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Bipolar disorder, a sometimes debilitating illness marked by severe mood swings between depression and mania, is usually treated with mood stabilizers such as lithium, valproate, carbamazepine or other medications that reduce mania. However, depression is more common than mania in bipolar disorder, and depressive episodes tend to last longer than episodes of mania.

“Treating depression in people with bipolar disorder is notoriously difficult,” says Thomas R. Insel, director of the National Institute of Mental Health (NIMH).

Antidepressant medications are often used in addition to a mood stabilizer for treating bipolar depression. But, two recent studies suggest that antidepressants, used alone or in combination with mood stabilizers, aren’t effective for bipolar depression.

An NIMH-funded study found that a combination of antidepressants and mood stabilizers is safe, but no more effective than a placebo – a sugar pill. A study published in the medical journal Australian Prescriber found that antidepressants used alone not only aren’t effective, but can cause a switch from a depressive episode to a manic episode.

Careful management of mood stabilizer medications is a reasonable alternative to adding an antidepressant medication for treating bipolar depression, according to researchers of the NIMH study, the large-scale, multi-site Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

In addition, education, self-monitoring of mood and mood diaries, involvement of family members and information about lifestyle changes can help patients get better and stay well longer, said the authors of the Australian Prescriber article. “Good communication and rapport between doctor and patient is particularly important in fostering compliance with treatment,” they said.

For bipolar II patients with major depression, the story may be different. While standard treatment has included mood stabilizers alone or combined with antidepressants as for bipolar I, some recent studies have found that, for bipolar II depression, the antidepressant Venlafaxine (Effexor, Efexor), used alone, could be an effective initial therapy with a low hypomanic switch rate.

The use of antidepressants for bipolar disorder remains controversial.

Health professionals should consider the diagnosis of bipolar disorder in patients with treatment-resistant or recurrent depression, says Dr Ajeet Singh, University of Melbourne, coauthor of the study.  

Related articles
Guide to psych drugs
Understanding bipolar disorder
Symptoms of depression

Sources
National Institute of Mental Health
Australian Prescriber,  published by the National Prescribing Service Limited (NPS), Australian Government Department of Health and Ageing.
Amsterdam JD, Shults J.(2008), Comparison of short-term venlafaxine versus lithium monotherapy for bipolar II major depressive episode: a randomized open-label study., J Clin Psychopharmacol, 28(2):171-81.

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