The treatment of bipolar depression.
OBJECTIVE
The treatment of the depressed phase of bipolar disorder is understudied and remains a common clinical dilemma for clinicians. Compared to the manic phases, episodes of bipolar depression are more frequent and of longer duration, yet the literature on this problem is minimal. The few methodologically sound studies find that treatment effective for unipolar depression are also efficacious for bipolar depression. However, standard antidepressant agents may cause acute mania or a long-term worsening of bipolar illness. This paper reviews the available literature on the treatment of bipolar depression and offers recommendations for clinical management.


METHODS
A literature search was conducted using keywords 'bipolar disorder', 'depression', 'drug therapy', 'antidepressants', 'lithium', and 'anticonvulsants'.


RESULTS
If effectively treated by lithium, patients are spared the risk of antidepressant-induced mania. If lithium is not sufficient treatment for acute depression, the combination of lithium and a standard antidepressant appears to reduce the risk of affective switch, as well as the induction of a long-term rapid-cycling course. Additionally, tapering antidepressant medication after periods of sustained remission can be beneficial in limiting the risk of affective switch and acceleration of the cycle rate.


CONCLUSIONS
Doctors must be cautious in prescribing antidepressants for bipolar depression. Use of antidepressants alone should be avoided.
Massachusetts General Hospital, Consolidated Department of Psychiatry, Harvard Medical School, Boston 02114, USA. sachsg@aol.com
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Sachs
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Koslow
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Ghaemi
D000927:Anticonvulsants / Q000009:adverse effects / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D018692:Antimanic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000175:diagnosis / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D006801:Humans; D016651:Lithium Carbonate / Q000009:adverse effects / Q000627:therapeutic use; D012008:Recurrence
D000927:Anticonvulsants; D000928:Antidepressive Agents; D018692:Antimanic Agents; D016651:Lithium Carbonate