Managing bipolar depression.

What should the clinician do when confronted with a patient who has depressive symptoms? Seek the proper diagnosis. Question the patient about depressive symptoms over a two-week course that interferes with social and/or occupational functioning. Determine if there is any history of mania or hypomania. Information from a significant other is extremely useful as well. Coexisting diagnoses, such as substance abuse, posttraumatic stress disorder, or medical conditions, must be ruled in or out. It is critical to include a suicide risk assessment in the evaluation. Lithium is still the gold standard for bipolar patients with its suicide preventative effects. Lamotrigine appears to have the advantage of efficacy against bipolar depression without high risk for inducing mania. Experts recommend that a mood stabilizer be used in combination with antidepressants. The tricyclic antidepressants and the monoamine oxidase inhibitors appear to have the highest risk for mania and are best avoided. Atypical antipsychotic medications are best utilized for psychotic symptoms and as adjuncts to existing antidepressants. Cognitive behavioral therapy may complement pharmacotherapy.