Bipolar Disorder and the Case Against Antidepressants
In reviewing the charts of more than 600 psychiatric patients whom I have evaluated in a general hospital, I was struck by a startling finding: all patients with a clinical diagnosis of bipolar disorder who were also evaluated for acute suicidal ideation (or a recent suicide attempt) (N = 46) were taking 1 or more antidepressants. I am well aware of the logical "traps" in interpreting this finding.
For example, patients with frequent bouts of depression whether unipolar or bipolar often experience suicidal ideation. These are the very patients who are likely to be given (wisely or not) a prescription for an antidepressant. Thus, the arrow of causality might run from depression to suicidal ideation to antidepressant prescription. However, based on my clinical experience with these patients, I believe that the causal arrow often runs the other way; that is, patients with bipolar spectrum disorders become suicidal at least partly because of recent antidepressant use. The following case histories support this view.
Mr A, 90 years old resided in a nursing home. He had had "manic depression" as far back as the 1940s and had a strong family history of bipolar disorder. He had been generally stable for the past 5 years on 1 mg/d risperidone. Because he had become increasingly depressed, citalopram, 20 mg/d, was added to the risperidone regimen. Five weeks after the start of dual therapy, Mr. A became sexually aggressive. When asked by the nursing home staff "to behave," he became agitated and threatened to kill himself with a knife. He reported that he had not slept in 2 days because his"mind would not shut off."
Ms B, in her 30s, had a strong family history of bipolar disorder. She was most recently evaluated after she was found lying unconscious, holding an empty bottle of the hypnotic agent eszopiclone. She bad been working full-time and was clinically stable on 300 mg/d quetiapine until 2 months before her suicide attempt. At that time, her complaint of "feeling down" prompted her physician to add 150 mg/d of bupropion to the quetiapine regimen. Severe insomnia and irritability rapidly ensued. Then eszopiclone 10 mg/d at half strength was prescribed, although this did not alleviate her symptoms, and Ms B became progressively irritable. At the time of evaluation she reported that she "could not live like this" and wanted "to end it all."
Ms D, a 47-year-old whose son had bipolar disorder, was evaluated after she drove her motorcycle into an oncoming car. When I evaluated her in the ICU, she stated, "My family will be better off without me." She showed severe psychomotor agitation and reported that her mind was working "10 times faster" than normal, adding, "I am a nut case." Six months before this evaluation, her psychiatrist had prescribed paroxetine 30 mg for "anxiety." (The patient clarified, however, that she was actually feeling "agitated," not anxious, at that time, and could not "slow down" her thoughts.) When the patient's symptoms failed to improve, approximately 2 months before my examination, her psychiatrist had added a second antidepressant, ven1afaxine 150 mg/d. The patient subsequently experienced several days without sleep and began "arguing with everybody'' at home.
My chart review revealed that none of these patients had a history of suicidality, suicide attempts, or substance abuse, and all had relatively stable courses in the months before 1 or more antidepressants were added to their treatment regimen. All had strong family histories of bipolar disorder. Recent studies and reviews have questioned the safety and efficacy of antidepressant medication in patients with bipolar disorder and have described the drugs potential for mood destabilization or cycle acceleration in this setting. Several screening tools are available to help clinicians uncover subtle or unsuspected cases of bipolar spectrum disorders 1-3
Further randomized, controlled, prospective studies are required to as certain what role, if any, antidepressants should play in the treatment of bipolar disorder. Furthermore, suicidality is a complex phenomenon with psychosocial and biological factors.
Nevertheless, I believe that antidepressants may contribute not only to mood destabilization but also to acute suicidal behavior in patients with bipolar spectrum disorder.
Manuel Mota-Castillo, M.D.
Lake Mary, FL
Dr Mota is psychiatric preceptor at St. Matthews University and consulting psychiatrist at Florida Hospital Fish Memorial in Orange City, Ra. He reports no conflicts of interest to disclose.
Pies R. WHIPLASHED:A mnemonic for recognizing bipolar depression. Psychiatric Times. 2007;24:10.
Nassif Ghaemi S, MIBer CJ, Belv DA. et al. Sensitivity and specifici1y of a new bipolar spectrum diagnostic scale. J Affect 0/sonf. 2005;84:273-277.
Angst J,Adolson R, Benazzl F, et al. The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disorders. 2005;88:217-233.