Step 5. Continuation of Mood Stabilizers. Mood stabilizers are typically continued for about 8 weeks, unless the patient shows signs of shifting to another mood state. If the patient remains stable at that time, the doctor may decide to continue maintenance treatment or to gradually withdraw medications.

Treatment Guidelines for Depressive Episodes

Depressive episodes are a particular challenge because many antidepressant drugs pose a risk for triggering mania. It is not clear if standard antidepressants work for bipolar depression. Depressive episodes are very difficult to control and patients who do not respond to mood stabilizers may endure prolonged depressive episodes up to 2 - 3 months.

Lithium or lamotrigine are the standard first-line treatments for depressive episodes. Many studies indicate that lithium works better for controlling manic states, and that lamotrigine works better for bipolar depression.

If improvement does not occur within 2 - 4 weeks, an antidepressant may be added. Antidepressants alone are not recommended. The first choices for antidepressants are bupropion (Wellbutrin, generic) or paroxetine (Paxil, generic). Alternatives include one of the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, generic), a newer antidepressant such as venlafaxine (Effexor, generic), or a monoamine oxidase inhibitor (MAOI).

Other drugs are also approved specifically for treatment of bipolar depression. Symbax combines the atypical antipsychotic olanzapine with the SSRI antidepressant fluoxetine. Quetiapine (Seroquel) is an atypical antipsychotic which is approved for both treatment of bipolar mania and bipolar depression.

Other Treatments. Cognitive-behavioral therapy or other psychotherapy programs may help patients cope with depressive episodes by developing ways to manage negative thoughts and behaviors. Electroconvulsive therapy is another treatment option for severe depression.

Treatment Guidelines for Mixed Episodes and Rapid Cycling

The first step in treating rapid cycling is to try to identify and resolve other factors, such as drug abuse or hypothyroidism, which may have caused this condition. Many patients may require a combination of medications to control rapid cycling:

• Antidepressants, particularly SSRIs, may prompt rapid cycling and are usually tapered off.
• Lithium or valproate is a first-line treatment for rapid cycling.
• Lamotrigine is an alternative treatment for rapid cycling.
• Atypical antipsychotics (olanzapine, aripiprazole, ziprasidone, risperidone, asenapine) are approved to treat mixed episodes. These drugs are used either alone or in combination with lithium or valproate.
• Electroconvulsive therapy may be useful in some situations.

In addition, other measures should be taken:

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Review Date: 01/28/2011
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org)