The Treatment of Bipolar Depression

Background: The treatment of bipolar depression represents a relatively understudied area in clinical psychiatry. The depressive phases of bipolar disorder can be very disabling, with significant associatedcomorbidity and suicide risk, impairment in functioning, and infringement on quality of life.We review the current evidence for the management of bipolar depression. Method: References for this review were obtained through MEDLINE searches of the medical literature on subjects pertainingto the treatment of bipolar depression. Search terms included bipolar depression, antidepressants, andbipolar disorder. Only publications in English are reviewed here. Results: Lithium is currently the gold standard and most appropriate initial treatment for the depressive phase of bipolar disorder. Othermood stabilizers have demonstrated preliminary efficacy. Of the antidepressants, bupropion and theselective serotonin reuptake inhibitors may be associated with less risk of inducing hypomania, mania,and rapid cycling compared with tricyclic antidepressants. Monoamine oxidase inhibitors shouldbe considered for patients with anergic bipolar depression. Electroconvulsive therapy has been shownto be highly efficacious. Other treatment modalities, including psychotherapy, sleep deprivation, phototherapy,and newer medications, require further research. Conclusions: Although the treatment ofbipolar depression can be a complicated clinical task, the treatment armamentarium is expanding. Furtherresearch, especially in the form of randomized controlled trials, is warranted. Clinicians shouldbe familiar with general guidelines for the use of psychopharmacologic agents for treating bipolardepression.