The use of antidepressants in bipolar disorder is a fairly hot topic. It’s also complicated. Let me start out by saying that I am a patient, not a doctor. I’m just reporting what I research and I get to research what is highly relevant to my life and I talk about it with my own doctor. The fact is, I am like half of bipolar patients in that my initial diagnosis was depression. When a person is diagnosed with depression they are typically given antidepressants. Makes sense, right? The problem is, when depression is a symptom of bipolar disorder, treating it with antidepressants can make things worse.
By “worse” I don’t mean using antidepressants with bipolar disorder makes depression worse. It has the opposite effect. That’s actually part of the problem. With some people, antidepressants can increase risk of going right through normal and into a manic state. Here’s where the controversy comes in. There is no consistent data that points to how much of a risk there is. Results range from 3% to 44% of people switching from depression to mania when prescribed an antidepressant alone. Some studies have found no link at all. State switching sounds unpleasant enough, but to that you can add an overall worsening of bipolar symptoms with continued use, especially in rapid cycling. This means more cycles overall and less time in between cycles. So if antidepressants make bipolar disorder worse, why are they still used?
One problem is that, even after patients had a manic episode, 37% of them were still prescribed antidepressants. So the first step is to get over that diagnosis hurdle. Bipolar disorder and Unipolar disorder are not the same, so they should not be treated the same way. Special attention has to be paid to psychiatric illnesses that have overlapping symptoms.
The second problem is that antidepressants can help in bipolar disorder treatment. There are three situations in which antidepressants are still prescribed in treating bipolar disorder.
For short-term treatment.
For an acute occurrence of depression, antidepressants can help alleviate depressive symptoms. Basically, for especially bad bouts of depression, using an antidepressant can help shorten the depressive period and lessen symptoms. You start taking the medication when the depression starts and start tapering off when the episode concludes. Shorter use can reduce the risk of switching. Use should be tapered with careful supervision by a physician.
For treating bipolar II disorder.
Bipolar II is its own special version of the bipolar beast. With bipolar II, mania is a rarity and hypomania is the norm. The difference is that hypomania doesn’t come with psychosis and the rate of hospitalization is lower. Since mania is not as common, the risk of switching states due to medication is potentially lowered. Since the risk is lowered, there is a potential benefit of short-term treatment of depression as well as staving off future episodes. This is a good thing.
For additional anxiety disorders.
Unfortunately, about half of bipolar disorder patients have at least one co-morbid anxiety disorder. A good portion of patients have symptom relief just from the mood stabilizers used to treat bipolar disorder. One less pill? Sounds great! However, there are those whose anxiety disorders are disruptive enough that additional treatment is required. Benzodiazepines are often prescribed for breakthrough anxiety, but there are those who do not respond to treatment. That’s when antidepressants are usually prescribed.
In each of these situations, dosage and timing of treatment with antidepressants should be closely monitored if they need to be used at all. The good news is that when used in conjunction with mood stabilizers, the use of antidepressants doesn’t seem to increase the risk of switching to a manic state.
The most important thing to take away is that everyone is different. If you have bipolar disorder you should be seeing a specialist regularly for medication management. What works now may need to be tweaked in a few months. That’s the nature of a spectrum disorder. Be open and honest, especially if you’re not taking your meds like you should be. This is a tough disease, don’t make it harder on yourself. Find the right doctor, work together and be better.