Applied Evidence

A primary care guide to bipolar depression treatment

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Lithium has strong supporting evidence of benefit in mood episodes of all bipolar disorders.

As a general rule, the strongest evidence for preventing recurrent BD episodes favors lithium—and most guidelines therefore support lithium as first-line maintenance therapy. It is important to note, however, that if a medication (or medications) successfully aborted an acute BD episode in a given patient, that agent (or agents) should be continued for maintenance purposes to prevent or minimize future episodes—generally, at the same dosage. First-line pharmacotherapeutic agents for the maintenance of bipolar disorder, and thus to prevent subsequent episodes of BD, are listed in Table 4.14-19

First-line maintenance treatment of bipolar disorder

antidepressantsin bipolar depression?

The use of antidepressants to treat BD remains a topic of ongoing deliberation. Antidepressant treatment of BD has historically raised concern for depressive relapse due to ineffectiveness and the ability of antidepressants to increase (1) the frequency of manic and hypomanic episodes23 and (2) mood instability in the form of induction of mixed states or rapid cycling. Among most authorities, the recommendation against using antidepressants for BD in both bipolar I and II is the same; however, limited evidence allows the use of antidepressant monotherapy in select cases of BD episodes in bipolar II,24,25 although not bipolar I.

The consensus in the field is that medications with mood-stabilizing effects should be considered as monotherapy before adding an antidepressant (if an antidepressant is to be added) to treat BD in bipolar II.26 In other words, if an antidepressant is to be used at all, it should be combined with a mood stabilizer or atypical antipsychotic15,27 and should probably not be used long term. The efficacy of antidepressants in treating BD in bipolar II should be assessed periodically at follow-up.

Nonpharmaceutical treatment options

Although pharmacotherapy is the mainstay of treatment of BD, adjunctive psychotherapy can be useful for treating acute BD episodes that occur during the maintenance phase of the disorder. Psychoeducation (ie, education on psychiatric illness and the importance of medication adherence), alone or in combination with interpersonal and social rhythm therapy (IPSRT), family-focused therapy (FFT), and cognitive behavioral therapy (CBT) can add to the overall efficacy of pharmacotherapy by lowering the risk of relapse and enhancing psychosocial functioning.28

IPSRT is supported by what is known as the instability model, which specifies that 3 interconnected pathways trigger recurrences of a bipolar episode: stressful life events, medication nonadherence, and social-rhythm disruption. IPSRT also uses principles of interpersonal psychotherapy that are applied in treating MDD, “arguing that improvement in interpersonal relationships can ameliorate affective symptoms and prevent their return.”29,30

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