Herbal 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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References:

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.

⁵Sarris J, Kavanagh DJ, Byrne G. Adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines.  J Psychiatr Res 2010;44:32-41.

⁶Iovieno N, Dalton ED, Fava M, etal. Second-tier natural antidepressants: Review  and critique.  J Affect Disord 2010; doi:10.1016/j.jad.2010.06.010

⁷Sarris J. Herbal medicines in the treatment of psychiatric disorders: a systematic review. Phytother Res 2007;21:703-16.

⁸Mischoulon D. Updatea nd Critique of Natural Remedies as Antidepressant Treatments. Psychiatr Clin N Am 2007;30:51-68.

⁹Parker G, Gibson NA, Brotchie H, etal. Omega-3 fatty acids and mood disorders. Am J Psychiatry 2006;163:99-978.

¹⁰Andreescu C, Mulsant BH, Emanuel JE. Complementary and alternative medicine in the treatment of bipolar disorder – a review of the evidence. J Affect Disord 2008;110:16-26.

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.