Medicating mood with maintenance in mind: bipolar depression pharmacotherapy

Authors

  • Gin S Malhi,

    1. CADE Clinic, Department of Psychiatry, Royal North Shore Hospital
    2. Northern Sydney Central Coast Mental Health Drug and Alcohol Services (NSCCAHS)
    3. Discipline of Psychological Medicine, University of Sydney, Sydney, NSW
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  • Danielle Adams,

    1. CADE Clinic, Department of Psychiatry, Royal North Shore Hospital
    2. Northern Sydney Central Coast Mental Health Drug and Alcohol Services (NSCCAHS)
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  • Michael Berk

    1. Melbourne University, Barwon Health and the Geelong Clinic
    2. Orygen Research Centre
    3. Mental Health Research Institute, Melbourne, Victoria, Australia
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  • As the Guest Editor of this supplement, GSM did not participate in any editorial decisions to accept or reject this paper or in choosing any referees, which was overseen by the Editors, who had no conflicts of interest in adjudicating this manuscript. In the past three years, GSM has served on a number of international and national pharmaceutical advisory boards, received funding for research and has been in receipt of honoraria for talks at sponsored meetings worldwide involving AstraZeneca, Eli Lilly & Co., Jansen-Cilag, Organon, Pfizer, Sanofi-Aventis, Servier, and Wyeth. MB has received funding for research from the Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, the Geelong Medical Research Foundation, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Organon, Novartis, Mayne Pharma, Servier, and AstraZeneca; has received honoraria for speaking engagements from AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Cilag, Lundbeck, Organon, Pfizer, Sanofi Synthelabo, Solvay, and Wyeth; and has served as a consultant to AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Janssen Cilag, Lundbeck, and Pfizer. DA has no competing interests to report.

Corresponding author:
Professor Gin S. Malhi
Department of Psychiatry, University of Sydney
CADE Clinic, Level 5, Building 36
Royal North Shore Hospital
St Leonards, NSW 2065
Sydney, Australia
Fax: +61 2 9926 7730
e-mail: gmalhi@med.usyd.edu.au

Abstract

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 a 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 PsychINFO) 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 a 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.

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