Applied Evidence

A primary care guide to bipolar depression treatment

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For this article, we searched PubMed and Google Scholar for guidelines for the management of bipolar disorders in adults that were published between July 2013 (when the US Food and Drug Administration [FDA] approved lurasidone for the treatment of BD) and March 2019. Related guideline-­referenced articles and clinical trials were also reviewed.

Our search identified 6 guidelines issued during the search period, developed by the:

  • Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD),14
  • British Association for Psychopharmacology (BAP),15
  • Japanese Society of Mood Disorders (JSMD),16
  • National Institute for Health and Care Excellence (NICE),17
  • International College of Neuropsychopharmacology (CINP),18 and
  • Royal Australian and New Zealand College of Psychiatrists.19

How to manage an episode of bipolar depression

First-line pharmacotherapeutic agents for the management of BD in acute bipolar I are listed and described in Table 2.4-19 Compared to the number of studies and reports on the management of BD in bipolar I, few studies have been conducted that specifically examine the treatment of BD in acute bipolar II. In practice, evidence from the treatment of BD in bipolar I has been extrapolated to the treatment of bipolar II depression. CANMAT–ISBD guidelines recommend quetiapine as the only first-line therapy for BD in bipolar II; JSMD, CINP, and NICE guidelines do not make distinct recommendations for treating BD in bipolar II.

Recommendations for first-line pharmacotherapy of bipolar I depression

Top recommended medications for bipolar depression are lithium, quetiapine, olanzapine, lamotrigine, and combined olanzapine/ fluoxetine.

Patients who have BD can present de novo (ie, not taking any medication for bipolar disorder) or with a breakthrough episode while on maintenance medication(s). In either case, monotherapy for BD is preferred, although combinations of medications (Table 214-19) can be more effective in some cases. Treatment guidelines overlap to a high degree, especially in regard to first-line treatments, but there is variation, especially beyond first-line therapeutics.20

The top recommended medications for BD are lithium, quetiapine, olanzapine, lamotrigine, and combined olanzapine/fluoxetine. FDA-approved agents for treating acute BD specifically include quetiapine, lurasidone, and combined olanzapine/fluoxetine. Guidelines generally recommend a first step of adjusting the dosage of medications in any established regimen before changing or adding other agents. If clinical improvement is not seen using any recommended medications, psychiatric referral is recommended. See Table 321,22 for dosing and titration guidance and highlights of both common and rare but serious adverse effects.

Continue to: Recommendations, best options for acute bipolar depression


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