Bipolar Depression
- 20% of Bipolar Depressive Episodes run a chronic course
- Mild depressive symptomatology may be successfully treated with CBT or IPT
- Lithium
- Response rates from 64% to 100%. Level I (A) evidence
- Antidepressants
- Level I (B) evidence.
- Watch for flips (more common with tricyclics)
- Use with concomitant mood stabilizer to avoid flips
Lamotrigine in Bipolar Depression
- Lamotrigine
- Sometimes added to lithium as mood stabilizer
- It works better from the “bottom up”
- Lithium and Epival work better from the “top down”
Atypical Neuroleptics in Bipolar Depression
- Atypical Neuroleptics can be used as acute antidepressants
- Olanzapine has level 1 evidence as monotherapy for acute depression
- Quetiapine now approved for bipolar depression
1st Line Treatments for Bipolar Depression
- Monotherapy:
- Lithium, lamotrigine, quetiapine
- Combination Therapy:
- Lithium and divalproate
- Olanzapine and SSRI
Drugs in Continuation Phase
- If Atypical Neuroleptics were used, gradually wean and discontinue unless:
- (1) persistent psychosis, or (2) adjunctive prophylaxis
- If antidepressants used, once depression has past, if asymptomatic for 6-12 weeks, gradually wean off over several weeks.
Maintenance/Prophylactic Phase
- Risk of recurrence? not sure, but:
- Mood stabilizers help with moderate-severe illness
- But there is a subgroup of patients with mild illness who may not need prophylaxis
- Hard to identify this group
- Indefinite maintenance pharmacotherapy has been supported by “decision analysis”, which analyzes:
- “costs” (e.g., lithium exposure)
- “benefits” - (i.e., decreased risk of relapse)
1st Line Treatments for Maintenance
- Monotherapy:
- Lithium, divalproate, lamotrigine, risperidone LA, olanzapine, quetiapine, aripiprazole
- Combination:
- Lithium or divalproate plus risperidone LA, quetiapine, or ziprasidone
1st Line Treatments for Bipolar II
- Depression: Quetiapine
- Maintenance: Lithium, Lamotrigine