Some comments by Aaron Wiegmann, MD
Bipolar patients are more likely to suffer from depressive symptoms than manic or hypomanic symptoms. Therefore, pharmacologic treatment of bipolar depression is of great interest to many bipolar patients.
For a patient who presents with acute bipolar depression (who is not currently taking an anti-manic medication) this general guideline would be deemed an appropriate treatment algorithm6.
However, it is strongly recommended that you work with your own doctor to develop a treatment plan tailored to your specific needs, which may differ from this generalized strategy.
- First line medications:
- Seroquel or Latuda monotherapy
- Second line medications: If first line is ineffective or intolerable
- Zyprexa plus Prozac; Depakote monotherapy; combination therapy with Seroquel or Latuda plus lithium or Depakote; or combination therapy with lithium plus Depakote or Lamictal
- Third line medications: If second line is ineffective or intolerable
- Monotherapy with Lamictal, lithium, or Zyprexa; monotherapy with Tegretol or Vraylar; combination therapy with Zyprexa plus lithium or Depakote; other antimanic drug combinations (i.e. lithium plus Tegretol); combination therapy with lithium or Depakote plus an antidepressant such as a selective serotonin reuptake inhibitor (i.e. Prozac) or Wellbutrin; or combination therapy with a second generation antipsychotic (usually Seroquel, Latuda, or Zyprexa) plus an antidepressant
- Refractory patients:
- Electroconvulsive therapy (ECT)
- De Dios, C., Ezquiaga, E., Garcia, A., Soler, B., & Vieta, E. (2010). Time spent with symptoms in a cohort of bipolar disorder outpatients in Spain: a prospective, 18-month follow-up study. Journal of affective disorders, 125(1-3), 74-81.
- Smith, L. A., Cornelius, V., Warnock, A., Bell, A., & Young, A. H. (2007). Effectiveness of mood stabilizers and antipsychotics in the maintenance phase of bipolar disorder: a systematic review of randomized controlled trials. Bipolar disorders, 9(4), 394-412.
- Young, A. H., McElroy, S. L., Olausson, B., Paulsson, B., Embolden I (D1447C00001), & Embolden II (D1447C00134) Investigators. (2014). A randomised, placebo-controlled 52-week trial of continued quetiapine treatment in recently depressed patients with bipolar I and bipolar II disorder. The World Journal of Biological Psychiatry, 15(2), 96-112.
- Shelton RC, Bobo WV. Bipolar major depression in adults: Choosing treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 27, 2020.)