McElroy Susan L, Kotwal Renu, Kaneria Rakesh, Keck Paul E
Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0559, USA.
Bipolar Disord. 2006 Oct;8(5 Pt 2):596-617. doi: 10.1111/j.1399-5618.2006.00348.x.
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.
双相情感障碍患者出现自杀意念、非致命性自杀行为及自杀的风险极高，且常接受抗抑郁药治疗。然而，尚无专门评估抗抑郁药对双相情感障碍患者自杀倾向影响的前瞻性、随机对照研究完成。事实上，抗抑郁药尚未被证明能减少抑郁症患者的自杀企图或自杀行为，且可能增加儿童（或许还有成人）重度抑郁症患者的自杀行为。关于抗抑郁药对双相情感障碍患者自杀倾向影响的现有数据不一。大量研究表明，混合状态与自杀倾向相关，抗抑郁药尤其是单药治疗时，与自杀倾向及躁狂转换均有关联。相比之下，越来越多的研究表明，抗抑郁药与心境稳定剂联合使用可能减轻双相抑郁症患者的抑郁症状。此外，唯一一项评估双相情感障碍患者抗抑郁药治疗及死亡率的前瞻性长期研究，尽管是开放标签研究，但发现抗抑郁药和/或抗精神病药与锂盐联合使用，而非单独使用锂盐，可降低双相及单相患者的自杀率（安格斯特F等人，《情感障碍杂志》2002年；68: 167 - 181）。我们得出结论，抗抑郁药可能在一部分有抑郁（可能还有焦虑）表现的人群中诱发自杀倾向；这种诱发可能代表一种躁狂转换形式，因而也是一种双相表型，并且锂盐的治疗特性可能包括预防抗抑郁药诱发自杀倾向的能力。
