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Antidepressant as First-Line Treatment for Bipolar Disorder?

Posted on August 18, 2008 by Joe

According to the results of a recent survey conducted by Decision Resources (”one of the world’s leading research and advisory firms focusing on pharmaceutical and healthcare issues”), 52.3 percent of newly diagnosed bipolar disorder patients are prescribed antidepressant drugs first line. (See the press release “Astonishing 52 Percent of Newly Diagnosed Bipolar Disorder Patients Receive Antidepressant Drugs in First-Line Treatment.”)

The new report entitled “Treatment Algorithms in Bipolar Disorder,” points out that although most people with bipolar disorder are diagnosed by a psychiatrist, increasing percentages are being diagnosed and treated by their primary care physician. (You can read the abstract by clicking here.) The numbers break down like this:

Although primary care physicians seem to be more comfortable in diagnosing bipolar disorder, Madhuri Borde, Ph.D., analyst at Decision Resources, points out that primary care physicians follow a very different treatment pattern as compared to the approach psychiatrists usually follow:

“Nearly half of the patients taking selective serotonin reuptake inhibitors first line receive these drugs as a monotherapy, despite guideline recommendations to give bipolar patients presenting with depression an antimanic first line.”

If the results of this study are an accurate indication of what’s really happening in doctors’ offices, this could be a disturbing trend, given that antidepressants (particularly SSRI’s) can possibly unmask bipolar disorder, especially in patients diagnosed as having Bipolar I. (The term “unmask” means that a person who has bipolar disorder and has not reported problems with mania may experience mania when treated for depression.) Prescribing an antidepressant (especially without the protection of an anti-manic agent, such as Lithium) could change the course of the illness, “triggering” a manic episode.

Important: As Dr. Fink points out in her comment following this post, we may need to approach the results of this survey cautiously.

The recommended guideline for treating people with bipolar depression is to use an antimanic medication first-line, preferably a medication that has strong antidepressant properties, such as Lithium or Lamictal. An antidepressant can then be added in later, if needed, and more safely, because the antimanic agent can help prevent a potential switch from depression to mania.

If you’ve been diagnosed as having bipolar disorder, we would like to know whether your primary care physician or a psychiatrist arrived at the diagnosis. What was the first-line treatment he or she recommended? What was the result? If you’re a doctor who has diagnosed and treated bipolar disorder, we would also like you to share your experiences and insights.

Comments

3 Responses to “Antidepressant as First-Line Treatment for Bipolar Disorder?”

  1. Candida Fink, MD on August 18th, 2008 11:38 am

    I have to say I am a little skeptical of this data and the conclusions that might be drawn from it. Here are some of the reasons I question this survey and whether it accurately reflects what’s actually happening in the doctor’s office:

    • I know very few primary care physicians (PCPs) willing to diagnose and treat bipolar comfortably – so I am wondering how many PCPs they actually surveyed.
    • Since the diagnosis is actually pretty complex, I wonder how much of this is related to diagnostic problems – missed bipolar (patients with bipolar presenting with only depression or other symptoms) – as much as poor prescribing.
    • I wonder about over diagnosis of bipolar disorder – especially in unsophisticated diagnosticians. (Do these patients who’ve been diagnosed bipolar really have bipolar?)
    • It would also be helpful to know what percentage of patients in the study were truly diagnosed Bipolar I. If a person really just had unipolar depression or something besides a true Bipolar I – then antidepressants alone wouldn’t necessarily be so bad.

    I just can’t tell you how many psychologists and social workers call to tell me about a patient we share that they’re “sure” must be bipolar just because the patient has rage outbursts or erratic moods over the course of a day. This is not the same as bipolar but lots of people – and I am sure primary care physicians included (because lots of psychiatrists are even confused about this) – don’t understand the difference. And those people with mood regulation problems, but not bipolar, often do really well on SSRI’s alone.

    The information in the study also doesn’t say anything about rates of negative consequences to these prescribing patterns – it just lists these patterns without any real context of what really happens out in the world.

    I think it is a worthy discussion – primary care docs are getting more involved in this because of inadequate availability of psychiatrists and poor reimbursement for mental health care – so it is important, but I’m just not sure this study gives us a great deal of useful info.

  2. » 52 Percent of Bipolar Patients Receiving Antidepressants as First-Line Treatment? - Bipolar Beat on August 18th, 2008 1:33 pm

    [...] some cases and change the course of the illness. We discuss this in a recent post, entitled “Antidepressant as First-Line Treatment for Bipolar Disorder?” on our Bipolar Blog. As Dr. Fink points out in her comments to the post, care must be taken [...]

  3. Lexapro Prescription Information on November 7th, 2008 7:42 am

    My name is Lisa Carter and i would like to show you my personal experience with Lexapro.

    I am 39 years old. Have been on Lexapro for 2 years now. This medication had an almost immediate positive effect on my life. Within 2 to 3 days of starting Lexapro, there was a noticeable lift in my general mood. A WARNING ABOUT STOPPING OR WEANING OFF LEXAPRO: I started taking 10 mg daily a couple of years ago for about 2 months, then decided I just didn’t want to take medicine every day. So I weaned myself off over a 2-wk period, first reducing the dose to 5 mg/day, then 5 mg every other day before I stopped altogether. I figured I would be able to tell if my mood was going downhill and I would just restart if it did. Well, there was no gradual decline. I was careful to monitor my mood and thoughts every day and everything went great for about 3 months, then C.R.A.S.H!!! I mean it hit me like a WALL, very very suddenly! Despite exercising 4-5x per week, healthy eating, etc., I hit an all-time low.

    I have experienced some of these side effects-
    Constant dull headache, jittery in the morning if taken before bed, dizziness. These negative side effects subsided within a week or two. Other side effects have continued, including sleepiness and yawning, apathy, vivid (but great) dreams. My libido died and never came back.

    I hope this information will be useful to others,
    Lisa Carter

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