Question:
Treatment of Bipolar Depression?
Answer:
The high risk of suicide in depressed Bipolar patients presents a compelling
need for antidepressant treatment, but risk of poor outcome is high. Response
rates to standard antidepressant medications appear substantially lower in in
bipolar patients than in unipolar depression. Furthermore, standard
antidepressant medications may worsen the course of bipolar illness. Use of
antidepressants is complicated by the risk of mania during the course of
treatment and during withdrawal of treatment (Risk of Depressive Relapse in
Bipolar Patients when Antidepressants are Discontinued: Lori Altshuler, M.D.
et al. UCLA Neuropsychiatric Institute and Hospital). In addition, Altshuler
et al (Antidepressant-induced mania and cycle acceleration: a controversy
revisited: American Journal of Psychiatry 1995 Aug;152(8):1130-8) have shown
antidepressant medications may accelerate cycling even without induction of
abnormal mood elevation. Therefore, clinicians treating bipolar depression
face a dilemma as they balance the risks and benefits of treatment with
antidepressant medication.
Guidelines for management of bipolar depression include four principles to
manage the risk of antidepressant medication: 1) Initiate acute phase
treatment with mood stabilizing agents, 2) if necessary offer standard
antidepressant medications proceeding stepwise from agents with lower risk
(bupropion) to higher medications (tricyclics), 3) minimize antidepressant
exposure by attempting a gradual taper after appropriate continuation phase
treatment, and 4) offer ECT for patients at immediate risk of self harm or
unable to tolerate pharmacological interventions. I discussed this with my pdoc last week. I am mostly depressed, with
occasional hypomania, and was worried that all the antidepressants I take
could push me into mania. She said it's very unlikely, although it is
something to consider. We did decide to start lithium though, just in case. So far it hasn't been a problem for me, as my hypomania is seldom, and the
only major hypomanic episode (2 months) was before I took any ADs. i get manic everytime i take prozac, except when i was on lithium
(eskalith)
