*Which antidepressants have greater or lesser risk in bipolar depression?*

. If we do decide to prescribe an antidepressant to a person with bipolar disorder, are there particular antidepressants that are either better or worse than others in terms of the risk? Please note that:

– Here we are not focusing on whether they help or not, but only on how likely it is that they will harm the course of bipolar disorder.

– Taking the antidepressant along with an antimanic mood stabilizer in an adequate dose tends to reduce the risk of inducing a switch. In some cases, the risk may be reduced to no more than that with placebo

The bottom line

The question has NOT been well studied, but since we have to take clinical decisions now rather than wait for further research, here is a simple version of the best answer we have (as of May 2017). In general:

1. Tricyclic antidepressants have the greatest risk of inducing mania/hypomania/increased cycling. Probably they should be avoided in persons with bipolar disorder.

2. SNRIs are probably worse than SSRIs in this regard. They should be avoided whenever possible in persons with bipolar disorder. I have seen several patients who came in with rapid cycling and were on an SNRI. On tapering off the SNRI, the rapid cycling stopped (though they still needed alternative treatment for the depression).

3. SSRIs have a lower risk. I use them in some situations, especially if there is a comorbid anxiety disorder, which is often the case with bipolar disorder.

4. Bupropion may have a lower risk than SSRIs. Bupropion is usually my first choice if an antidepressant is prescribed for a person with bipolar depression. Especially if the person also has ADHD, which is not rare.

So, to summarize, speaking very generally: Bupropion > SSRIs > SNRIs > TCAs.