title: Bipolar depression: criteria for treatment selection, definition of refractoriness, and treatment options.
abstract: OBJECTIVE
  This paper reviews controlled studies of bipolar depression, outlines criteria for choosing treatment, defines refractoriness in bipolar depression, and provides options for treatment of refractory bipolar depression.
  
  
  METHODS
  Controlled studies that examined the efficacy of treatments for acute and long-term treatment of bipolar depression were located through electronic searches of several databases and by manual crosssearch of references and proceedings of international meetings.
  
  
  RESULTS
  Lithium comes close to fulfilling the proposed criteria for first-line treatment for bipolar depression, and those not responding to lithium should be considered to have refractory bipolar depression. Options for such patients include addition of lamotrigine or a second mood stabilizer, or a newer-generation antidepressant such as a serotonin re-uptake inhibitor or bupropion, or the atypical antipsychotic olanzapine.
  
  
  CONCLUSIONS
  Although there is a paucity of research in the treatment of refractory bipolar depression, available data could be used for providing rational treatment options for such patients. However, further studies are urgently needed to determine which options are most appropriate for which type of patients.
authors.affiliation: Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada. yatham@interchange.ubc.ca
authors.forename: Lakshmi N
authors.initials: LN
authors.lastname: Yatham
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Calabrese
authors.forename: Vivek
authors.initials: V
authors.lastname: Kusumakar
mesh_terms: D000927:Anticonvulsants / Q000627:therapeutic use*; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use*; D018692:Antimanic Agents / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000175:diagnosis* / Q000188:drug therapy*; D006801:Humans; D018579:Patient Selection; D016032:Randomized Controlled Trials as Topic; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000927:Anticonvulsants; D018687:Antidepressive Agents, Second-Generation; D018692:Antimanic Agents; D014150:Antipsychotic Agents