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psychiatry06

DURATION OF ANTIDEPRESSANT THERAPY IN BIPOLAR DEPR

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Hi

Can anybody advice me regarding any guideline about how long to give antidepressant in Bipolar Depression.

I have a middle-aged female patient with BPAD who switches to hypomania very quickly whenever started on antidepressants, it has happened in the past 3-4 times.

any advice / any experience will be very much appreciated

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NICE guidelines (2006) says...

to avoid ADs in people who switch to hypomania/ have a rapid cycling...

They ask us to try

1. Increase current MS

2. Add another MS like Lamotrigine

3. Quetiapine

IF not... they suggest that the ADs be tapered and stopped once the patient is in remission for 8 weeks...

TMAP guidelines (2002) say

Following response, antidepressant (AD) treatment should be limited to 3-6 months, unless the previous history shows that continuing treatment is indicated.

The expert consensus guidelines .... Sachs and co.. says (2000)

An antidepressant for severe depression with or without psychosis -  9–23 weeks

An antidepressant for moderate depression -  8–20 weeks

An antipsychotic for severe psychotic depression - 7–22 weeks

All this to be done only in the cover of an MS...

The NICE guidelines looks sensible...

But again guidelines are just to guide us... not for us to follow blindly..

I tthink the treatment shud be individually tailored... especially now that you know she is going to switch, be very careful and consider alternatives to ADs...

From a PMP point of view, I will investigate the reasons for the depression, for eg: Li induced hypothyroidism etc and consider all other strategies before starting on an antidepressants...

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Thank you very much

this patient has got history of switching to hypomania 3 times after increase in AD dose, I was not sure abot the 8 weeks guideline of NICE thats why I posted this problem, at the end of the day your suggestion is right the treatment should be individualised.

Does the American practice suggest >1 year AD therapy?

thanks once again

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how depressed is the patient? what are the risks of the depression? how do they compare with the risks of the hypomania? when previously treated with antideps has she been on mood stabilisers? type/dose/number/adherence?

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patient moderately depressed, she is always given AD in the past under the cover of mood stabiliser Valproate.I have already increased her Mirtazapine to 30mg ,she willbe completing 8 weeks on it in Jan, I have seen her recently doing well,not high.Husband very worried about she going high, he prefers her to be depressed as that is more managable.quite understandably I suppose!!

Now the question is if she continues to do well in Jan should I decrease her AD or stop it/

Earlier it mostly took 3-5 months for her to go hypomanic.

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the nice guidelines say to consider stopping after 8 weeks of remission of significantly less severe depressive symptoms. that seems to fit with your patient's history if in the past she had a hypomanic episode after 3-5 months antidepressant treatment. so, it looks like january would be a good time to review progress and make a decision.

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Remember to get your seniors involved- would think they need to know about and have the ultimate say so on someone with such frequent relapses??? Also, what about looking at her mood stabiliser in a bit more depth? dose? type?

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