Dr. Bob's Psychopharmacology Tips

Antidepressants and bipolar disorder

From: "George Nasra" <nasdoc@penn.com>
Date: Thu, 8 Jun 1995 00:11:42 -0400
Subject: Antidepressants and bipolar disorder

The current recommendations in treating patients with bipolar disorder include avoiding whenever possible the use of antidepressants as most of them have been implicated in the phenomenon of switching to mania. Also antidepressants have been implicated in producing a more malignant form of the illness with rapid cycling and subsequent refractoriness. However currently available antimanic agents are not always adequate to treat the depressive phase of patients with bipolar illness and we often have to resort to the addition of antidepressants. When this is necessary, we have to make sure the patient is adequately covered with an antimanic agent, we try to taper down and withdraw the antidepressant as soon as possible, and we will use an antidepressant that is less likely to cause a switch into mania, e.g., bupropion (Wellbutrin).

Date: 21 Dec 1995 10:19:51 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Antidepressants and bipolar disorder

I have had very good luck treating patients with moderately severe bipolar disorder. I have primarily used Depakote (divalproex), lithium, or lithium and Depakote. Patients getting or needing ongoing antidepressants have not been as stable. This may reflect their having a more severe illness, although I have clearly seen some who stabilized with reduction of their antidepressants.

I have been finding that if their condition is subacute -- there is no current concern with lethality--and they can tolerate a four week period of medication stabilization during which they may not get much better, then many of these moderately ill patients with bipolar depression will improve substantially over the next four to eight weeks on mood stabilizers alone.

We recently completed a program designed to test the value of adding Paxil (paroxetine) to lithium in patients with bipolar depression who were still depressed after 6 weeks of a therapeutic lithium dose. We did not expect that this would be a problem as we had not perceived lithium to be an adequate antidepressant for bipolar depression. Surprisingly, only 2 of 10 or so patients were still depressed at the end of 6 weeks. The rest (some of whom also were treated with Depakote) had had substantial improvements in mood and most were euthymic or close to it. This may have been an anomaly, or the patient characteristics may differ from those in other clinical settings. Nevertheless, I was impressed with these responses and I will be less likely in the future to add an antidepressant until it is clear that there will not be a full response to a mood stabilizer alone.

Date: Sun, 11 May 1997 15:12:24 -0700
From: Leonardo Franklin da Costa Fontenelle <fontenel@mtec.com.br>
Subject: Antidepressants and bipolar disorder

In the treatment of bipolar depression, it is possible that various antidepressant agents differ in their propensities to induce mania. The literature favors the use of MAOI and bupropion as safer antidepressants, less likely to inducing severe mania:

Stoll AL, Mayer PV, Kolbrener M, Goldstein E, Suplit B, Lucier J, Cohen BM, Tohen M. Antidepressant-associated mania: a controlled comparison with spontaneous mania. American Journal of Psychiatry. 151 (11): 1642-5, 1994 Nov.

As both agents have remarkable dopaminergic actions, and we don't have bupropion in Brazil, amineptine may be an alternative. I'm treating four depressed bipolar patients with amineptine (similar to bupropion), up to 200 mg a day, with very good responses and no switches.

Date: Wed, 10 Dec 1997 17:34:30 -0500
From: Mike Johnson <johnsomr@smtpgw2.musc.edu>
Subject: Antidepressants and bipolar disorder

Hypomania is as likely to be induced by stopping an antidepressant as it is to starting an antidepressant (in my personal experience).

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