Guidance for medication in bipolar depression published

By Eleanor McDermid, Senior medwireNews Reporter

Solid evidence to guide the use of antidepressants in patients with bipolar disorder is “remarkably limited,” says the International Society for Bipolar Disorders (ISBD) Task Force.

The panel of international experts, led by Eduard Vieta (University of Barcelona, Spain), found that it “is not currently possible to make firm clinical recommendations that are soundly evidence based.” As well as the evidence being very limited, “much of it is methodologically weak,” they say.

Nevertheless, the group put together 12 consensus recommendations based on a systematic review of the literature and expert opinion (using the Delphi method); these are published in the American Journal of Psychiatry.

Most of the recommendations detail situations to avoid. The group advises against the use of antidepressant monotherapy in patients with bipolar I disorder, and in those with bipolar I or II depression if patients have “two or more concomitant core manic symptoms.” The latter recommendation also applies to adjunctive acute treatment.

Antidepressants should be avoided in patients with high mood instability or with current or predominant mixed episodes, and in those with a history of developing manic or mixed episodes during antidepressant treatment.

However, physicians may consider acute adjunctive antidepressant therapy if the patient has a history of a positive response, and may continue treatment if patients lapse back into depression when treatment is halted. When antidepressants are used, patients should be carefully monitored for signs of emerging mania, and treatment must be halted if these occur.

Vieta and colleagues also examined the relative efficacy of various antidepressants in bipolar disorder patients, but found “little evidence to support the proposition that one type of antidepressant, at clinically equivalent doses, is more or less effective or dangerous than another.”

They say: “In short, we conclude that the use of antidepressants to treat depressive phases or components of bipolar disorder can neither be condemned nor endorsed without carefully evaluating individual clinical cases and circumstances.”

They urge further research to address “the many remaining major and urgent clinical questions” relating to use of antidepressants in bipolar disorder.

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