar depression. [2] Obviously, there is a need to take a balanced stance that is true to evidence and also takes into account the clinical complexities of presentation. In this regard, I wish to interpret and highlight the recent International Society for Bipolar Disorders (ISBD) task force recommendations on the use of anti-depressants in bipolar disorder, [3] which has relevance to clinical teaching and practice.

The experts' consensus appears to be clearly in favor of considering anti-depressants for bipolar depression in three situations:

  1. When there is a positive history of a previous response to these agents
  2. If there is a history of relapsing when taken off anti-depressants
  3. When there are less than two manic symptoms concurrent with depression, with minimal/no psychomotor agitation or rapid cycling.

Furthermore, as antidepressant-induced mood elevations are more common and more severe in Bipolar I than Bipolar II disorders, the recommendations are that monotherapy with anti-depressants should be strictly avoided in the former, and in the latter, when the depressive presentation is contaminated with two or more manic symptoms. Clinicians are discouraged from using anti-depressants in the presence of mixed features during manic or depressive presentations or in predominant mixed state presentations. Other factors that should deter one from initiating these agents include a history of rapid cycling or high mood instability (which may be interpreted as a high number of episodes) or a history of previous mania, hypomania or mixed episodes. Careful monitoring for signs of hypomania/mania or psychomotor agitation is advised in all cases receiving adjunctive anti-depressant therapy. Serotonin norepinephrine reuptake inhibitors (SNRI) or tricyclic anti-depressants (TCA) carry an increased risk of mood switch, and hence, are to be less preferred to Selective serotonin reuptake inhibitors (SSRI) in bipolar disorder.

To conclude, anti-depressants need not be treated as 'untouchables' in bipolar depression, provided a careful risk-benefit assessment is carried out on a case by case basis and the above clinical caveats are kept in mind. There are huge unmet needs in the care of bipolar depression. This includes a lack of rigorous, long-term prophylactic efficacy trials. Only three agents - Olanzapine-Fluoxetine, Quetiapine, and Lurasidone are currently approved for treatment of this condition, which is disproportionate to its magnitude and impact. [4] Considering that bipolar patients spend most of their time in depression than mania or hypomania, [5] more research needs to be carried out in order to come up with effective agents that can limit the impact of depression in bipolar individuals.

  References Top

1.Gijsman HJ, Geddes JR, Rendell JM, Nolen WA, Goodwin GM. Antidepressants for bipolar depression: A systematic review of randomized, controlled trials.Am J Psychiatry 2004;161:1537-47.  Back to cited text no. 1
2.Salvi V, FagioliniA, Swartz HA, Maina G, Frank E. The use of antidepressants in bipolar disorder. J Clin Psychiatry 2008; 69:1307-18.   Back to cited text no. 2
3.Pacchiarotti I, Bond DJ, Baldessarini RJ, Nolen WA, Grunze H, Licht RW, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry 2013;170:1249-62.  Back to cited text no. 3
4.Cerullo MA, Strakowski SM. A systematic review of the evidence for the treatment of acute depression in bipolar I disorder.CNS Spectr 2013;18:199-208.  Back to cited text no. 4
5.Chang JS,Ha K.Management of bipolar depression. Indian J Psychol Med 2011;33:11-7.  Back to cited text no. 5
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