Acute depressive episode (Bipolar I or II)

As with any medical disorder, proper treatment of bipolar disorder is reliant upon correct diagnosis. Due to the nature of bipolar depression, what distinguishes it is careful history taking and attention to past hypomanic or manic episodes which may have gone unreported and untreated. Also careful attention to possible family history of mood disorders and of bipolar disorder is very useful. In terms of actual symptoms there are very few differences which help us distinguish a bipolar depressive episode from its ‘non-bipolar’ cousin, so getting the story right is really important.

Once it is clear that a diagnosis of a bipolar depressive episode has been made it is vital to assess the severity of the episode and in particular to consider how well the the individual is able to function with the support available. In particular, a careful and open assessment of suicidal thoughts, ideas or plans is vital.

It is true that on one hand that it is normal to experience suicidal ideas when one is significantly depressed – and that it can be a major relief for people to realise this, but on the other hand this does not mean that these ideas must not be taken seriously and dealt with, with the utmost judgement, care and concern by skilled professionals who are uesd to assessing such issues.

At this stage, a practical decision needs to be made as to whether the individual can be best managed as an outpatient, day patient or much less commonly nowadays with the help of an inpatient admission.

At this point, an immediate treatment plan needs to be put in place considering which modalities of treatment and support are to be used.  The various treatment guidelines referenced in the ‘What’s New’ section give outlines in great detail.  Both Pharmacological and Psychological  interventions should be considered.

Pharmacological Interventions

Licenced Agents:

In the USA there are only two agents which are currently (July 2011) licenced for treatment of acute bipolar depression:

  • Olanzapine-Fluoxetine  combination  (OFC
  • Quetiapine

(Lamotrigine although frequently used, is used off licence. Similarly SSRI antidepressants do not have a specific indication for bipolar depression though they have been widely used)

In the UK and Europe the following agents have a specific indication for depression in bipolar disorder

  • Quetiapine has a licence specifically for depression in bipolar disorder
  • The SSRI and other antidepressants have a licence for treatment of depression but not specifically for ‘depression in bipolar disorder’.

Lamotrigine has a licence for prevention of episodes of depression in bipolar disorder but not acute treatment of episodes of depression. It is nevertheless frequently used ‘off licence’.

“Off Licence Prescribing”

Off Licence Prescribing occurs when a treating physician uses a drug which does not have a specific licence for the indication it is being used for. In psychiatry this is done relatively commonly, for example in the use of Lamotrigine in the treatment of acute bipolar depression for which it does not have a licence but where there is some evidence to support its use.  When a drug is being used “off licence” this should be explained to the patient and the reasons for doing so discussed.