BIPOLAR DEPRESSION (see algorithm)

The treatment of bipolar depression is one of the major conundrums of psychiatric practice. An essential and early component in management is to deal with any alcohol and substance abuse which may be exacerbating the depression. Although antidepressants are efficacious, Lithium is increasingly being recommended as the first choice in non-psychotic, non-suicidal acute bipolar depression. If a patient is already on Lithium, Divalproex or Carbamazepine, dose optimization is the first step. If suicidality is a major concern, ECT should be considered early on in the algorithm of treatment choices. Cognitive behavioural and or interpersonal therapy can be useful as adjuncts, particularly with patients who are able to actively participate in these therapies. In moderate to severe bipolar depression mood stabilizer may be combined with antidepressants or a second mood stabilizer or with Lamotrigine or Gabapentin. Antidepressants are effective in bipolar depression but there is little evidence that one is more efficacious than another. If psychotic features are present, the addition of a neuroleptic is advisable. Risperidone is increasingly commonly used. It is advisable to avoid a TCA, as these medications have the highest risk of switch into hypomania and induction of rapid cycling when compared with other antidepressants. Bupropion, which is available in Canada on an emergency drug release program, is reputed to present the least risk of switch into hypomania. However, there is only limited data about this medication in bipolar depression. In addition to the concern that antidepressants, particularly TCAs, induce switch into hypomania and accelerate cycles, there is growing concern that antidepressnats interfere adversely with achieving mood stability even when they do not overtly cause switch into mania. If one uses an antidepressant, and the patient remains refractory to treatment, augmentation strategies with antidepressants may be considered. ECT should also be considered at various points in the algorithm. The use of three mood stabilizers in combination or Clozapine may be considered in truly refractory situations. There are reports of the successful use of light therapy in selected patients.