March 15, 2007 -- There is widespread concern that antidepressants may increase suicide risk, but an Italian psychiatric disorders expert says this may only be true when the drugs are used incorrectly.
In an essay appearing March 17 in The Lancet, Franco Benazzi, MD, PhD, writes about a common but poorly recognized form of bipolar disorder, called bipolar disorder II.
"These patients need to be on mood-stabilizing drugs, and if depression persists an antidepressant can be added," Benazzi says. "Treating these patients with antidepressants alone can actually increase the manic episodes and worsen the disorder."
What Is Bipolar Disorder II?
Once known as manic depression, bipolar disorder is characterized by dramatic mood swings in which patients experience extreme highs and extreme lows. Bipolar disorder II is considered a less severe form of the disease, with mild to moderate levels of mania known as hypomania.
Patients with bipolar I may have psychotic episodes, but hallucinations and delusions do not occur with bipolar II.
Because mood swings are less obvious than with bipolar I, diagnosing bipolar disorder II remains a challenge. Patients often suffer from depression as well and that is why so many are treated only with antidepressants.
"The depression is recognized, but the bipolar disorder is not," Benazzi says.
The problem may be especially common in children and adolescents.
"Misdiagnosis of bipolar disorder as attention deficit hyperactivity disorder [ADHD] and major depressive disorder is common, leading to the use of stimulants and antidepressants, which might worsen the course instead of mood-stabilizing agents," he notes.
Benazzi writes that patients who show symptoms of what appears to be depression should be evaluated for manic or hypomanic symptoms. If bipolar disorder is diagnosed, treatment should include mood-stabilizing drugs like lithium, with or without antidepressants.
The widespread use of antidepressants alone in patients with mixed depression may explain the reported increase in suicides among patients on these drugs.
"The suicidality sometimes related to antidepressants is probably not caused by the [drugs], but by clinicians using only antidepressants to treat mixed depression," Benazzi concludes.
More Study Needed
Researcher Rif S. El-Mallakh, MD, of the University of Louisville School of Medicine, says clinicians have gotten better in recent years at identifying bipolar disorder II. But he adds that too many patients are still being improperly treated.
El-Mallakh, who is an associate professor of psychiatry, tells WebMD that in addition to increasing the frequency of manic or hypomanic episodes, antidepressants can worsen depression and increase the likelihood of future depression.
When bipolar patients experience four or more manic or hypomanic or depression episodes within a year it is known as rapid cycling.
Prior to the introduction of antidepressants, rapid cycling was quite rare in bipolar disorder, occurring in just 2% to 3% of patients, El-Mallakh says. These days, he adds, 20% to 25% of patients experience rapid cycling.
The researchers agree that more research on bipolar disorder II and the related spectrum of disorders is needed.
Benazzi points to studies suggesting that on average patients with bipolar disorders are misdiagnosed for eight to 10 years before their disease is correctly identified.
"Depression tends to get worse as the disorder progresses, especially if patients are taking the wrong drugs for many years," he says.