Table 4.
Treatment of bipolar depression across practice guidelines
| Guidelines | First-line treatment | Next-step intervention | Later intervention |
|---|---|---|---|
| KMAP-BP 201412 | Mild to moderate: MS, MS + AAP, AAP + LTG | Mild to moderate: AAP, LTG, add AAP or MS or LTG, change AAP | Add or change AAP or MS or LTG or AD, add stimulant or thyroid hormone, buspirone, ECT, or CLZ |
| Nonpsychotic severe: MS + AAP, LTG + AAP, MS + AD | Nonpsychotic severe: add AAP or MS or LTG or AD, change MS to LTG | ||
| Psychotic: AAP + (MS or LTG or AD), AAP + MS + LTG, AAP + AD + MS (or LTG) | Psychotic: add MS or LTG or AD, change AAP, change MS to LTG | ||
| BAP 200913 | Mild and/or previous mood instability: QTP or LTG | Add antimanic agent if BP-I | |
| Moderate: QTP or LTG, SSRI or other AD (not TCA) | |||
| Consider ECT in severe depression | |||
| CANMAT 201314 | Li, LTG, QTP, QTPXR, Li or Val + SSRI, OLZ + SSRI, Li + Val, Li or Val + BUP | Val, lurasidone, QTP + SSRI, Li or Val + LTG, adjunctive MDF, Li or Val + lurasidone | CBZ, OLZ, ECT, Li + CBZ, Li + pramipexole, Li or Val + VEN, Li + MAOI, Li or Val or AAP + TCA, Li or Val or CBZ + SSRI + LTG, QTP + LTG |
| NICE 201415 | Without AM: OLZ + FX, QTP, OLZ, LTG | Adding LTG | |
| With MS: optimization, adjunctive OLZ + FX, adjunctive QTP, adjunctive OLZ, adjunctive LTG | |||
| WFSBP 201017 | QTP, adjunctive QTP, OFC, OLZ, LTG, LTG + Li, Val | Optimization of first-line treatment, QTP, add CBZ, Li, MDF + Li/Val/ADs, ECT |
Abbreviations: KMAP-BP 2014, Korean Medication Algorithm Project for Bipolar Disorder 2014; BAP 2009, The British Association for Psychopharmacology Guidelines for Treatment of Bipolar Disorder 2009; CANMAT 2013, Canadian Network for Mood and Anxiety Treatments Clinical Guidelines for the Management of Patients with Bipolar Disorder 2013; NICE 2014, National Institute for Health and Clinical Excellence Clinical Guideline for Bipolar Disorder 2014; WFSBP 2010, World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Bipolar Disorder 2010 (treatment of acute bipolar depression); MS, mood stabilizer; AAP, atypical antipsychotic; LTG, lamotrigine; AD, antidepressant; ECT, electroconvulsive therapy; CLZ, clozapine; QTP, quetiapine; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; BP-I, bipolar I disorder; Li, lithium; QTPXR, quetiapine XR; Val, various kinds of valproic acids; OLZ, olanzapine; BUP, bupropion; MDF, modafinil; CBZ, carbamazepine; VEN, venlafaxine; MAOI, monoamine oxidase inhibitor; AM, antimanic agents; FX, fluoxetine; OFC, olanzapine–fluoxetine combination.