Bipolar depression: Clinical correlates of receiving antidepressants

Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain.
Journal of Affective Disorders (Impact Factor: 3.38). 03/2012; 139(1):89-93. DOI: 10.1016/j.jad.2012.01.027
Source: PubMed


The efficacy and tolerability of antidepressants (ADs) to treat or avoid episodes of depression in bipolar disorder (BPD) patients as well as reasons for using them remain unresolved.
We analyzed patient-characteristics and outcomes of episodes of acute major depression among 290 adult, DSM-IV BPD patients (71% type-I, 52% women) at the Hospital Clinic of Barcelona; 80% were given an AD and 20% were not; 80% of both groups also received mood-stabilizers. We evaluated factors associated with AD-treatment using bivariate analyses and multiple logistic-regression modeling.
Factors associated with AD-use by multivariate modeling ranked: [a] more years ill, [b] depressive first-lifetime episode, [c] more depressions/year, [d] melancholic index episode, and [e] less affective illness in first-degree relatives. Within 8weeks, depression improved by ≥50%, less often among BPD patients given an AD (64.4%; 38.6% without switching into hypo/mania) than not (82.1%; 78.6% without switching).
Use of ADs to treat acute BP-depression was very common and associated with a more severe clinical history. Mood-switching was prevalent with AD-treatment even with mood-stabilizers present.

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    • "The use of antidepressants for bipolar depression is still controversial. The major criticism regarding use of antidepressants in instances of bipolar depression is based on the risk of destabilizing mood, switching into mania or hypomania [54-56] or increasing the cycle frequency [57,58]. Such negative effects appear to be limited to certain classes of antidepressants [59-61]. "
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    ABSTRACT: Many new approaches have been adopted for the treatment of bipolar disorder (BD) in the past few years, which strived to produce more positive outcomes. To enhance the quality of care, several guideline recommendations have been developed. For study purposes, we monitored the prescription of psychotropic drugs administered to bipolar patients who had been referred to tertiary care services, and assessed the degree to which treatment met specific guidelines. Between December 2006 and February 2009, we assessed 113 individuals suffering from BD who had been referred to the Royal Ottawa Mental Health Centre (ROMHC) Mood Disorders Program by physicians within the community, mostly general practitioners. The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis. The prescribed treatment was compared with specific Canadian guidelines (CANMAT, 2009). Univariate analyses and logistic regression were used to assess the contribution of demographic and clinical factors for concordance of treatment with guidelines. Thirty-two subjects had BD type I (BD-I), and 81 subjects had BD type II (BD-II). All subjects with BD-I, and 90% of the BD-II group were given at least one psychotropic treatment. Lithium was more often prescribed for subjects with BD-I (62%) than those with BD-II (19%). Antidepressants were the most frequently prescribed class of psychotropics. Sixty-eight percent of subjects received treatment concordant with guidelines by medication and dose. The presence of a current hypomanic episode was independently associated with poorer concordance to guidelines. In more than half the cases, the inappropriate use of antidepressants was at the origin of the non concordance of treatment with respect to guidelines. Absence of psychotropic treatment in bipolar II patients and inadequate dosage of mood stabilizers were the two other main causes of non concordance with guidelines. The factors related to treatment not concordant with guidelines should be further explored to determine appropriate strategies in implementing the use of guidelines in clinical practice.
    Full-text · Article · Aug 2013 · BMC Psychiatry
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    • "It can be assumed that in most cases the use of antidepressants in long-term treatment of bipolar disorder is not de novo as a pure prophylactic treatment, but a continuation in acute antidepressant responders. Univariate factor analysis in large cohorts revealed that antidepressant use in bipolar patients is associated with lifetime depressive morbidity (including fi rst-episode depression, more depressive episodes, and melancholic features at index episode), more years ill, and less affective illness in fi rst-degree relatives (Undurraga et al. 2012). Especially the presence of anxiety symptoms are a strong indicator for antidepressant use, but the causality remains unclear (Pacchiarotti et al. 2011). "
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    ABSTRACT: Abstract Objectives. These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults. Methods. Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned. Results. Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios. Conclusions. Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.
    Full-text · Article · Apr 2013 · The World Journal of Biological Psychiatry
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    • "including mania, psychosis, and potentially dangerous behavioral dyscontrol (Ghaemi et al., 2006; Amsterdam and Shults, 2010; Tondo et al., 2010; Swartz and Thase, 2011; Undurraga et al., 2012). There may also be a lack of clinical confidence that mood-stabilizers can prevent risk of mania associated with antidepressant treatment, in keeping with the inconclusive research evidence to support this plausible expectation (Tondo et al., 2010). "
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    ABSTRACT: Evidence concerning efficacy of antidepressants in bipolar disorder remains inconsistent and inconclusive. As the appropriate clinical use for such patients remains unclear, we characterized outpatients with bipolar disorders who were or were not treated with antidepressants. Clinical data were collected systematically from consecutive outpatients in 11 participating Argentine mood-disorder clinics in 2007-2008. Diagnoses met DSM-IV criteria, supported by structured interviews based on the MINI-500. Of 338 outpatients diagnosed with bipolar I (45.0%), II (29.3%), or not-otherwise-specified (NOS) (25.7%) disorder, 128 (37.9%) received antidepressants. Subjects given antidepressants or not did not differ significantly by presence or severity of current depression or being suicidal but were more likely to be women. Bipolar I disorder patients were three times less likely than types II or NOS to receive an antidepressant, with or without a mood-stabilizer or antimanic agent. Despite inconclusive evidence for efficacy and safety of antidepressants in various phases of bipolar disorders, 37.9% of such patients were receiving an antidepressant in 11 Argentine outpatient clinics. Antidepressant treatment was least likely with type I disorder and was independent of current depression and not associated with more use of mood-stabilizing or antimanic agents. Copyright © 2012 John Wiley & Sons, Ltd.
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