Treating Bipolar Depression

Treatment for bipolar depression has come a long way from the days (not so long ago) when patients were given sedatives and medications with numerous side effects. Today, mood stabilizing drugs are a mainstay treatment for bipolar disorder. Doctors may prescribe lithium, an antimanic drug, or an antipsychotic drug -- or a combination of both -- in order to alleviate symptoms of depression without triggering a manic episode.

While depression episodes are far more common than manias and have a tremendous effect on the lives of patients, there are only a few established treatments for bipolar depression.

What's the standard treatment for bipolar depression?

Lithium and the anticonvulsants lamotrigine and valproate are mood stabilizers that are sometimes used "off label" as treatments for bipolar depression, although none of these has been established as an FDA-approved first-line treatment for bipolar depression. For many years, psychiatrists have traditionally added an antidepressant to a mood stabilizer if a mood stabilizer alone is ineffective; however, research shows that antidepressants are often not effective for bipolar depression.

A mood-stabilizing medication works on improving social interactions, mood, and behavior and is recommended for both treatment and prevention of bipolar mood states that swing from the lows of depression to the highs of hypomania or mania. According to the American Psychiatric Association (APA), lithium, lamotrigine, valproate, carbamazepine, and most atypical antipsychotic medications are approved by the FDA for treating one (or more) phases of bipolar disorder.

In some patients with bipolar disorder, a mood stabilizer may be all that's needed to modulate the depressed mood. However, in bipolar patients who do not respond to one mood stabilizer, another mood stabilizer or an atypical antipsychotic is sometimes added to the treatment regimen.

Are antidepressants used to treat bipolar depression?

While antidepressants are effective treatment for people with major depressive (unipolar) disorder, antidepressants they are not always as effective for bipolar depression, and generally should not be given alone (monotherapy) in people with bipolar I disorder. When antidepressants are given alone to someone with bipolar disorder, there's a risk the drug might ignite a manic episode in some patients. Knowing this, most doctors may avoid using antidepressants as monotherapy for bipolar depression.

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A very large randomized study sponsored by the National Institute of Mental Health (NIMH) called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that mood stabilizers alone produced a stable improvement only in about 1 in 4 people with bipolar depression, and surprisingly, adding an antidepressant to the mood stabilizer did not increase the chances for improvement. The STEP-BD study underscored the need to find treatments other than mood stabilizers or antidepressants for bipolar depression.

How are antipsychotic medications used in treating bipolar depression?

Studies have shown that some (but not all) antipsychotic drugs are in themselves effective treatments for bipolar depression. Seroquel and Seroquel XR are used for the treatment of depressive episodes associated with bipolar disorder. Another effective drug with rapid onset for the treatment of bipolar depression is Symbyax, a combination medication of the atypical antipsychotic Zyprexa (olanzapine) and the selective serotonin reuptake inhibitor (SSRI) Prozac (fluoxetine), an antidepressant. The atypical antipsychotic Latuda(lurasidone) is FDA-approved for use alone or with lithium or valproate for treating bipolar depression. These three drugs are currently the only FDA-approved treatments for bipolar depression.

These medications work by affecting brain receptors involved in mood and behavior, and helping to restore the balance of certain natural chemicals in the brain (neurotransmitters).

Your doctor will weigh the benefits and risks of the available medications to help you get relief from the bipolar depression without the risk of mania and/or drug interactions.

How do the CNS depressants help with bipolar disorder depression?

Central nervous system (CNS) depressants, which include the benzodiazepines, act on neurotransmitters to slow down normal brain function. CNS depressants are commonly used to treat anxiety and sleep disorders and may be an effective alternative or adjunctive therapy in some bipolar patients with acute mania.

Some commonly used benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium). These drugs all can be habit-forming/addictive and can cause sluggish thinking. They generally should be used only to treat agitation or sleep problems during the acute phase of the illness and not as long-term medications. They typically should be tapered off rather than stopped abruptly, in order to minimize the risk of drug withdrawal.

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Is electroconvulsant therapy (ECT) a viable treatment for bipolar depression?

Guidelines from the American Psychiatric Association suggest that ECT is a reasonable alternative in those patients who may have suicidal ideation or psychosis. In addition, ECT may benefit women who are pregnant and suffer with severe bipolar depression or mania.

What about psychotherapy for help with bipolar depression?

Along with medications for bipolar depression, patients may benefit from ongoing psychotherapy. This one-on-one therapy combines interpersonal psychotherapy with behavioral techniques to help patients learn how to diminish interpersonal problems, stay on their medications, and normalize their lifestyle habits. The STEP-BD study mentioned earlier found that in addition to medications, adding a structured psychotherapy -- such as cognitive behavioral therapy, interpersonal/social rhythm therapy, or family-focused therapy -- can speed up treatment response in bipolar depression by as much as 150%.

WebMD Medical Reference Reviewed by Joseph Goldberg, MD on August 15, 2015

Sources

SOURCES:

National Institute of Mental Health: Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

American Psychiatric Association: "2002 Practice Guidelines."

Sunovion Pharmaceuticals Inc.

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