Why Do Clinicians Maintain Antidepressants in Some Patients With Acute Mania? Hints From the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a Large Naturalistic Study

Bipolar Disorders Program, Hospital Clinic, University of Barcelona, CIBERSAM, Barcelona, Spain.
The Journal of Clinical Psychiatry (Impact Factor: 5.14). 03/2010; 71(8):1000-6. DOI: 10.4088/JCP.09m05026gre
Source: PubMed

ABSTRACT Antidepressants are supposed to be withdrawn during a manic episode. The aim of this study was to analyze the characteristics of manic patients who received antidepressants during a manic phase in a large, naturalistic study.
The European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year prospective observational study of inpatients and outpatients with acute mania/mixed mania (DSM-IV or ICD-10 criteria) conducted in 14 European countries. Of 2,416 manic patients who continued into the maintenance phase of the study, 345 (14%) were taking an antidepressant and 2,071 (86%) were not taking an antidepressant at baseline, week 1, and/or week 2 postbaseline. Demographic and clinical variables were collected at baseline and each study visit up to 24 months. Outcome measures included the Clinical Global Impressions-Bipolar Disorder scale (CGI-BP overall, mania, and depression scores) at 12 weeks and 24 months, the 5-item Hamilton Depression Rating Scale (HDRS-5), and the Young Mania Rating Scale (YMRS) at 12 weeks only. The present study was conducted from December 2002 to June 2004.
More antidepressant maintenance use was seen in patients with mixed episodes (P < .001), rapid cyclers (P < .02), patients with more previous depressive episodes (P < .001), and patients with higher mean HDRS-5 score at baseline (P < .001)-specifically patients with anxiety (P = .013). Patients in the antidepressant group had significantly higher CGI-BP depression scores (P < .001) and a significantly higher rate of depression relapse (P < .001) at both 12 weeks and 24 months.
Patients with mania receiving antidepressants are more likely to be outpatients with mixed episodes, anxiety, or rapid cycling and have a higher risk of depression relapse during follow-up.

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    • "The third reason, possibly as a main reason, is that treatment with antidepressant administered during episodes of depression or for purposes of preventing further episodes in patients with a recent depressive or mixed episode or a depressive episode at first onset, is not suspended in time during maintenance treatment phase (Paterniti and Bisserbe, 2013). Finally, there is agreement on the discontinuance of treatment with antidepressant during manic episodes in both different guidelines and clinical practice (Dennehy et al., 2005; Rosa et al., 2010). Thus, the patients with a hospitalization history due to manic episode were less likely to be prescribed with antidepressant in our sample. "
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    • "Accordingly, colleagues at the present study-site recently evaluated factors associated with responsiveness to ADtreatment in BPD patients (Pacchiarotti et al., 2011a), those associated with manic-switching during AD-treatment (Valentí et al., 2011), use of AD in mixed states (Valentí et al., in press), comparisons of AD alone or combined with mood-stabilizers (Pacchiarotti et al., 2011b), and factors that explain why clinicians maintain AD-treatment even during acute manic episodes (Rosa et al., 2010). We now report on an independent study involving 290 adult, currently depressed BPD patients at the University of Barcelona to distinguish characteristics of those who did or did not receive AD treatment during acute episodes of major depression. "
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    • "During the acute manic phase, the treatment with antidepressant drugs was associated with a higher rate of depressive relapse at 12 week (26.6% vs 15.6%, p = 0.001) and 24 month (31.3% vs 19.3%, p = 0.001) follow-ups compared to subjects not taking antidepressants (Rosa et al., 2010). Gao et al. (2008) showed that, in rapid cyclers, about 50% of subjects experienced manic episodes during monotherapy with antidepressant medications, with the higher rates of manic episodes reported for fluoxetine (42%), bupropione (35.71%) and venlafaxine (30.56%). "
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