Q. Are the depressions in bipolar illness different from unipolar depressions?

  A. Yes, but no. First off, depression has a high suicide rate accompanying it as a symptom, so you have to treat it regardless of the down-the-road consequences so the patient does not die now. There are differences between unipolar and bipolar depressives, so the clinician, and well-informed patient need to know about these.

Most of the time, the antidepressants work well with few side effects in unipolar and bipolar depression. As we have discussed in earlier questions, however, bipolars make up a conglomerate of illnesses with mood swings and impulsivity. There are many different kinds of bipolars, so there are many different types of bipolar depressions. Bipolars, as a general rule, do lousy on tricyclic antidepressants (Sinequan = doxepin, Pamelor = nortriptyline, Anafranil = clomipramine, Elavil = amitriptyline, and Tofranil = imipramine). These medications can induce "rapid cycling." The literature has a few good trials showing the SRIs, MAOIs, and Wellbutrin do not induce rapid cycling any more than placebo. TCAs are 6-8 fold higher.

In bipolars, many patients are also on anti-epileptic drugs (carbamazepine = Tegretol, valproate = Depakote, gabapentin = Neurontin, etc.). Some of the antidepressants can change the metabolism of the antiepileptic agents. Likewise, drugs like Tegretol can make the antidepressants breakdown more quickly, so you may need to take a higher dosage of antidepressant for it to work. All these questions should be discussed with your clinician until you are happy with the answers he or she gives. This improves compliance and makes everyone's life easier.