A primary care guide to bipolar depression treatment
Manage uncomplicated cases following guidelines on medical therapy and with adjunctive psychotherapy. Refer complicated and severe cases to Psychiatry.
PRACTICE RECOMMENDATIONS
› 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
Recommendations, best options for acute bipolar depression
Start with lithium, lamotrigine, quetiapine, or lurasidone as the first-line medication at the dosages given in Table 3.21,22 Olanzapine alone, or in combination with fluoxetine, can be used when it has been determined that the medications listed above are ineffective.
Note that lithium requires regular blood monitoring (Table 321,22). However, lithium has the advantage of strong supporting evidence of benefit in all mood episodes of bipolar disorders (depressive, manic, hypomanic), as well as maintenance, prevention of recurrence, and anti-suicidal properties.
Also of note: Lurasidone is much more costly than other recommended medications because it is available only by brand name in the United States; the other agents are available as generics. Consider generic equivalents of the recommended agents when cost is an important factor, in part because of the impact that cost has on medication adherence for some patients.
Last, olanzapine should be used later in the treatment algorithm, unless rapid control of symptoms is needed or other first-line medications are ineffective or not tolerated—given the higher propensity of the drug to produce weight gain and cause metabolic problems, including obesity and hyperglycemia.
The importance of maintenance therapy
Almost all patients with BD require maintenance treatment to prevent subsequent episodes, reduce residual symptoms, and restore functioning and quality of life. Maintenance therapy is formulated on the basis of efficacy and tolerability in the individual patient.
Continue to: As a general rule...
