Applied Evidence

A primary care guide to bipolar depression treatment

Author and Disclosure Information

Manage uncomplicated cases following guidelines on medical therapy and with adjunctive psychotherapy. Refer complicated and severe cases to Psychiatry.


› Become knowledgeable in identifying an episode of bipolar depression and differentiating it from major depressive disorder, so as to provide effective treatment for bipolar depression. A

› Begin treatment of bipolar depression with one of the recommended first-line medications, especially lithium, lamotrigine, quetiapine, or lurasidone. A

› Treat bipolar II depression similar to the way bipolar I depression is treated: primarily, using a mood stabilizer alone or, occasionally, using a mood stabilizer plus an antidepressant. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



Bipolar disorder is a prevalent disorder in the primary care setting.1,2 Primary care providers therefore commonly encounter bipolar depression (BD; a major depressive episode in the context of bipolar disorder), which might be (1) an emerging depressive episode in previously undiagnosed bipolar disorder or (2) a recurrent episode during the course of chronic bipolar illness.3,4

A primary care–based collaborative model has been identified as a potential strategy for effective management of chronic mental health conditions such as bipolar disorder.5,6 However, this collaborative treatment model isn’t widely available; many patients with bipolar disorder are, in fact, treated solely by their primary care provider.

Two years ago in this journal,7 we addressed how to precisely identify an episode of BD and differentiate it from major depressive disorder (MDD; also known as unipolar depression). In this review, in addition to advancing clinical knowledge of BD, we provide:

  • an overview of treatment options for BD (in contrast to the treatment of unipolar depression)
  • the pharmacotherapeutic know-how to initiate and maintain treatment for uncomplicated episodes of BD.

We do not discuss management of manic, hypomanic, and mixed episodes of bipolar disorder.

How to identify bipolar depression

Understanding the (sometimes) unclear distinction between bipolar I and bipolar II disorders in an individual patient is key to formulating a therapeutic regimen for BD.

Bipolar I disorder consists of manic episodes, alternating (more often than not) with depressive episodes. Bipolar I usually manifests first with a depressive episode.

Bipolar II disorder manifests with depressive episodes and hypomanic episodes (but never manic episodes).

Continue to: Depressive episodes in the bipolar disorders


Next Article: