Originally Posted by
tiptoes
Interesting article Jack, although it does appear to focus on prediagnosis bipolar and those taking antidepressants as a monotherapy. The use of anti psychotics and mood stabilisers should reduce this. They were also comparing the switching rate of those with unipolar depression and those that later turned out to have bipolar depression, and that is more likely to occur with bipolar anyways. There is a lot of interesting research on the use of AD's in bipolar, I couldn't find the paper when I looked for it but I read one recently that said that taking into account the disruption that depression caused versus the subsequent hypomania that the AD caused, and the inherent cycling nature of bipolar, in some patients there was still an net benefit the antidepressants. It's a complex area!
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Yes it is and that's why I always caution people that the "experts" are widley divided and for practical purposes many people are essentially serving as guinea pigs without really realising it.
The journal (Psychiatric Times) I quoted is the largest professional journal for psychiatrists (60k members) so its mainstream. Even they dispute the term "mood stabiliser" and admit the "bipolar" label is prodigiously overused and elusively defined
In a Psychiatric Times recent article (Integrative Treatment of Bipolar Disorder: A Review of the Evidence and Recommendations ) there was a note of caution:
"A significant percentage of patients with bipolar disorder rely on maintenance antidepressant therapy to control depressive mood swings, which significantly increase the risk of mania. Commonly prescribed pharmacological regimens used to treat bipolar disorder combine mood stabilizers with antidepressants or atypical antipsychotics; however, a systematic review found only modest improvements in outcomes when such combination therapy was used.13
The limited effectiveness and safety issues associated with conventional psychotropics in the management of bipolar disorder have resulted in high relapse rates in individuals taking mood stabilizers and other psychotropic medications, with associated impairment in social, academic, and occupational functioning, and increased risk of suicide.14 These issues underscore the urgent need to identify more effective, better-tolerated treatments for bipolar disorder and invite rigorous and open-minded consideration of emerging research findings for promising CAM and integrative treatments."
Now none of that means certain modes of treatment are never effective. Especially in certain acute circumstances they can serve their purpose (and with supervision). However people need caution as more drugs are mixed in and as the period of use expands.
Since we have been talking about mixed states and depression I would add this from same journal ( "Bipolar Mixed States: Dangerous, Common—and Sometimes Iatrogenic" = Dr Caused):
"Mixed states are far more common than previously recognized, ranging from 20% to 70% of patients presenting with depression, depending on the definition and the setting.1 Really?
The majority of patients with depression might be mixed? That would be clinically very important, if true: mixed states are associated with increased risk of suicide.2
Antidepressants have been associated with the development of mixed states.3 Thus follows an ironic corollary: in theory, then, one way to address suicidal depression is to taper off the patient’s antidepressant. A 12-patient case series supports this idea.4
But this treatment plan is quite counterintuitive for patients: “Here I am severely depressed and your plan is to stop my antidepressant?” Such a plan will not make any sense unless they understand what mixed states are and that antidepressants can induce them...
DSM-5 and the Cincinnati views of mixed states create a spectrum from very mixed to slightly mixed to not at all mixed. Although this might seem to complicate management of mood states, the bottom line is rather simple: when a depression is mixed, adding an antidepressant is not likely to help and may well make things worse. "
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