management of depressive symptoms

Last edited 08/2018

Consult specialist advice.

Managing bipolar depression in adults in secondary care

Psychological interventions

• adults with bipolar depression should be offered:
  • a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence-based manual describing how it should be delivered or
  • a high-intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy)

Pharmacological interventions

• if a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder
  • then either fluoxetine combined with olanzapine, or quetiapine on its own, should be offered depending on the person’s preference and previous response to treatment
    • if the person prefers, consider either olanzapine (without fluoxetine) or lamotrigine on its own
    • if there is no response to fluoxetine combined with olanzapine, or quetiapine, consider lamotrigine on its own
      
      
• if a person develops moderate or severe bipolar depression and is already taking lithium
  • then check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the person’s preference and previous response to treatment.
    • if the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to lithium
    • if there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to lithium
      
      
• if a person develops moderate or severe bipolar depression and is already taking valproate
  • then consider increasing the dose within the therapeutic range. If the maximum tolerated dose, or the top of the therapeutic range, has been reached and there is a limited response to valproate, add fluoxetine combined with olanzapine or add quetiapine, depending on the person’s preference and previous response to treatment
    • if the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to valproate
    • if there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to valproate

Notes (2):

• valproate in women of childbearing potential
  • do not offer valproate to women of childbearing potential for long-term treatment or to treat an acute episode
  • if a woman of childbearing potential is already taking valproate, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy

Reference:

• NICE (September 2014). Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care
• NICE (April 2018). Bipolar disorder.