Medicating mood with maintenance in mind: bipolar depression pharmacotherapy

Objectives: Bipolar depression is a core feature of bipolar disorder, a phase in which many patients spend the majority of time and one that confers I significant degree of burden and risk. The purpose of this paper is to briefly review the evidence base for the pharmacotherapy of bipolar depression and to discuss the recommendations for its optimal management. Methods: A detailed literature review was undertaken with a particular emphasis on pharmacological treatment strategies for bipolar depression across the acute and maintenance phases of the illness. Electronic library and Web-based searches were performed using recognised tools (MEDLINE, PUbMED, EMBASE and PsychlNFO) to identify the pertinent literature. A Summary of the evidence base is outlined and then distilled into broad clinical recommendations to guide the pharmacological management of bipolar depression. Results: Partitioning treatment into acute and maintenance therapy is difficult based on the paucity of current evidence. The evidence from treatment trials favours the use of lithium and lamotrigine as first-line treatment in preference to valproate, and indicates that, for acute episodes, quetiapine and olanzapine have perhaps achieved equivalence at least in terms of efficacy. However, the effectiveness of the atypical antipsychotics in maintenance therapy is constrained by the potential for significant side effects of individual agents and the lack of both long-term research data and clinical experience in treating bipolar disorder as compared to other agents. Conversely, lithium and the anticonvulsants are generally slower to effect symptomatic change, and this limits their usefulness. Conclusions: There has been I tendency for research trials of bipolar depression to differentiate the illness cross-sectionally into the acute and maintenance phases of bipolar depression; however, in clinical terms, bipolar depression invariably follows a longitudinal course in which the phases of illness are inextricably linked, and useful acute treatments are typically continued in maintenance. Therefore, when medicating mood in acute bipolar depression it is imperative to keep maintenance in mind as it is this aspect of treatment that determines long-term Success.