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Goals of Treatment
of the symptoms of major depression and return the patient to usual
levels of psychosocial functioning.
Avoid precipitating a manic or hypomanic
initial treatment modality.
not yet in treatment for bipolar disorder, initiate either lithium
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
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
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
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.
- severe or treatment-resistant
- psychotic features,
- catatonic features.
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.