I Have Bipolar Depression – Should I Take an Antidepressant?
Would you like the short answer or the long answer? In short, if you have bipolar disorder, no, you shouldn’t be taking an antidepressant – even if you’re depressed – in many, if not most, cases.
The long answer is, naturally, more complicated.
It’s at this point I must remind you that I’m not a doctor and nothing in this article should be taken as medical advice. Do not make medication changes based on this article. Do have a conversation with your doctor if you have any concerns.
Bipolar I and Antidepressants
I can say, with quite a bit of certainty, that if you have bipolar I you should not be taking an antidepressant alone (this is called monotherapy). In fact, the International Society for Bipolar Disorder (ISBD) Task Force agrees with me on this. No antidepressant monotherapy in bipolar I. Period.
Additionally, antidepressants should not be used in bipolar I mixed states. Period. Antidepressant use, even adjunctively (with another medication), should be avoided if two or more manic/hypomanic symptoms or psychomotor agitation is present. Antidepressants should not be used in people with bipolar disorder who rapid cycle.
Now, in some cases, antidepressants can be used in bipolar I disorder if a mood stabilizer is on board first, if you’re in a straight bipolar depression. However, you should keep in mind that researchers who have looked at this have not seen treatment benefits for people with bipolar I who take antidepressants. This does not mean that it never works, but that means that it often doesn’t and, in fact, can, in many cases, make the bipolar disorder worse.
Bipolar II and Antidepressants
I can say, with slightly less certainty, that people with bipolar II should not use antidepressant monotherapy either. Now, the ISBD Task Force did not explicitly make this recommendation – but I think they’re wrong. I think it’s clear that people with bipolar disorder should not be put on antidepressants alone no matter what variety of bipolar disorder they have.
As for adjunctive therapy, I think adjunctive therapy with antidepressants is reasonable in bipolar disorder if:
- You don’t rapid cycle, are in a straight depressive episode and you’ve tried anticonvulsants and antipsychotics first
- If you’ve previously responded positively to antidepressants
- If your depression returns immediately upon cessation of an antidepressant
What’s the Big Deal about Antidepressants?
Antidepressants are dangerous in bipolar disorder because they increase switching from depression to hypomania, mania or mixed states and rapid cycling. And none of those is where you want to be. And, as I mentioned above, there actually is no good evidence of the effectiveness of antidepressants in bipolar disorder and that is why no antidepressant is Food and Drug Administration (FDA)-approved for use in bipolar disorder treatment.
What Can a Person with Bipolar Take Instead of an Antidepressant?
The medications that have been approved for the treatment of bipolar depression are:
- Quetiapine (Seroquel)
- A combination of olanzapine and fluoxetine (Symbax)
- Lurasidone (Latuda)
And while the trial data I’m aware of was negative, doctors often use lamotrigine as well (although this use is off label).
In addition, aripiprazole (Abilify) has shown to be antidepressant-like when used adjunctively in unipolar depression so it’s often used this way in bipolar depression as well.
Finally, psychiatrists will often try other anticonvulsants and antipsychotics to lift the mood as well. This study suggests that there is some evidence for the efficacy of carbamazepine (Tegretol) and valproate (Depakote, Epival).
There Should Be Fewer Antidepressants in Bipolar Treatment
The telling statistic for me in bipolar treatment with antidepressants is this: when a person with bipolar disorder is treated:
- By a community psychiatrist – 80% are on antidepressants (and I bet you the number is higher for those treated by general practitioners)
- By a mood disorder clinic – 50% are on antidepressants
- By a speciality bipolar clinic – 20% of people are on antidepressants
So the more of a specialist you are, the less likely you are to prescribe antidepressants. We, the average patients, do not necessarily have access to speciality bipolar clinics, but we sure can use that piece of information in our own treatments.
If You’ve Got Bipolar – Try Antidepressants Last
I’m not saying that antidepressants are never appropriate, of course sometimes they are, what I’m saying is that antidepressants should be tried after other options because not only might those other options make you better, they are much more likely not to make you worse.
So please, please, if you’re bipolar and a doctor is just prescribing an antidepressant for you: get a new freaking doctor – they don’t know what the heck they are doing.
I laid out more information and the new recommendations for antidepressant use as recommended by the ISBD here.