Antidepressants in bipolar depression: yes, no, maybe?

Antidepressants are widely used in the treatment of bipolar depression despite relatively meagre evidence for their efficacy and significant concerns that their prescription can precipitate an acute affective switch into mania/hypomania and that long-term administration can lead to mood instability. Therefore, the use of antidepressants to treat bipolar depression is an important but contentious issue that two recent studies, which provide important new evidence, attempt to inform. One study suggests that long-term continuation of antidepressants in patients with rapid-cycling bipolar disorder leads to a threefold increase in mood episodes during the first year of follow-up-supporting the notion that antidepressants can cause more harm than good, and that they should be used sparingly. However, this is countered by findings from the other study, which suggests that continuation antidepressant monotherapy provides patients with bipolar II disorder reasonable prophylaxis, and that the risk of switching into mania/hypomania is actually quite low. In addition to contrary findings both studies are modest in sample sizes and have significant design limitations and hence the debate remains unresolved. This brief perspective presents both views in the context of evidence and provides some key insights into the complexity of this challenging but common clinical issue.