Bipolar & Depression...Serious Treatment Options ?
Q.When treating patients with bipolar depression, Zajecka described a number of issues to be considered by the clinician: defining the type of bipolar disorder; choice of treatment; duration of treatment; association between antidepressant treatment and affective cycling; and managing depression in rapid-cycling bipolar and treatment-refractory patients.
A.The ideal treatment option, according to Zajecka, is a mood stabilizer which could be used to treat both phases of the illness, and the different forms of bipolar disorder, without having to utilize antidepressants that often cause or exacerbate cycle acceleration or "precipitate a rapid-cycling episode." "In the old days, lithium was our only approved treatment, but now we have divalproex sodium (Depakote) approved for use for bipolar disorder, so we have really the two gold standards," he said. "And we have quite a bit of information about carbamazepine (Tegretol), although not as much compared to the former two. The atypical neuroleptics also are playing more of an important role, not only in acute treatment but also in long-term treatment. Additionally, some newcomers, including lamotrigine (Lamictal) and possibly gaba-pentin (Neurontin) may play a role in the treatment of bipolar depression." Zajecka listed a number of antidepressants used in the management of bipolar depression: tricyclics, selective serotonin reuptake inhibitors (SSRIs), bupropion (Wellbutrin), venlafaxine (Effexor), nefazo-done (Serzone), mirtazapine (Remeron) and monoamine oxidase inhibitors (MAOIs). "Other options? We should not to forget the usefulness of electroconvulsive therapy for bipolar depression; ECT works on both phases of the illness," he said. "Certainly if someone has a mild depression with a seasonal component, phototherapy is a warranted treatment." Psychotherapy is a critical component, Zajecka added. "There are studies that show as soon as you introduce education and talk more to patients and their family members, the more you are going to increase compliance, and compliance is a big issue with this illness," he said. For very mild depressions, "waiting it out" also can be considered a treatment option. At the initiation of treatment, in particular, Zajecka recommended ruling out hypothyroidism. "I cannot tell you how many times I have patients come into my office who have been on lithium for five or six years, yet their physicians had not checked their thyroid levels. These patients were so severely hypothyroid that they looked depressed. In actuality, a lithium-induced hypothyroid state had occurred. So if any of your patients, particularly those on lithium, get depressive symptoms, check thyroid functioning," he said. Another key element of treatment is to review prior treatment responses and failures and side effects, Zajecka said. Consideration must also be given to the type of depression the patient is experiencing. "If you have a psychotic bipolar depressed patient, you might want to use an antidepressant and neuroleptic or ECT," he said. "Also, alone or in combination, divalproex has been shown in schizoaffective patients, particularly refractory ones, to be very effective when there is psychosis involved with the depression."
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