Antidepressant-induced hypomania or mania is defined as a short-term reaction to medication. This phenomenon, referred to as “switching”, occurs within 2 months of treatment initiation (if it occurs).1 Antidepressants can also cause long-term mood destabilization in bipolar treatment even in the absence of a short-term manic or bipolar switch.1,2 Properly diagnosing bipolar disorder is challenging and can take time. It may take up to 8 years for a depressed patient to manifest manic symptoms and/or receive a proper diagnosis.3Herbal and natural supplements can induce hypomania or mania in those with bipolar disorder. St. John’s Wort, SAMe (S-adenosyl methionine) and Omega 3 fatty acids can cause switching in bipolar.4,5,6,7,8,9,10 Ephedra sinica, Rhodiola rosea, Gingko biloba, Ginseng and Inositol are also implicated in antidepressant-induced hypomania/mania.6,7,10
There is insufficient evidence to support long-term use of antidepressant herbs in bipolar disorder. Studies with antidepressant medications generally do not support long-term use of antidepressant agents in bipolar disorder. Current recommendations are to use these herbs as adjuvant treatments with mood stabilizers in bipolar disorder.6,7,8,10 Cautious, selected use of antidepressants, as opposed to routine use, is advised in bipolar disorder.11,12,13
There are a number of predictors of antidepressant-induced hypomania and mania. Patients with bipolar I subtype, mixed episodes or past antidepressant-induced hypomania/mania are prone to switching. Comorbid substance use increases the risk of switching. Rapid cycling is strongly associated with increased risks of antidepressant-induced hypomania/mania.2,14
Patients with bipolar disorder are advised to consult a licensed physician to safely use herbal supplements.4 Avoid abrupt withdrawal of antidepressant medications and/or herbs.14 Herbal antidepressants are not recommended in those with a higher likelihood of antidepressant-induced hypomania or mania.
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1Ghaemi SN. Treatment of Rapid–Cycling Bipolar Disorder: Are Antidepressants Mood Destabilizers? Am J Psychiatry 2008;165:300-1.
2Ghaemi SN, Hsu DJ, Soldani F, etal. Antidepressants in bipolar disorder: a case for caution. Bipolar Disord 2003;5:421-33.
3Holma KM, Melartin TK, Holma IA, etal. Predictors for switch from unipolar majord epressive disorder type I or II: a 5-year prospective study. J Clin Psychiatry 2008;69:1267-75.
4Nierenberg AA, Burt T, Matthews J, etal. Mania associated with St. John’s Wort. Biol Psychiatry 1999;46:1707-8.
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9Parker G, Gibson NA, Brotchie H, etal. Omega-3 fatty acids and mood disorders. Am J Psychiatry 2006;163:99-978.
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11Ghaemi SN, Goodwin FK. Antidepressants for Bipolar Depression. Am J Psychiatry 2005;162:1545-5.
12Ghaemi SN, Ostacher MM, El–Mallakh RS, etal. Antidepressant Discontinuationin Bipolar Depression: A Systematic Treatment Enhancement Program for Bipola rDisorder (STEP–BD) Randomized Clinical Trial of Long–Term Effectiveness and Safety. J Clin Psychiatr 2010;71;372-80.
13Viet aE. Cause for caution, case for action. Bipolar Disord 2003;5:434-5.
14Goldberg JF. Antidepressants in bipolar disorder: 7 myths and realities. Current Psychiatry 2010;9:41-9.