title: Antidepressants worsen rapid-cycling course in bipolar depression: A STEP-BD randomized clinical trial.
abstract: BACKGROUND
  The use of antidepressants in rapid-cycling bipolar disorder has been controversial. We report the first randomized clinical trial with modern antidepressants on this topic.
  
  
  METHODS
  As part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, we analyzed, as an a priori secondary outcome, rapid cycling as a predictor of response in 68 patients randomized to continue vs. discontinue antidepressant treatment, after initial response for an acute major depressive episode. Outcomes assessed were percent time well and total number of episodes. All patients received standard mood stabilizers.
  
  
  RESULTS
  In those continued on antidepressants (AD), rapid cycling (RC) subjects experienced 268% (3.14/1.17) more total mood episodes/year, and 293% (1.29/0.44) more depressive episodes/year, compared with non-rapid cycling (NRC) subjects (mean difference in depressive episodes per year RC vs. NRC was 0.85 ± 0.37 (SE), df = 28, p = 0.03). In the AD continuation group, RC patients also had 28.8% less time in remission than NRC patients (95% confidence intervals (9.9%, 46.5%), p = 0.004). No such differences between RC and NRC subjects were seen in the AD discontinuation group (Table 1). Analyses within the rapid-cycling subgroup alone were consistent with the above comparisons between RC and NRC subjects, stratified by maintenance antidepressant treatment, though limited by sample size.
  
  
  CONCLUSIONS
  In an a priori analysis, despite preselection for good antidepressant response and concurrent mood stabilizer treatment, antidepressant continuation in rapid-cycling was associated with worsened maintenance outcomes, especially for depressive morbidity, vs. antidepressant discontinuation.
authors.affiliation: Department of Psychiatry, University of Louisville, Louisville, KY, United States.
authors.forename: Rif S
authors.initials: RS
authors.lastname: El-Mallakh
authors.affiliation: Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, United States; Clinic University Hospital, University of Chile, Santiago, Chile, United States.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Vöhringer
authors.affiliation: Department of Psychiatry & Behavioral Sciences, Stanford School of Medicine, Palo Alto, CA, United States.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Ostacher
authors.affiliation: Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Claudia F
authors.initials: CF
authors.lastname: Baldassano
authors.affiliation: Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, United States.
authors.forename: Niki S
authors.initials: NS
authors.lastname: Holtzman
authors.affiliation: Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, United States.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Whitham
authors.affiliation: Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, United States.
authors.forename: Sairah B
authors.initials: SB
authors.lastname: Thommi
authors.affiliation: Department of Psychiatry, The George Washington University, Washington, DC, United States.
authors.forename: Frederick K
authors.initials: FK
authors.lastname: Goodwin
authors.affiliation: Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, United States; Tufts University School of Medicine, Boston, MA, United States.
authors.forename: S Nassir
authors.initials: SN
authors.lastname: Ghaemi
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D001714:Bipolar Disorder / Q000188:drug therapy* / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D063189:Symptom Assessment
chemical_list: D000928:Antidepressive Agents
keywords: Antidepressants; Bipolar disorder; Depression; Rapid cycling