A highlight from Antidepressants in Bipolar II: What the Experts Do

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Disorder. Welcome to the carlisle. Psychiatry podcast keeping psychiatry. Honest since two thousand and three on crusade can the editor in chief of the carlisle psychiatry report. And i'm kelly newsom psychiatric n. p. and a dedicated reader of every issue in this month's carlisle report we featured a review of a new trial by nasa gammy on antidepressants in bipolar disorder. And in this companion podcast. We're going to look at what actually goes on behind closed doors. In the practices of bipolar experts. When they turn to the antidepressant page of their pharmacopoeia. I a little more background. Most of what we know about antidepressants in bipolar disorder comes from studies in bipolar one disorder. And they're the answer is clear antidepressants should be avoided because they can cause mania that risk is lower if they are given with an anti manic mood stabiliser in other words. Any mood stabiliser except lamotrigine. This idea was actually debated for a long time as some argued that we didn't have good enough data to say with certainty. That antidepressants actually caused mania. In my mind the question was settled around two thousand fourteen when a large study by alexander victorian and colleagues showed that the risk of mania was three times higher when anti-depressants were used on their own as monotherapy without a mood. stabiliser. I don't claim to have hard evidence that that article put an end to the debate on whether antidepressants 'cause mania but here's what i've seen. Lectures on the subject often the audience for a show of hands on whether they think antidepressants are safe and bipolar disorder. Before two thousand fourteen. A lot of hands were raised in defense of their safety after two thousand fourteen. It's been a small minority like fewer than ten percent who raised their hands and support. And the editorial that accompanied victorians article. Put the nail in the coffin. It was titled antidepressants in bipolar one. Never as monotherapy. So that says never bipolar one. What about bipolar to dr victorian wasn't able to parse out bipolar one from bipolar to in his data set. So that leaves a big question. Mark we do know from other research. That antidepressants are safer in bipolar to than they aren bipolar one but outside of that it's not clear just how helpful or harmful antidepressants aren bipolar two disorder. We actually don't know too much about medications. And how they affect bi polar to as there are no fda approved treatment specifically for bipolar two disorder quota pins cirque will is medication with the most data in bipolar too and it worked there for bipolar to depression. In contrast charip presumed very lar- did not work in the bipolar two studies where it was tested out. So it's fda approval is in bipolar depression. But maybe it should be just in bipolar one depression. And what about lithium. Isn't that mall for bipolar. One it's better trading mania than depression. Not exactly you know what. I love about research. Is that many of the ideas. That seem intuitive. Like the one you just said about. Lithium are then contradicted by the research. Like i can think of one study. It was from nineteen ninety eight and was done by leonardo tondo and ralph's battle sereni. It was a large but non randomized study where lithium actually worked better in bipolar to depression than it did. In bipolar wound. Depression and the difference. There was not trivial compared to bipolar one. Those with bipolar to were twice as likely to fully remit with lithium and those with bipolar to stayed well six times longer on lithium compared to the bipolar. Ones my take on all the research is that lithium works. Great in about thirty percent of people with bipolar disorder. And whether they have bipolar one or two does not tell you who is going to respond to lithium. In our september issue last year we had an interview with dr ryback kaczynski and there we listed the signs of a good lithium responder and the main one is having a tendency toward classic. Euphoric mania or hype. Ameinias and that could be true for people with bipolar one or bipolar. To this is all new to me. I was taught that lithium is much more effective against the than depression and depression is much more common by politics than bipolar one. Yes and what you said is probably true. In the short term lithium's short-term effects and depression don't always hit the big effect sizes but when it comes to long-term prevention lithium had one of the highest effect sizes against both manic end the depressive polls it tied with cotija pain sarah quilt for that prize in long-term prevention a. Here's a tip if you're going to use lithium never judge lithium by its short-term effects if it works its main benefits are going to be in the long term prevention of new episodes so lithium's benefits are likely to be delayed and that means you're likely to miss them in practice so you need to use some sort of long term mood measured to pick up on this. What i often see is that patients will say that lithium did nothing but their mood. Scores are consistently improved when they were on it and consistently worse when they're off it that's just as important when using antidepressants in bipolar. If your patients get worse soon after starting an antidepressant you're going to notice. They may call you in full blown mania traveling across the country and spending outrageously at every stop. But unless you're doing long-term mood ciardi you miss rapid cycling on antidepressants. Which is the main risk that dot com as new study identified. Here's what it looks like in practice. A patient with bipolar disorder gets depressed at first. They wait hoping it will go away on. Its own three weeks. Go by then. They called a see you and they get in a week later. You start an antidepressant vaccine effects or until them. It's gonna take three to six weeks to work and like clockwork full weeks later. It works that oppression lifts note of the time line. The episode lifted two months after it began. And that's about how long the average bipolar depression episode less. So this could have been the natural course of things and not the antidepressant. But how will

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