Evaluation and Management of Breakthrough Depressive Episodes

Clinicians are faced with a diagnostic challenge when a bipolar patient reports breakthrough depressivesymptomatology. Breakthrough depressive symptoms during treatment for a bipolar depressiveepisode may be a manifestation of recurrent bipolar depression or the emergence of a mixed episode.Treatment of recurrent bipolar depression and mixed episodes differs considerably, andantidepressant therapy during a mixed episode can worsen the episode and initiate or exacerbate rapidcycling. Therefore, accurate diagnosis and appropriate treatment are imperative to achieving a positiveoutcome. Research indicates that optimizing the current mood stabilizer therapy or adding anothermood stabilizer may be the best treatment options for patients with a history of rapid cycling—in patients without a history of rapid cycling, adding an antidepressant to a mood stabilizer may beless risky and therefore a reasonable choice. Combination therapy with a mood stabilizer and an atypicalantipsychotic may also be effective in managing bipolar depressive episodes.