Top Paper: Antidepressants for Acute Treatment of Bipolar Disorder

by Ronald Pies | March 21, 2011 2:55 PM EDT

• My thanks to Dr. Pistone for his supportive observation, and to Dr. Liebowitz for his interesting hypothesis re: shorter-acting antidepressants in bipolar disorder. It's certainly worth investigating as regards risk of "switching", as well as the ARAD phenomenon I describe. However, given that antidepressants have very limited evidence of efficacy in bipolar disorder [see Dr. Ghaemi's recent discussion of this], I would be reluctant to recommend routine use of these agents in most patients with bipolar disorder. Of course, we "never say never" in medicine, and there may be a small subset of BP patients for whom antidepressants are safe and effective, under carefully monitored conditions. --Best regards, Ron Pies

by Daniel Pistone | March 18, 2011 7:54 PM EDT

To echo Dr. Pies speech, I learned of 'ARAD' (although we didn't call it that) in residency as early as 1994. I have seen it plenty of times in my clinical practice, and I subscribe to Dr. Pies' comments on antidepressants in acute or bipolar depression, not to speak of mixed states. Thanks for your great contributions Dr. Pies, Daniel Pistone, MD Wilmington, NC

by Neil Liebowitz | January 28, 2011 8:13 PM EST

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The Use of Short Half-Life Antidepressants in the Treatment of Bipolar Depression

To the editor: In the February 2009 issue of the Journal, Mark A. Frye, M.D., et al. (1), and Joseph F. Goldberg, M.D., et al. (2) examined the predictors of treatment-emergent mania and mixed states in depressed bipolar patients. I would encourage both groups of investigators to review their data to examine two variables that have not been reported. The first is the diurnal variation of mood, which I find to be more extreme in patients who have bipolar depression and may be a predictor of a response to a mood stabilizer in unipolar patients. The second variable is the form of antidepressant given to patients. A convention in publishing is to use the generic names of medications, but this does not distinguish among the three preparations of bupropion (immediate release, 12-hour release, and 24-hour release) and two forms of venlafaxine (immediate- and time-release). Although time-release preparations technically have the same half-life of the underlying compound, their sustained presence keeps blood and brain levels more constant, resulting in differing side effects and efficacy profiles.

I have found that in bipolar patients with extreme diurnal variation of mood (characterized by severe a.m.-hour depression followed by significant brightening in the evening), the non-time-release preparations of medications, such as bupropion and venlafaxine, given in low doses in the a.m. hours only can be very helpful and less likely to cause manic switching. Conversely, the long acting preparations of the same medications tend to cause a reversal of diurnal variation, with improvement in the a.m. hours and agitation in the p.m. hours. It might turn out that short half-life reuptake inhibitors have a place in treating bipolar depression. Other relatively short-acting agents, such as atomoxetine, may also fall into this category.

References

1

Frye MA, Helleman G, McElroy SL, Altshuler LL, Black DO, Keck PE Jr, Nolen WA, Kupka R, Leverich GS, Grunze H, Mintz J, Post RM, Suppes T: Correlates of treatment-emergent mania associated with antidepressant treatment in bipolar depression. Am J Psychiatry 2009; 166:164-172

2

Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB, Calabrese JR, Nierenberg AA, Sachs GS: Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 2009; 166:173-181

NEIL R. LIEBOWITZ, M.D.

Farmington, Conn.

Dr. Liebowitz is Director of the Connecticut Anxiety and Depression Treatment Center; he has received speaker's honoraria from Forest Laboratories.

This letter (doi: 10.1176/appi.ajp.2009.09030331) was accepted for publication in April 2009.

I've just released a book with other clinical pearls

by tom kelly | December 16, 2010 12:42 PM EST

Whether speaking of "ARAD,"of "mixed episodes," or of any aspect of psychiatry or psychology, I think psychiatrists and psychologists need to view this series of videos http://www.youtube.com/watch?v=v1Cwpx8inKY&feature=related

and to read Eckhart Tolle's The Power of Now.

If one agrees that all men and women have a right to equal basic human rights simply because they are created equal, then one agrees that there is at least one creator - something which of its very nature is likely to defy human description, definition or understanding - and probably also that all men and women have souls, for it can only be as souls that we are equal.

I suggest that for as long we abandon the struggle to define Creator, Psyche, Soul, and Mind, we condemn ourselves to a losing battle to understand how Humankind may best rule self and allow its species to rule itself.

Every good wish.

Tom Kelly.

by Peter Lynch | November 24, 2010 12:15 PM EST

I've written a first-person, semi-autob iographica l account of a young man's descent into madness and psychosis, and it loosely follows my own path to being diagnosed with bipolar disorder and the proper treatment thereof. It's important to realize that many inventors, public servants, and artists who changed the world suffered from mental illness. My story can be found at: http://newmanx.blogspot.com/ I hope someone reads it and gains a little insight into what it's like to have a mental illness. Best, PSKL