For decades, one of the most controversial issues within psychiatry has being whether or not antidepressants have any role to play in the treatment of bipolar disorder.

Bipolar disorder consists of periods of depression and periods of mood elevation. On the face of it, it has seemed logical to many psychiatrists and researchers that antidepressants should be used to treat depressive episodes in bipolar disorder.

On the other side of this debate many authors have pointed out the potential adverse effects that antidepressants may have in bipolar disorder :

1. antidepressants may cause switches into mania or hypomania

2. antidepressants may cause repeated cycles of depression even without switches into mania.

3. antidepressants may induce mixed states. Mixed states consist of dark feelings of depression and despair combined with high energy, overactivity, racing thoughts and irritability. Mixed states pose a very high risk of suicide.

Now two articles in the January 2016 issue of the Psychiatric Clinics of North America confirm many of the reservations about the use of antidepressants in bipolar disorder.

Robert Post a long-time researcher and member of the Bipolar Collaborative Network concludes that:

 “Conventional treatment of bipolar depression toward the end of the twentieth century typically included antidepressant augmentation of mood stabilizers.

However, the past decade has seen increasing evidence that this is not only a generally ineffective treatment approach, but one that may be counterproductive.”

The article reaffirms the primary place of lithium in the treatment of bipolar disorder and the use of lamotrigine, valproate and carbamazepine as mood stabilizers.

Post makes the case for the adjunctive use of several of the second-generation antipsychotic medications if needed. [However the potential serious adverse effects of these medications, including metabolic syndrome and tardive dyskinesia limit their application].

In the same edition of  Psychiatric Clinics , John Beyer and Richard Weisler in discussing the risk of suicidal behavior in bipolar disorder state that:

“Overall, the best available evidence suggests that antidepressant use in bipolar disorder does contribute to suicidal behaviors. In fact, the new onset of suicidal thoughts after introduction of an antidepressant in depressed patients should raise the clinician’s suspicion of an underlying bipolar illness”.

These articles reinforce the findings of the International Society for Bipolar Disorders task force on the use of antidepressants in bipolar disorder:

“The evidence continues to accumulate that antidepressants alone and in combination with mood stabilizers have a very small role if any, in the pharmacological management of bipolar depression. There is increasing acknowledgement that antidepressants can be harmful. Antidepressants can lead to long-term mood instability, cycle acceleration, mood switching, mixed states and increased risk of suicide.”
 Perhaps this debate can now be put to rest.


Post R.  Treatment of Bipolar Depression Evolving Recommendations Psychiatric Clinics of North America 39 (2016) 11–33.

Beyer J, Weisler R. Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician Psychiatric Clinics of North America 39 (2016) 111–123.

The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders.  Am J Psychiatry. 2013 Nov 1;170(11):1249-62.

Eppel AB: Antidepressants in the Treatment of Bipolar Disorder: Decoding Contradictory Evidence and Opinion’, Harvard Review of Psychiatry 2008; 16:3, 205 – 209.

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