Bipolar depression: Pharmacotherapy and related therapeutic strategies

The depressed phase of bipolar affective disorder is a significant cause of suffering, disability, and mortality and represents a major challenge to t reating clinicians. This article first briefly reviews the phenomenology an d clinical correlates of bipolar depression and then focuses on the major p harmacological treatment options. We strongly recommend use of mood stabili zers as the first-line treatment for the type I form of bipolar depression, largely because longer-term preventative therapy with these agents almost certainly will be indicated. Depressive episodes that do not respond to lit hium, divalproex, or another mood stabilizer, or episodes that "breakthroug h" despite preventive treatment, often warrant treatment with an antidepres sant or electroconvulsive therapy. The necessity of mood stabilizers in the type II form of bipolar depression is less certain, aside from the rapid c ycling presentation. Both experts and practicing clinicians recommend bupro pion and the selective serotonin reuptake inhibitors as coequal initial cho ices, with venlafaxine and monoamine oxidase inhibitors, such as tranylcypr omine, preferred for more resistant cases. The risk of antidepressant-induc ed hypomania or mania with concomitant mood stabilizer therapy is low, on t he order of 5% to 10% during acute phase therapy. Additional therapeutic op tions and optimal durations of therapy also are discussed. (C) 2000 Society of Biological Psychiatry.