Manning J Sloan
Moses Cone Family Practice Residency, University of North Carolina, Greensboro, NC, USA.
Prim Care Companion J Clin Psychiatry. 2005;7(6):259-67. doi: 10.4088/pcc.v07n0601.
Bipolar depression is the underrecognized and unappreciated phase of bipolar disorder. Nevertheless, bipolar depression is responsible for much of the morbidity and mortality associated with the disorder. Depressive symptoms are far more prevalent than hypomanic or manic symptoms in bipolar patients, and they are associated with a heavier burden of illness, including reduced functioning, increased risk of suicidal acts, and high economic costs. Because most patients with bipolar disorder present with depression, misdiagnoses of major depressive disorder are common, even typical. Comorbid psychiatric disorders are also prevalent and may obscure the diagnosis and complicate treatment strategies. Depressed patients should be carefully assessed for manic or hypomanic symptoms to help reveal possible bipolar disorder. In addition to evaluation of psychiatric symptoms, a close examination of family history, course of illness, and treatment response will aid the clinician in making an accurate diagnosis. Treatment of acute depression in bipolar patients may require therapy combining agents such as lithium, divalproex, lamotrigine, carbamazepine, and atypical antipsychotics or using such agents in combination with an anti-depressant. Olanzapine/fluoxetine combination is the only medication currently approved for the treatment of bipolar depression. Antidepressant monotherapy should not be used, because there is evidence that such treatment increases the risk of switching into mania/hypomania and could induce treatment-refractory conditions such as mixed or rapid-cycling states. Maintenance therapy will be required by most patients, since discontinuation of mood stabilizers or antidepressants frequently leads to relapses in depressive symptoms. Prompt diagnosis and the use of specific therapeutic agents with evidence of efficacy may help reduce the disease burden associated with bipolar depression.
双相抑郁是双相情感障碍中未得到充分认识和重视的阶段。然而，双相抑郁是该疾病相关的许多发病率和死亡率的原因。在双相情感障碍患者中，抑郁症状比轻躁狂或躁狂症状更为普遍，并且它们与更重的疾病负担相关，包括功能下降、自杀行为风险增加和高昂的经济成本。由于大多数双相情感障碍患者表现为抑郁，重度抑郁症的误诊很常见，甚至很典型。共病的精神障碍也很普遍，可能会掩盖诊断并使治疗策略复杂化。对于抑郁患者，应仔细评估其躁狂或轻躁狂症状，以帮助揭示可能的双相情感障碍。除了评估精神症状外，仔细检查家族史、病程和治疗反应将有助于临床医生做出准确诊断。双相情感障碍患者急性抑郁的治疗可能需要联合使用锂盐、丙戊酸、拉莫三嗪、卡马西平和非典型抗精神病药物等药物进行治疗，或者将这些药物与抗抑郁药联合使用。奥氮平/氟西汀组合是目前唯一被批准用于治疗双相抑郁的药物。不应使用抗抑郁药单药治疗，因为有证据表明这种治疗会增加转为躁狂/轻躁狂的风险，并可能诱发难治性状态，如混合或快速循环状态。大多数患者需要维持治疗，因为停用心境稳定剂或抗抑郁药经常会导致抑郁症状复发。及时诊断并使用有疗效证据的特定治疗药物可能有助于减轻与双相抑郁相关的疾病负担。
