Understanding and Therapeutic Strategy of Bipolar Depression

Park, Won Myung; Lee, Kyoung Uk

Abstract

The ability to distinguish between unipolar and bipolar depression and the knowledge to bring the appropriate effective treatment is particularly crucial to psychiatrists. Because the pharmacologic strategies indicated for each disorder differ. Failure to make the correct diagnosis may lead to a lack of response to treatment, or complications such as switches into mania or rapid cycling. Common mood symptoms are melancholy, tearfulness, and irritability; common cognitive and perceptual symptoms are self-deprecatory and self-accusatory thoughts, poor concentration, diminished clarity and speed of thought, and suicidal ideation. Absence of a history of hypomania or mania does not rule out a bipolar diagnosis. Retardation, hypersomnia, hyperphagia, suicide attempts, and psychotic symptoms are more frequently found in these patients than in patients with unipolar depression. Few studies have examined the efficacy of somatic treatments in acute bipolar depression. Less than 20 controlled pharmacological studies have been conducted for the depressive phase of bipolar disorder. In addition, these studies examined small sample sizes and with only a few of the available treatment options. Because there is very little data specific to treatment of bipolar depression, most of the approaches to bipolar depression are derived from experience with unipolar depression. The basic premise of treatment os that these patients frequently respond to mood stabilizing agents without antidepressants, and that antidepressants should be reserved for those cases in which mood stabilizers alone have not worked, because of the well-known risk of triggering manic episodes(switching) and rapid cycling. Antidepressants should not be continued any longer than necessary. Mood stabilizers should be considered as first-line agents in view of the fact that their efficacy is at lease equal to, if not greater than, treatment with antidepressant, and that their use is rarely associated with the complications of cycle acceleration or with manic switch. It is recommended to use bupropion or SSRI because of low risk of manic switch and rapid cycling. In the future, research and pharmaceutical communities will have to focus on the short- and long-term effectiveness of antidepressants, and the development of new drugs for the treatment of bipolar depression. More experience is needed with the anticonvulsant lamotrigine, gabapentin, topiramate. The preliminary studies of lamotrigine suggests the antidepressant effect and mood stabilizing efficacy.