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Commentary


Antidepressant complexity

Vol. 9, No. 7 / July 2010

I treat adults with bipolar II and cyclothymic disorders; I am concerned about the dogmatic view that antidepressants should not be used to treat bipolar spectrum disorders (“Antidepressants in bipolar disorder: 7 myths and realities,” Current Psychiatry, May 2010). As I have been advising my patients, managed care reviewers, and even a few psychiatric editors during the past several years, it is a flawed dogma for reasons identified by the author of this article, Dr. Joseph F. Goldberg. He correctly cites Tohen et al,1 who showed a 56% response rate for fluoxetine plus olanzapine in treating bipolar depression vs olanzapine alone or placebo. He also cites another study by Amsterdam2 on the efficacy of venlafaxine in bipolar II depression.

I would add 2 observations to Dr. Goldberg’s critique. The frequently cited Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study by Sachs et al3 argues antidepressants are not effective for bipolar depression. What many colleagues may not know is that STEP-BD achieved only a 28% positive treatment response. Also, only 6% of subjects were taking atypical antipsychotics, usually high doses—typically olanzapine, >10 mg. These doses of olanzapine—like high doses of other mood stabilizers—may exacerbate fatigue and depressive symptoms. Secondly, the scant research and dogmatism about antidepressants in bipolar treatment has tended to focus on bipolar I disorder, as Dr. Goldberg points out. In addition, it tends to ignore the issue of highly prevalent comorbid anxiety disorders and attention-deficit/hyperactivity disorder in early-onset bipolar spectrum disorders.

William Niederhut, MD
Denver, CO

References

1. Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression. Arch Gen Psychiatry. 2003;60:1079-1088.

2. Amsterdam JD, Wang CH, Shwarz M, et al. Venlafaxine versus lithium monotherapy of rapid and non-rapid cycling patients with bipolar II major depressive disorder: a randomized, parallel group, open-label trial. J Affect Disord. 2009;112(1-3):219-230.

3. Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722.

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