The treatment of bipolar depression

The treatment of bipolar depression represents a relatively understudied area in clinical psychiatry. The depressive phases of bipolar disorder can be very disabling, with significant associated comorbidity and suicide risk, impairment in functioning, and infringement on quality of life. We review the current evidence for the management of bipolar depression.

References for this review were obtained through MEDLINE searches of the medical literature on subjects pertaining to the treatment of bipolar depression. Search terms included bipolar depression, antidepressants, and bipolar disorder. Only publications in English are reviewed here.

Lithium is currently the gold standard and most appropriate initial treatment for the depressive phase of bipolar disorder. Other mood stabilizers have demonstrated preliminary efficacy. Of the antidepressants, bupropion and the selective serotonin reuptake inhibitors may be associated with less risk of inducing hypomania, mania, and rapid cycling compared with tricyclic antidepressants. Monoamine oxidase inhibitors should be considered for patients with anergic bipolar depression. Electroconvulsive therapy has been shown to be highly efficacious. Other treatment modalities, including psychotherapy, sleep deprivation, phototherapy, and newer medications, require further research.

Although the treatment of bipolar depression can be a complicated clinical task, the treatment armamentarium is expanding. Further research, especially in the form of randomized controlled trials, is warranted. Clinicians should be familiar with general guidelines for the use of psychopharmacologic agents for treating bipolar depression.