Challenges in the Management of Bipolar Depression

Bipolar depression has started to receive more attention in clinical trials only relatively recently,despite the fact that patients spend more time in the depressed phase than in the manic phase of bipolardisorder. The diagnosis and management of bipolar depression are challenging, and many patients areundiagnosed or misdiagnosed due to symptom similarities with unipolar depression or other illnessesand/or comorbidities. Untreated or inappropriately treated bipolar depression adds to the burden ofillness and is associated with a greater risk of suicide. Treatment options include lithium, lamotrigine,atypical antipsychotics, and traditional antidepressants, such as the selective serotonin reuptake inhibitors.However, traditional antidepressants are recommended with caution due to their potential risk ofswitching patients into mania. Some atypical antipsychotics have shown efficacy in bipolar depression,although longer-term studies are warranted. The choice of treatment for different subgroups ofpatients with bipolar depression, including those with comorbid anxiety, may vary and also needs furtherstudy. Other important issues that require further investigation include the recognition of the corefeatures of bipolar depression and the threshold symptoms for treatment, as well as the optimal treatmentchoices for monotherapy or combination therapy, and acute versus long-term management ofbipolar depression.