Les antidépresseurs ont-ils encore un intérêt dans la dépression bipolaire ?

Abstract

Bipolar disorder is a common psychiatric illness with lifetime prevalence of about 1% and up to 4% if defined by the concept of bipolar spectrum. Depression is the most difficult to treat and the most frequent state of the bipolar disorder. Bipolar depression is also probably underdiagnosed because of the limited criteria of previous hypomanic or manic episode. Antidepressants are the most common treatment prescribed in bipolar depression but their use in this context remains controversial. ObjectiveThe aim of this article is to review literature and guidelines in order to help psychiatrists in their decision to prescribe or not an antidepressant agent in bipolar depression. MethodThe author conducted a computerized literature search of the Medline and ScienceDirect databases to identify studies involving antidepressants use in bipolar disorder through 2015. ResultsUse of the antidepressants in bipolar depression in clinical practice is very large, mostly in combination with a mood stabilizer. The single use of a mood stabilizer agent is rare. Most of type 1 bipolar depressions are treated with an antidepressant in association, but the use of monotherapy is not uncommon in type 2 bipolar depression. Since the 2000's their widespread use remains (even if monotherapy is declining compared to combination with mood stabilizers). This fact can be explained by the difficulties to diagnose a bipolar depression without any history of previous manic episode. In this aim, many authors have tried to define the bipolar spectrum. Early start of the disease, family history of bipolar disorder, hyperthymic temperament, atypical depression and more than 4 previous episodes have to be considered in clinical evaluation. The risks of the use of antidepressants in bipolar disorder are now better known: Mood switch, rapid cycle, treatment-resistance, Antidepressant-associated Chronic Irritable Dysphoria, and activation syndrome. The significant use of antidepressant in bipolar depression could be explained by diagnoses difficulties and divergent findings in literature. The authors highlight the lack of strong comparative studies assessing respective efficacy between antidepressants and efficacy versus addition of a mood stabilizer concerning this important public health question. ConclusionThe prescription of an antidepressant is a matter of the clinical and pharmacological expertise of the psychiatrist. First, he has to be above in the reassurance of his prescription if he decides to prescribe an antidepressant in bipolar depression.