Treatment options for acute depression in bipolar disorder

Bipolar Disorders, 04/20/2012

Treatment decisions in bipolar depression involve a range of different pharmacological and non–pharmacological options. Monitoring potential unwanted effects and the appropriateness of treatment can help to effectively balance benefits and risks in individual situations.


  • The evidence is largely based on a systematic literature search and appraisal that was part of the development of the German Guideline for Bipolar Disorders.
  • All relevant randomized controlled trials were critically evaluated.


  • Overall, the number of suitably controlled studies for the treatment of bipolar depression is relatively low.
  • There are two common scenarios.
  • Scenario A, if a patient with bipolar depression is currently not being treated with a mood-stabilizing agent (de novo depression, first or subsequent episode), then quetiapine or olanzapine are options, or alternatively, carbamazepine and lamotrigine can be considered.
  • Antidepressants are an option for short-term use, but whether they are best administered as monotherapy or in combination with mood-stabilizing agents is still controversial.
  • In practice, most clinicians use antidepressants in combination with an antimanic agent.
  • Scenario B, if a patient is already being treated optimally with a mood-stabilizing agent (good adherence and appropriate dose) such as lithium, lamotrigine is an option.
  • There is no evidence for additional benefit from antidepressants where a patient is already being treated with a mood stabilizer; however, in practice an antidepressant is often trialled.
  • Efficient psychotherapy is an important part of the treatment regimen and should span all phases of the illness.

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