Mood stabilizers are usually effective in treating acute mania. Treating bipolar depression, however, is often more challenging for two reasons:

1. Antidepressants tend to be less effective in treating bipolar depression than in treating unipolar depression, especially in people who have the Bipolar I diagnosis (characterized by severe episodes of depression alternating with manic episodes).
2. Antidepressants carry some risk of unmasking mania in people who are prone to it, especially people who have the Bipolar I diagnosis.

Because depression is often the “pole” of bipolar that causes the most misery and carries the highest risk for suicide, it’s essential that we have a safe and effective way to treat it. Unfortunately, no single solution is safe and effective for everyone. In this post, we explore four options:

1. An antidepressant alone
2. A mood stabilizer alone
3. A mood stabilizer with an antidepressant
4. Non-medication therapies

Treating Bipolar Depression with an Antidepressant Alone

When someone visits the doctor reporting depression and has no history of elevated mood or family history of bipolar, the doctor usually prescribes an antidepressant alone. If you carry a bipolar diagnosis other than Bipolar I – in other words, you’ve experience depression but never had a manic or mixed (depression and mania) episode – treating your depression with an antidepressant may be a reasonable approach.

Discuss this option with your doctor, and be sure to address the possibility of manic switching – triggering a manic episode when treating depression. Ask your doctor to describe any symptoms of manic switching you should be aware of. This way, if you start to cycle into mania, you’ll be more sensitive to the warning signs. (Have a close friend or family member help you watch for the warning signs, because you may not recognize them yourself.)

Treating Both Poles with a Mood Stabilizer

Ideally, a mood stabilizer does exactly what its name implies; it stabilizes your moods so you feel good – neither manic nor depressed. And in a subset of people with bipolar disorder, this treatment works perfectly. A few mood stabilizers have proven more effective than others in treating both mania and depression:

1. Lithium: Lithium prevents both poles of the disorder from appearing, and people can manage well as long as they take their medication. (Unfortunately, lithium doesn’t work or keep working for everyone.)
2. Lamictal: Lamictal is another mood stabilizer that often has a good antidepressant effect. It is an anticonvulsant (used primarily to treat seizures) that has been approved for the treatment of bipolar disorder – specifically to prevent recurrence of mood cycles.
3. Seroquel: The atypical agent quetiapine (Seroquel) has recently been approved for the treatment of bipolar depression, and therefore it could treat both poles of bipolar disorder in some people.

Note: The antimanic agent divalproic acid (Depakote or Depakene) has not been shown to have an antidepressant effect.

Combining an Antidepressant with a Mood Stabilizer

Doctors often prescribe a mood stabilizer in combination with an antidepressant for one of the following reasons:

1. The mood stabilizer alone is ineffective in treating the depression.
2. You’re in a high-risk group for experiencing a manic switch on an antidepressant alone, so the doctor wants to reduce the risk by adding a mood stabilizer.
3. Antidepressants alone seem to be ineffective in treating your depression.

One of the few medications that contains both an antimanic and an antidepressant in a single pill is Symbyax, which combines the antidepressant fluoxetine (Prozac) with olanzapine (Zyprexa) in one capsule. This medication has FDA approval to treat bipolar depression.

Without the benefit of a combination pill, doctors often combine antidepressants with atypical mood stabilizers such as risperidone (Risperdal) and Aripiprazole (Abilify).

The jury is still out on how effective these mood stabilizer + antidepressant treatments really are. You’ll need to work closely with your doctor to develop a treatment plan that’s effective for you.

Exploring Non-Pharmaceutical Options

Beyond all of the medication managing and adjusting, non-medication treatments are just as essential to the management of all types of bipolar disorder. Recent large studies have shown significant improvement in quality of life and function with the addition of some type of structured and intensive psychosocial interventions – such as Cognitive Behavioral Therapy (CBT), Interpersonal Rhythm Therapy (IRT), or family-focused therapy.

Don’t get lost in the maze of medication treatments to the exclusion of these and other forms of treatment.

This is Part I of our three-part series on the challenges of treating bipolar depression. In Parts II and III, we will be answering two often-asked questions: “Is my antidepressant making me manic?” and “How effective are antidepressants in treating bipolar depression?” Stay tuned.