The mainstay of medication treatment for patients diagnosed with bipolar disorder is a mood stabilizer. These medications ideally can help manage the manic/hypomanic symptoms as well as the depressive symptoms that can occur in bipolar disorder. Patients with bipolar disorder, either Bipolar I or Bipolar II, typically spend more time in depression than in mania. Clinicians worry more when patients are in mania because there can be a greater risk of hospitalization, suicide and reckless and dangerous behavior. In many cases the mood stabilizer in use helps with both the mania and depressive symptoms, but what about clinical situations when a patient is having a depressive episode which is causing a great deal of distress and impairment and not responding to the mood stabilizer in place?
One option to consider is increasing the dose of the current mood stabilizer. Another relatively safe option would be to add or cross taper to another mood stabilizer, one that is studied and known to be helpful for bipolar depression. These mood-lifting stabilizers include: lithium, lamotrigine (Lamictal), and possibly depakote in the traditional mood stabilizer category, and quetiapine (Seroquel), lurasidone (Latuda), and olanzapine-fluoxetine (Symbyax) combination in the neuroleptic mood stabilizer category. If a patient is stable in terms of her manic/hypomanic symptoms on the mood stabilizer she is on, she should stay on that medication and a second one could be added on.
It can be safe to use low dose antidepressants for short periods of time to treat depression in bipolar disorder, as long as the patient has a mood stabilizer on board to prevent a manic or hypomanic episode. This is more true for bipolar II disorder than bipolar I disorder. There is greater worry in using an antidepressant in bipolar I disorder. The worry about using antidepressants in bipolar disorder is that it can lead to a manic or hypomanic episode or a mixed state or rapid cycling. Studies have shown that the SNRIs and tricyclic antidepressants are at higher risk of leading to mania than the SSRIs and bupropion. When considering using an antidepressant, it is important to ask the patient about his past experience with antidepressant trials and if other mood stabilizer medications were more helpful than his current medication to manage both manic and depressive episodes. It is best to avoid them if a patient has recently had a manic or hypomanic episode or recently was rapid cycling.
Some advocate for using other non-antidepressant medications that can help uplift mood without the risks of antidepressant medications. These include: omega 3 fatty acids; thyroid supplementation; pramipexole (Mirapex), which is currently used for Parkinson disease, but has some promising studies to be useful for bipolar depression; and modafinil (Provigil). Of course, one should also consider therapy particularly for mild-moderate depression because it helps avoid potential side effects from medication treatments.
It is our hope that this introduction on treatment for bipolar depression has been helpful. Please call SmartCare for questions about specific cases and we can help formulate a treatment plan for these challenging clinical scenarios.