WebMD Health News
Louise Chang, MD
March 15, 2007 -- There is widespread concern that antidepressants may
increase suicide risk, but an Italian psychiatric disorders expert says this
may only be true when the drugs are used incorrectly.
In an essay appearing March 17 in The Lancet, Franco Benazzi, MD,
PhD, writes about a common but poorly recognized form of bipolar disorder,
called bipolar disorder II.
Because the disorder is so often misdiagnosed, patients are often wrongly
treated with antidepressants alone, which can make the problem worse, the
professor of psychiatry tells WebMD.
"These patients need to be on mood-stabilizing drugs, and if depression
persists an antidepressant can be added," Benazzi says. "Treating these
patients with antidepressants alone can actually increase the manic episodes
and worsen the disorder."
Once known as manic depression, bipolar disorder is characterized by
dramatic mood swings in which patients experience extreme highs and extreme
lows. Bipolar disorder II is considered a less severe form of the disease, with
mild to moderate levels of mania known as hypomania.
Patients with bipolar I may have psychotic episodes, but hallucinations and
delusions do not occur with bipolar II.
Because mood swings are less obvious than with bipolar I, diagnosing bipolar
disorder II remains a challenge. Patients often suffer from depression as well
and that is why so many are treated only with antidepressants.
"The depression is recognized, but the bipolar disorder is not,"
The problem may be especially common in children and adolescents.
"Misdiagnosis of bipolar disorder as attention deficit hyperactivity
disorder [ADHD] and major depressive disorder is common, leading to the use of
stimulants and antidepressants, which might worsen the course instead of
mood-stabilizing agents," he notes.
Benazzi writes that patients who show symptoms of what appears to be
depression should be evaluated for manic or hypomanic symptoms. If bipolar
disorder is diagnosed, treatment should include mood-stabilizing drugs like
lithium, with or without antidepressants.
The widespread use of antidepressants alone in patients with mixed
depression may explain the reported increase in suicides among patients on
"The suicidality sometimes related to antidepressants is probably not
caused by the [drugs], but by clinicians using only antidepressants to treat
mixed depression," Benazzi concludes.
Researcher Rif S. El-Mallakh, MD, of the University of Louisville School of
Medicine, says clinicians have gotten better in recent years at identifying
bipolar disorder II. But he adds that too many patients are still being
El-Mallakh, who is an associate professor of psychiatry, tells WebMD that in
addition to increasing the frequency of manic or hypomanic episodes,
antidepressants can worsen depression and increase the likelihood of future
When bipolar patients experience four or more manic or hypomanic or
depression episodes within a year it is known as rapid cycling.
Prior to the introduction of antidepressants, rapid cycling was quite rare
in bipolar disorder, occurring in just 2% to 3% of patients, El-Mallakh says.
These days, he adds, 20% to 25% of patients experience rapid cycling.
The researchers agree that more research on bipolar disorder II and the
related spectrum of disorders is needed.
Benazzi points to studies suggesting that on average patients with bipolar
disorders are misdiagnosed for eight to 10 years before their disease is
"Depression tends to get worse as the disorder progresses, especially if
patients are taking the wrong drugs for many years," he says.
SOURCES: Benazzi, F. The Lancet, March 17, 2007; vol 369: pp 935-945.
Franco Benazzi, MD, PhD, professor of psychiatry, Hecker Psychiatry Research
Center, Forli, Italy. Rif S. El-Mallakh, MD, assistant professor of psychiatry,
University of Louisville School of Medicine, Louisville, Ky.
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