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Manisk switch inducerad av antidepressiva

“Switching” of Mood From Depression to Mania With Antidepressants skrev:Bipolar disorder often presents initially with one or more episodes of major depression, and an episode of mania or hypomania may first occur during treatment with an antidepressant, stimulant, or other agent with mood-elevating effects. Such “switching” of mood into mania, a mixed-state, or psychosis can be dangerous. This switching is particularly prevalent among juveniles and young adults exposed to treatment with an antidepressant or stimulant for a depressive, anxiety, or attention disorder.¹ Such pathological shifts of mood and behavior may represent adverse drug actions or a manifestation of undiagnosed bipolar disorder.

[...]We considered 12 studies of patients initially thought to have unipolar MDD who required a new diagnosis of bipolar disorder, usually with verification by occurrence of spontaneous mania or hypomania. Such diagnostic changes occurred in 3.3% within 5.4 years, or 5.6 times less than the rate of mood switching with antidepressants. If the relatively low rates of new bipolar diagnoses are not due to under-reporting, their marked difference from rates of antidepressant-associated mood switching leaves open the possibility that direct pharmacological, mood-elevating actions of antidepressants may be involved in mood switching, in addition to hypothesized “uncovering” or perhaps even “causing” of bipolar disorder. Of particular concern is that these ambiguous possibilities leave specifically uncertain the potential value of long-term treatment with antimanic or putative mood-stabilizing agents.

[...]Even a single occurrence of mood switching with antidepressant treatment can support a DSM-5 diagnosis of bipolar disorder but may not be sufficient to support indefinitely continued treatment aimed at mood stabilization.⁴ Indeed, it is not even proved that drugs considered to be mood-stabilizing are highly protective against antidepressant-associated mood switching, although such protection is widely assumed.^3,4 Moreover, there is very limited evidence that prolonged antidepressant treatment provides substantial protection against recurrences of bipolar depression and that it might contribute to emotional instability or rapid cycling.⁴
Our findings also underscore the need for caution in starting antidepressant treatment in a new patient with depression. Several clinical factors may suggest increased risk of either drug-induced switching or spontaneous mania-like responses in depressed patients. They include a family history of bipolar disorder or psychosis, onset before age 25, multiple recurrences of depression within several years, particular temperamental traits (cyclothymic, hyperthymic, or irritable), previous postpartum disorder, psychomotor-retarded depression with hypersomnia and increased appetite, previous excessive activation with a mood-elevating drug, current agitated-dysphoric features, a possible comorbid substance use disorder, and treatment with a TCA or venlafaxine.⁴
An additional clinical implication of switching from depression to mania in patients with bipolar disorder is that following a depression before mania course pattern (versus mania before depression) is associated with less favorable responses to mood-stabilizing agents. This predicts an excess of future depression episodes, with associated risks of substance abuse, disability, and excess mortality from suicide or, later, an intercurrent medical illness.^5,6