Table 6.

Medications for Acute Bipolar Depression^a

	Agent	Target Dose	Notable Adverse Effects	Notes
First-line treatments	Quetiapine	300–600 mg/d	Sedation, weight gain, less commonly EPS	Titrate immediate-release form over 6 days
	Olanzapine/fluoxetine combination	Olanzapine 6–12 mg/fluoxetine 25–50 mg	Sedation, weight gain, less commonly EPS	…
	Lamotrigineb	200 mg/d	Stevens-Johnson syndrome, especially with enzyme-inhibiting medications (eg, divalproex)	Titrate to target dosage based on schedule appropriate for coadministered medications (see package information)
Second-line treatments	Lithiumb	Sufficient for blood level of 0.6–1.2 mEq/L; usual dose 900–1,800 mg	Sedation, dry mouth, polyuria; more rarely kidney or thyroid failure	…
	Divalproexb	Titrate rapidly to a blood level of 85–125 μg /mL; up to 60 mg/kg	Sedation, nausea, weight gain; may cause menstrual irregularities; rare pancreatitis or liver failure	Very high risk of neural tube defects with fetal exposure; caution in women of childbearing age
	Combinations: SSRI or bupropion with SGA, lithium, or divalproexb	Antidepressants should be used only with an effective antimanic agent when treating bipolar depression	Those of constituent agents	While these combinations are a common practice, evidence of their efficacy is controversial

^aBased on Suppes et al,⁸ Malhi et al,¹⁷ Yatham et al,²⁹ Goodwin.³⁰

^bNot approved by the US Food and Drug Administration for this indication.

Symbol: … = no data.