Making Optimal Use of Combination Pharmacotherapy in Bipolar Disorder

Because patients with bipolar disorder often do not respond sufficiently to treatment with 1 moodstabilizer, psychiatrists frequently employ combination therapy and add antipsychotics, antiepileptics,or antidepressants to mood stabilizers. Combination therapy can be more effective than monotherapyin controlling breakthrough or treatment-resistant episodes. For example, atypical antipsychotics havebeen shown to be effective adjunctive treatments for mania and for patients with psychotic symptomsduring a depressive episode, while the combination of a mood stabilizer and lamotrigine or an antidepressanthas been found to control bipolar depression. The American Psychiatric Association guidelinefor the treatment of bipolar disorder recommends optimizing individual medications beforeswitching to combination therapy. Selecting a combination treatment regimen with an acceptable sideeffect profile is critically important because patients may discontinue therapy they cannot tolerate.Agents should be added carefully, with continued monitoring of adverse effects. Physicians shouldgive patients only as much medication as needed.