The largest and most rigorous study to date on the treatment of bipolar depression was just published in the New England Journal of Medicine. The study, conducted as part of the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), enrolled a total of 366 subjects with either bipolar I or II disorder during a major depressive episode. These patients, all of whom were already taking a mood stabilizer, were randomly assigned to two groups: 179 received their current mood stabilizer plus an antidepressant (paroxe- tine or bupropion), and 187 received their mood stabilizer plus placebo. The investigators found that the addition of either paroxetine or bupropion did not improve either response or remission rates compared to a placebo control group. On a somewhat reassuring note, antidepressants did not increase rates of either suicidal ideation or switches to mania (Sachs GS et al., NEJM 2007;356:1-12).

TCPR’s Take: These disappointing results argue against the standard practice of adding antidepressants to mood stabilizers in bipolar depression. These findings will likely cause a boost in prescriptions of atypical antipsychotics in bipolar depression, particularly in light of Seroquel’s (queti- apine) recent FDA approval for this indica- tion (see TCPR Feb 2007 for details).