New Treatment Guidelines for Bipolar I Depression ?

Q.Based on the quality of available data, the authors classified evidence for each agent used to treat bipolar depression. Drugs meeting category 1 evidence had randomized, placebo-controlled trials in acute bipolar depression and in long-term treatment of both depression and mania. Category 2 evidence consisted of randomized, placebo-controlled trials in acute bipolar depression or in long-term treatment of either depression or mania, while category 3 evidence had randomized controlled trials in any phase of bipolar disorder treatment.

A.Bipolar depression is often underdiagnosed or misdiagnosed as unipolar depression. Antidepressant monotherapy continues to be the most common treatment for bipolar I depression throughout the world despite the lack of evidence showing efficacy, according to a study by Ghaemi and colleagues, published in the July 2001 issue of the Journal of Clinical Psychiatry. Indeed, antidepressants, alone or in combination with lithium, may induce rapid cycling or mania in bipolar I patients. A study by Gyulai and colleagues, published in the July 2003 issue of Neuropsychopharmacology, showed that antidepressant monotherapy is significantly less effective at preventing depressive relapse than an antidepressant-mood stabilizer combination. Treatment guidelines such as those from the American Psychiatric Association now recommend avoiding antidepressant monotherapy for bipolar depression. The International Consensus Group on Bipolar I Depression met in December 2003 to develop international treatment guidelines based on currently available evidence from randomized, placebo-controlled, double-blinded clinical trials of pharmacotherapy. The group agreed that bipolar disorder is a chronic condition that requires lifelong treatment, and that both acute and long-term safety and efficacy should be considered when selecting first-line treatments. In addition, the group stressed that therapy should be tailored to individual patient needs and response to previous therapy. Although limited in quality, the research supported the efficacy of lithium over placebo in bipolar depression. Outcome measures that have been examined include symptom relief, return to premorbid functioning, and several depression rating scales. Lamotrigine was found to be superior to placebo for the outcomes of improvement on several depression scales, proportion of patients who were intervention-free (including use of antidepressants and ECT) for depressive episodes, and time to intervention for any depressive episode.

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