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Continuation of Antidepressant Treatment Beneficial for Some Patients With Bipolar Disorder

In bipolar patients who remain well on antidepressants for at least 2 months, treatment should be continued, as discontinuation can increase the risk of depression relapse without preventing mania, researchers write.

Considerable controversy continues to persist regarding the use of unimodal antidepressants in combination with mood stabilisers for the treatment of bipolar depression.

Robert M. Post, MD, National Institute of Mental Health, Biological Psychiatry Branch, Bethesda, Maryland, United States, and colleagues reviewed three new studies to evaluate the rate of depression in bipolar illness, switch rates on antidepressants, and risks of antidepressant discontinuation.

In the first study reviewed, 258 outpatients with bipolar illness were assessed prospectively on a daily basis for 1 year using the National Institute of Mental Health-Life Chart Method (NIMH-LCM). These patients showed three times as many days depressed as days manic, re-emphasizing the considerable depressive morbidity that exists in bipolar disorder.

In the second study, 127 bipolar depressed patients were randomised to receive 10 weeks of sertraline, bupropion or venlafaxine as adjuncts to mood stabilisers. Patients who did not respond were re-randomised and responders were offered a year of continued antidepressant therapy.

Acute augmentation of antidepressant dose was associated with a modest response rate, with 18.2% switched from a hypomanic to a manic episode, and 35.6% of the patients on continuation trials showed these two types of switches.

In the third study, the risk of depressive relapses in patients who remained on antidepressants after 2 months of euthymia compared with those who discontinued treatment were retrospectively and prospectively assessed.

Those who remained well on any antidepressant for more than 2 months (15-20% of those initially treated) and who continued on these drugs showed a lesser rate of relapse into depression over 1 year (35% and 36% in the first and second study, respectively) compared with those who discontinued their antidepressant (68% and 70% relapsing into depression).

"One is reluctant to make a formal schematic or treatment algorithm for patients with breakthrough bipolar depression in light of the rapidly changing perspectives," Dr. Post and colleagues note. However, in their report, they provide a table of "soft recommendations" suggesting treatment for breakthrough depression with mood stabiliser use.
Bipolar Disord 2003 Dec;5:6:396-406. "A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network"

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