Treatment of Bipolar Depression

On average people with Bipolar I Disorder spend three times more in a depressive episode than in a manic or hypomanic state; those with Bipolar II Disorder spend 40 times more in a depressive episode than in a manic or hypomanic state. According to DSM-5 a bipolar depressive episode and a unipolar depressive episode have the same diagnostic criterea marked by five of the following nine symptoms for two weeks:

• Depressed mood
• Loss of pleasure
• Weight or appetite change
• Change in sleep
• Psychomotor agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Indecisiveness or trouble concentrating
• Suicidal ideation

Bipolar I patients have had at least one manic episode lasting at least one week during which time the person feels euphoric and overly optimistic or is extremely irritable marked by three of the following symptoms:

• Unrealistic, grandiose beliefs about one’s abilities or powers
• Rapid speech that makes it difficult for others to keep up
• Acting recklessly without thinking about the consequences
• Racing thoughts, jumping quickly from one idea to the next
• Distractibility marked by poor concentration and attention
• Impulsiveness, poor judgment, agitation or excessive goal pursuit
• Sleeping very little but without loss of energy

Bipolar II patients have had at least one hypomanic episode that differs from mania by intensity and duration. A hypomanic episode is only required to persist for four days instead of seven. Those in a hypomanic state can make bad decisions that harm relationships, careers, and reputations, but they are able to perform without losing touch with reality.

Three medications have been approved by the FDA for the treatment of acute bipolar depressive episodes:

     1. Seroquel (quetiapine)

     2. Symbyax (a combination of fluoxetine and olanzapine)

     3. Latuda (lurasidone)

Seroquel can contribute to significant weight gain and metabolic syndrome as can Symbyax. Both Latuda and Symbyax are expensive.

Lithium, listed as first-line treatment for acute bipolar depression in the APA practice guidelines, works rapidly, is inexpensive, and substantially decreases suicide risk. Because lithium has been a generic medication for decades there is little incentive for pharmaceutical companies to seek FDA approval.

Lithium, like ECT, has a negative connotation for some people so preparing patients for this gold standard treatment requires education. For example the clinician can say: “Lithium is a natural element. You’ll find it on the periodic chart. Dosing is more exacting than with most other medications because we can measure blood levels regularly. Like all medications lithium has side effects but we will routinely monitor this side effect potential with a series of laboratory studies.”

Once the educational groundwork has been laid the clinician can prescribe 300 mg immediate-release lithium at night. (Data shows that immediate-release once daily is better for kidney function.) After five days the dose can be increased to 600 mg. Following another five days the dose can be increased to 900 mg. Baseline labs and a lithium level can be drawn within a week of starting lithium.