[Are there substantial reasons for contraindicating antidepressants in bipolar disorder? Part II: facts or artefacts?].

After having dedicated the first part of this article to the prevalence and impact of depressive symptoms in the context of bipolar disorders, the authors now delineate advantages and disadvantages of antidepressants in bipolar depression. A literature search was performed using PubMed, and Mesh Database using the keywords, bipolar disorder, antidepressants and depression. Additional information was gained by cross-referencing from papers found in the data base. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. In contrast to the worldwide uniformly used guidelines in the treatment of mania, there is a controversial discussion, on the use of antidepressants in bipolar disorder. Whereas European guidelines exert a more allowing attitude towards the use of antidepressants, currently published US-guidelines do explicitly not recommend antidepressants in the treatment of bipolar depression, unless depression is severe. In fact, antidepressants are yielded to destabilize the disease by triggering switches into mania and to increase cycle acceleration. Despite that, antidepressants, in addition to, or without mood-stabilizers, are broadly used in clinical practice in acute or maintenance therapy. Literature of the use antidepressants as first line treatment in bipolar depression is too sparse to favour or to refute such a therapy. In order to prevent from affective side effects, antidepressant substances like tricyclics should be avoided. Instead substances like SSRI or bupropion with less affective side effects should be used. If antimanics are added, SSRI or bupropion seem to exert switch rates on placebo level. Specific subtypes of bipolar disorder, such as mixed episodes, rapid cycling courses, seem to be extensively associated to antidepressants induced switch phenomena. Antidepressants should be avoided in this sample of patients. Bipolar-II-subtype seems to be associated with low switch-rates, independent from the used substance class. Patient-specific features, such as comorbidities, a history of mania, early beginning, psychotic features, a positive genetic load) seem to negatively influence the onset of antidepressant induced affective side-effects. An extended assessment of the individual medical history is therefore warranted. Literature on the use of antidepressants in maintenance is virtually absent. The authors present current literature and guidelines of recent treatment recommendations in bipolar depression.