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Antidepressants and suicidal behavior in bipolar disorder

Authors

  • Susan L McElroy,

    1. Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine
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  • Renu Kotwal,

    1. Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine
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  • Rakesh Kaneria,

    1. Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine
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  • Paul E Keck Jr

    1. Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine
    2. Mental Health Care Line and General Clinical Research Center, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH, USA
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  • SLMcE is a principal or co-investigator on research studies sponsored by AstraZeneca, Bristol-Myers Squibb, Esai, Eli Lilly & Co., Forrest Laboratories, NIMH, Ortho-McNeil, Pfizer, Sanofi-Synthelabo and Somaxon Pharmaceuticals Inc.; and is a consultant to or a member of the scientific advisory boards of Abbott Laboratories, Eli Lilly & Co., GlaxoSmithKline, Janssen Pharmaceutica, Ortho-McNeil and Wyeth-Ayerst. RKo serves on the speakers bureau for Bristol-Myers Squibb. RKa is the principal investigator or co-investigator on research studies sponsored by AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., Forrest Laboratories, NIMH, Ortho-McNeil, Pfizer, Sanofi-Synthelabo and Sepracor. PEK is a principal or co-investigator on research studies sponsored by Abbott Laboratories, the American Diabetes Association, AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Pharmaceutica, Merck, NIDA, NIMH, Organon, Ortho-McNeil, Pfizer, the Stanley Medical Research Institute (SMRI) and UCB Pharma; and is a consultant to or member of the scientific advisory boards of Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Pharmaceutica, Memory Pharmaceuticals, Neurocrine Biosciences, Ortho-McNeil, Pfizer and Shire.

Susan L. McElroy, MD, Department of Psychiatry, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 559, Cincinnati, OH 45267-0559, USA. Fax: +1 513 558 6131; e-mail: susan.mcelroy@uc.edu

Abstract

Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167–181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.

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