How do you approach the use of SSRIs to treat bipolar depression?  

I don't consider antidepressants first-line treatment for my patients with bipolar disorder. I have all my bipolar patients on a mood stabilizer, usually lithium or lamotrigine. I also tend to add an antipsychotic to the mood stabilization regimen for the majority of my patients, usually generic fo...

I agree with this approach. I like to use bupropion because it is more activating and the SSRIs are dulling, and patients do not like it. Depression in bipolar patients is much harder to treat and bipolar patients can get stuck for longer periods of time in this phase.

Not clear. This article by Bender, Psychiatric Times 2024 says that you can use antidepressants.  Better options would be cariprazine (Vraylar), lurasidone (Latuda), olanzapine (Zyprexa) with fluoxetine (Prozac), and quetiapine (Seroquel). Also consider the 'strange' stuff like ketamine, Mirap...

You don't. I have been teaching for 50 years and remember; SSRIs and all antidepressants will increase cycling 3x and will not work. You might have a little hypomanic bump at the beginning and your patient will commend what a genius you are. Don't.

I rarely use antidepressants for bipolar depression. Some of the worst cases of rapid cycling I have seen were patients on antidepressants and their providers were not aware that they were cycling. Taking time to talk to patients makes a significant difference in what we believe as providers. If you...

In my experience, if the patient is not on any medication, starting a mood stabilizer like Latuda or lamotrigine first is helpful. If the patient is partially responding to the mood stabilizer but continues to have depressive symptoms, then I would start an SSRI. Long-acting antidepressants like Pro...

Antidepressants in bipolar disorder are not contraindicated, unopposed antidepressant treatment in bipolar disorder is not indicated. When a patient is already on a mood stabilizer and goes through a severe depressive episode, I generally do this: Consider second-generation antipsychotics, if not...

There has been much written and said about the dangers of antidepressants in bipolar disorder and the advice best be very well taken. Nevertheless, many patients come to us with antidepressants on board who are dysphoric and labile. That situation certainly warrants a discontinuation of the antidepr...

Never. The increase in rapid cycling is quite a burden. Let us not make the patient worse.

Lithium is the gold standard. Typically as the main agent, but also as adjuvant if SGA is already established with partial, but substantial benefit. Although the data is conflicting, I have learned from my outpatient population that the use of an SSRI in the context of bipolar I or II will ultimatel...