If you have bipolar disorder, you have almost certainly been put on an antidepressant before, but did your doctor ever tell you about the risks associated with bipolar disorder and antidepressants?
Here in lies the problem with antidepressants: destabilization (switches to mania and cycle acceleration). All antidepressants of all categories (SSRI, SNRI, TCA, MAOI, and Atypical) carry the risk of destabilizing someone with bipolar disorder.
You might then ask, why would doctors and nurses prescribe antidepressants if they carry such a risk? That is the controversy of antidepressants.
Psychiatrists tend to fall into two camps: antidepressants are safe if used in conjunction with a mood stabilizer, and the other side, they’re not safe at all.
For the safe camp, the idea is that mood stabilizers counteract the destabilizing nature of antidepressants. Furthermore, not all antidepressants carry the same risks. SSRIs and the Atypical bupropion have the safest and lowest risk profiles. SNRIs and MAOI are next safest. And finally, tricyclics (TCAs) are the most risky. Doctors can choose the safest type for the situation. It should also be noted that this position assumes that antidepressants work. More about that later.
For the unsafe camp, the idea is that there is still a risk even if using a mood stabilizer of increased switching and cycle acceleration, which can be reflected as more episodes or even to more mood fluctuations at the day-to-day level.
Let me further complicate this matter. Some doctors argue for an in between position. They argue that one subgroup of people with bipolar disorder respond safely to antidepressants, and the other subgroup does not. Thus antidepressant use should be done at a case-by-case basis.
So, there are (predominantly) two camps, but the antidepressants-are-safe camp tremendously outweighs the are-not-safe camp. Again, most people with bipolar disorder have undoubtedly been put on an antidepressant before.
The reason is simple: psychiatrists and psychiatric nurse practitioners (APRNs) alike think that antidepressants work for bipolar depression. But do they?
The Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) came together to produce a well-researched guideline for treating bipolar depression and analysis the use of antidepressants was an important part of that.
There analysis takes us to our first split between BD-I and BD-II.
In BD-I the risk of switching and cycle acceleration pushes SNRIs, MAOIs, and especially TCAs to borderline last resort treatments. SSRIs and bupropion –the safest antidepressants — are considered back-up options. In BD-I, their efficiency are significantly lower than mood stabilizers and neuroleptics. Furthermore, they are unsafe to prescribe as monotherapy, and even with a mood stabilizer, there is still the risk of switching with them.
Simply put, there are better options out there, and those options should always be tried first.
In BD-II, the controversy of antidepressants still exists, but to a lesser extent. The risk of switching is significantly lower and a switch would lead to hypomania instead of destructive mania. Thus SNRIs, MAOIs, and TCAs, can be used. Antidepressants can actually be used as monotherapy in BD-II, and some have shown equal efficiency as lithium.
The biggest weakness in antidepressants and BD-II is the paucity of studies on the topic. Some antidepressants have shown to be efficient and others not. Interest in researched these drugs with BD-II is meager at best. Worst still is the design of the currents studies are criticized by the CANMAT.
Nevertheless, the CANMAT and ISBD recommend antidepressants second only to the neuroleptic quetiapine (Seroquel).
So are antidepressants safe?
If you’re BD-I, probably not. You should really talk to your doctor about whether the benefits outweigh the risks if he has you on one or if you’re thinking about starting one.
If your BD-II, most likely yes, but you should give Seroquel genuine consideration first.