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  • Goals of Treatment

    • Achieve remission of the symptoms of major depression and return the patient to usual levels of psychosocial functioning.

    • Avoid precipitating a manic or hypomanic episode.

  • Choose an initial treatment modality.

    • For patients not yet in treatment for bipolar disorder, initiate either lithium or lamotrigine.

      • As an alternative, especially for more severely ill patients, consider initiating treatment with both lithium and an antidepressant simultaneously (although supporting data are limited).

      • Antidepressant monotherapy is not recommended.

      • Consider ECT for

        • - patients with life-threatening inanition, suicidality, or psychosis or

        • - severe depression during pregnancy.

      • Treatment selection should be guided by illness severity, associated features such as rapid cycling or psychosis, and, where possible, patient preference.

      • Interpersonal therapy and cognitive behavior therapy may be useful when added to pharmacotherapy.

      • Although psychodynamic psychotherapy for bipolar depression has not been empirically studied, it is widely used in combination with medication.

    • For patients who suffer a breakthrough depressive episode while on maintenance treatment, optimize the medication dosage.

      Ensure that serum levels are within the therapeutic range; in some instances, achieve a higher serum level (but still within the therapeutic range).

    • If the patient fails to respond to optimized maintenance treatment, consider adding lamotrigine, bupropion, or paroxetine.

      • Alternative next steps include adding another newer antidepressant (e.g., another selective serotonin reuptake inhibitor [SSRI] or venlafaxine) or a monoamine oxidase inhibitor (MAOI).

      • Tricyclic antidepressants may carry a greater risk of precipitating a switch and are not recommended.

      • MAOIs may be difficult to use because of the risk of severe drug and dietary interactions.

      • Psychotic features during depression usually require adjunctive treatment with an antipsychotic medication. Some evidence suggests efficacy for antipsychotic medication (e.g., olanzapine, quetiapine) in treating non-psychotic bipolar depression.

      • Consider ECT for

        • - severe or treatment-resistant depression,

        • - psychotic features, or

        • - catatonic features.

      • Clinicians may elect to use antidepressants earlier for bipolar II depression than for bipolar I depression because patients with bipolar II disorder probably have lower rates of antidepressant-induced switching into hypomania or mania.

References

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