Bipolar disorder in adults: Pharmacotherapy for acute depression
- Jeffrey Stovall, MD
Jeffrey Stovall, MD
- Associate Professor of Psychiatry
- Vanderbilt School of Medicine
Bipolar disorder is an illness characterized by periods of pathologic mood elevation. Patients with bipolar I disorder have manic episodes or mixed (concurrent mood elevation and depression) episodes, and nearly always experience depressive episodes. The clinical course in patients with bipolar II disorder is characterized by one or more episodes of major depression, with at least one hypomanic episode.
Recognition of bipolar disorder is important for at least two reasons: it is associated with substantial morbidity and mortality if untreated, and treatment differs from that of unipolar depression. Bipolar disorder is often misdiagnosed, especially when patients present with symptoms of depression . A careful history, including information from family members, may find evidence of prior manic, mixed, or hypomanic episodes.
The treatment of acute bipolar depression is reviewed here. Treatment of acute mania, mixed states, hypomania; maintenance treatment; and the epidemiology, clinical manifestations, and diagnosis of bipolar disorder are discussed elsewhere. (See "Bipolar disorder in adults: Pharmacotherapy for acute mania and hypomania" and "Bipolar disorder in adults: Choosing maintenance treatment" and "Bipolar disorder in adults: Epidemiology and pathogenesis".)
STAGE OF ILLNESS
The goals for treating for bipolar depression are based upon the patient's current stage of illness, generally categorized as three phases :
●The acute phase of treatment focuses upon managing the patient’s safety and the presenting symptoms. Patients in the acute phase may be suicidal, psychotic, and display such poor judgment as to pose an imminent risk to themselves. Hospitalization is often necessary until the severity of symptoms lessens.
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- STAGE OF ILLNESS
- GENERAL PRINCIPLES
- SPECIFIC TREATMENTS
- - Lamotrigine plus lithium
- Valproate (Divalproex)
- Second-generation antipsychotics
- - Quetiapine
- - Lurasidone
- - Cariprazine
- - Olanzapine
- Electroconvulsive therapy (ECT)
- Omega-3 fatty acids
- Investigational approaches
- SUGGESTED PATIENT MANAGEMENT
- Medication combinations
- - Adjunctive antidepressants
- - Other combinations
- BIPOLAR II DISORDER
- SPECIAL CIRCUMSTANCES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS