During a recent webinar hosted by Medical Academic and Adcock Ingram, psychiatrist Dr Antoinette Miric provided an in-depth review of the prescribing guidelines for managing bipolar depression and mixed mood states.
During a recent webinar hosted by Medical Academic and Adcock Ingram, psychiatrist Dr Antoinette Miric provided an in-depth review of the prescribing guidelines for managing bipolar depression and mixed mood states.
Bipolar disorder, characterised by significant mood swings including episodes of depression and mania, requires a nuanced approach to pharmacological treatment, especially for bipolar depression and mixed mood states.
The cornerstone of pharmacological intervention for bipolar depression includes several first-line agents that have been rigorously evaluated for efficacy and safety. According to the latest guidelines from CANMAT and ISBD 2018, the preferred medications include:
Quetiapine: Recommended at doses ranging from 300 to 600mg, quetiapine is effective for the core symptoms of bipolar depression. It has the advantage of rapid onset of action and is also beneficial during maintenance treatment to prevent recurrence. The common side effects include sedation and weight gain, but its overall tolerance is favourable.
Lithium: With a target serum level of 0.8-1.2mEq/L, Lithium is not only effective in treating acute bipolar depression but also in preventing future mood episodes. It is particularly noted for its ability to reduce the risk of suicide in bipolar patients. Lithium's efficacy in mixed states can be less predictable, and it may require combination with other medications.
Lamotrigine: This medication is particularly effective in the maintenance phase of bipolar disorder, helping to prevent depressive episodes. For acute bipolar depression, Lamotrigine is started at a low dose and titrated slowly to avoid side effects, with a target dose usually exceeding 200mg.
Adjunctive treatments
In cases where monotherapy is insufficient or in patients presenting with severe symptoms, adjunctive treatments may
be necessary:
Antidepressants: While traditionally used in depression, antidepressants must be used cautiously in bipolar disorder due to the risk of triggering manic episodes. They are generally recommended in combination with mood stabilisers or antipsychotics rather than as monotherapy.
Valproate and olanzapine: These are effective in managing mixed episodes and can be used alone or in combination. They help control manic symptoms while also addressing depressive symptoms.
Alternative and third-line treatments
For patients who do not respond adequately to first-line treatments, alternative or third-line options may be considered:
- SSRIs and bupropion: As adjunctive therapies, these can be useful when combined with mood stabilisers.
- Aripiprazole and carbamazepine: These agents are considered when other treatments fail or are not tolerated.
- Ketamine and levothyroxine: Used in more resistant cases or specific clinical scenarios, these treatments offer additional options for complex cases.
Treatment considerations and monitoring
Effective management of bipolar disorder requires careful consideration of the patient’s history, symptom profile, and response to previous treatments. Regular monitoring of medication levels, particularly for lithium and valproate, is crucial to ensure therapeutic efficacy and to minimise side effects.
