From the Guidelines
Antidepressants, particularly when used alone without mood stabilizers, should be avoided in the treatment of bipolar disorder as they can trigger manic episodes or rapid cycling in bipolar patients. Several medications should be avoided in the treatment of bipolar disorder due to their potential to worsen symptoms or trigger mood episodes. Specific antidepressants of concern include tricyclics (like amitriptyline and imipramine) and monoamine oxidase inhibitors (MAOIs) 1. Stimulants such as methylphenidate (Ritalin) and amphetamines should be used cautiously as they may precipitate mania, although they may be helpful for addressing ADHD symptoms once the patient’s mood symptoms are adequately controlled on a mood stabilizer regimen 1. Corticosteroids like prednisone can also trigger mood episodes and should be used with careful monitoring if medically necessary. Certain anticonvulsants such as carbamazepine and lamotrigine require careful dosing and monitoring due to potential side effects and drug interactions. Additionally, substances like alcohol and recreational drugs should be avoided as they can interfere with medication effectiveness and exacerbate mood instability. The reason these medications pose risks is that they can disrupt the delicate neurotransmitter balance in bipolar disorder, particularly affecting dopamine, serotonin, and norepinephrine systems that regulate mood stability.
Some key points to consider when treating bipolar disorder include:
- Avoiding unnecessary polypharmacy and using agents that are approved by the FDA for bipolar disorder in adults 1
- Using mood stabilizers such as lithium, valproate, or lamotrigine as first-line agents 1
- Considering the use of atypical antipsychotics such as olanzapine, risperidone, or quetiapine for acute mania or maintenance therapy 1
- Monitoring for potential side effects and drug interactions, particularly with anticonvulsants and atypical antipsychotics 1
- Avoiding the use of antidepressants without a mood stabilizer, as they can trigger manic episodes or rapid cycling 1
Any medication changes should always be discussed with a psychiatrist who specializes in mood disorders to ensure proper management of bipolar symptoms.
From the FDA Drug Label
The use of concomitant strong CYP3A4 inducers such as carbamazepine should be avoided with temsirolimus. The use of carbamazepine with lapatinib should generally be avoided. Coadministration of carbamazepine with nefazodone is contraindicated
The following drugs should be avoided in treatment of bipolar disorder when used with carbamazepine:
- Temsirolimus: due to strong CYP3A4 induction
- Lapatinib: generally should be avoided
- Nefazodone: contraindicated due to insufficient plasma concentrations of nefazodone and its active metabolite 2
From the Research
Drugs to Avoid in Bipolar Disorder Treatment
The following drugs should be avoided or used with caution in the treatment of bipolar disorder:
- Antidepressants, particularly tricyclics, as they can cause manic switch and cycle acceleration 3, 4
- Antidepressant monotherapy, as it is not recommended for bipolar disorder treatment 5, 4
- Certain antipsychotics, such as paliperidone, which did not outperform placebo in some studies 6
- Carbamazepine, which did not outperform placebo for recurrence/relapse rate of any mood episode 6
Specific Considerations
When considering the use of antidepressants in bipolar disorder treatment:
- Modern antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), may be safer than older antidepressants 4
- Predictors of affective switching with antidepressants include bipolar I disorder, mixed features during depression, and rapid cycling 4
- Antidepressants may be helpful and safe for certain subgroups of patients, such as those with bipolar II depression 4
Alternative Treatment Options
First-line therapy for bipolar disorder includes: