Determining patient candidacy for antidepressant use in bipolar disorder

The psychiatric literature is filled with strong sentiments condemning antidepressant use as inappropriate or otherwise harmful to treatment outcomes in bipolar disorder. However, the literature from prospective controlled trials actually shows that monoaminergic antidepressants are neither all-good nor all-bad, but rather, like most medications, can be beneficial, detrimental, or ineffective according to individual patient subtypes and profiles. Large randomized trials point to lack of efficacy, more than risk for polarity switch or cycle acceleration, as the overriding concern when using antidepressants for bipolar disorder. Underappreciated is that the extant literature is based on only a small handful of antidepressants, with a striking lack of randomized trials using any antidepressants developed after 1999, limiting the extent to which class generalizations can be drawn fairly. Clinicians are encouraged to think of individualized bipolar patient candidacy for antidepressant use in light of identifiable patient-specific moderators of treatment outcome.