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Treating Depression in Bipolar I Disorder

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Step 1:  Getting started:

Step 2:  Start with one of the following options:

    • The above medications usually require about 2-4 weeks at a therapeutic dose for improvements to take place, but a check-up with a physician should be offered after 1-2 weeks of starting the medication to check for any side-effects and monitor the individual's condition.
    • If there are no signs of improvement even after 4 weeks of treatment, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same time repeat Step 2 with a different treatment option.
    • On the other hand, if after 4 weeks there are signs of improvement, then continue the treatment with check-ups with a physician every 2 weeks.
      • As long as the depressive symptoms continue to improve, there is no need to increase the dose.
      • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
    • If with this approach the depressive symptoms resolve completely, go to Step 5.
    • On the other hand, if after 2 weeks at the maximum tolerated dose the condition has not resolved completely, go to Step 3.

Step 3:  Choose one of the following options:

    • As long as the depressive symptoms continue to improve with this intervention, there is no need to increase the dose.
    • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
      • If with this approach the depressive symptoms resolve completely, go to Step 5.
      • If there are no signs of improvement even after 4 weeks of this step, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same time repeat Step 3 or go to Step 4.
      • If after 2 weeks at the maximum tolerated dose the symptoms have improved but not resolved completely, repeat Step 3 or go to Step 4 while continuing the current medications.

Step 4:  Choose one of the following options:

    • As long as the depressive symptoms continue to improve with this intervention, there is no need to increase the dose.
    • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further. Regarding ECT, a full course should be given.
      • If with this approach the depressive symptoms resolve completely, go to Step 5.
      • If there are no signs of improvement even after 4 weeks of this step, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same time repeat Step 4.
      • If after 2 weeks at the maximum tolerated dose the symptoms have improved but not resolved completely, repeat Step 4 while continuing the current medications.

Step 5:  Maintenance treatment:

    • Continue to focus on Lifestyle Managements skills.
    • Consider starting psychotherapy if not already done. This can be especially important if
    • If antidepressants were used, taper and discontinue them after 6-8 weeks.
    • Continue all other effective medications for at least a year so as to prevent further episodes.  However, for individuals who have experienced multiple previous Bipolar mood episodes (Hypomania, Mania, Depressive or Mixed), or even just one severe episode, it is recommended that they remain on medications indefinitely.
    • If a decision is taken to stop medications, this should be done very gradually, one medication at a time, over a period of at least a couple of months for each medication, and with close monitoring by a physician. Monitoring and follow-ups should continue even after the medications have been stopped.
    • If the goal is to reduce the number of medications being used, Lithium, Olanzapine, Lamotrigine and Quetiapine have all been shown to be effective in preventing relapses to Depression and are thus the first choice in maintenance treatment. Lithium also has the added advantage of being the only agent with proven effect in reducing the risk of suicide when taken over a long term.
    • If the successful treatment that was used was ECT, then once the course of ECT is completed any medications that were partially effective should be continued.

 

Unless otherwise indicated, the above treatments strategies are based on the CANMAT Guidelines for the Management of Patients with Bipolar Disorder [ref, ref, ref, ref] and the Texas Medical Algorithm Project.

 

Manic, Hypomanic or Mixed Episode

Bipolar II Depression