Principles of managing bipolar depression in adults and young people

For multifaceted management of bipolar disorder that is not restricted to an episode of depression, see Principles of managing bipolar disorder in adults and young people.

In order to recognise a depressive episode as bipolar depression, a previous episode of mania or hypomania must have occurred (see Approach to diagnosing bipolar disorder in adults and young people). Refer patients with bipolar depression to a psychiatrist, a mental health service or an acute mental health facility but do not delay treatment if prompt review is not available.

A safety assessment determines the most appropriate treatment setting. It is crucial to assess the risk of suicide in patients with bipolar depression because most suicide attempts occur during a depressive episode. Also assess the severity of depression, level of functional impairment, ability to adhere to treatments and availability of psychosocial supports. Bipolar depression is usually managed by a psychiatrist, with care delivered by a community mental health team, a shared-care program with the general practitioner, or an outpatient program. Patients with severe symptoms of bipolar depression who are a danger to themselves or others require urgent treatment in hospital1. Patients with depressive stupor need urgent psychiatric referral.

Note: Assess suicide risk in patients with bipolar depression.

The primary aim of treatment is to alleviate depressive symptoms and restore functional capacity. Pharmacotherapy is usually required for bipolar depression (unless the episode is very mild or self-limiting). Drug choice is influenced by current or previous pharmacotherapy and response, the safety and tolerability of the drug, and clinical features. Continue treatment for at least 6 to 12 months to prevent relapse, then assess if prophylaxis of bipolar disorder is required.

While pharmacotherapy is usually required for bipolar depression, psychological interventions  can be used adjunctively. Start psychological interventions during an acute bipolar depressive episode, if possible, or soon afterwards when the patient may be more able to engage with treatment. Effective interventions include cognitive behavioural therapy (CBT), interpersonal and social rhythm therapy and family-focused therapy. These interventions can result in a more rapid recovery and improved functioning. Continue psychosocial interventions after the acute depressive episode has settled, as they can help to prevent relapse and restore quality of life—see Psychosocial interventions for bipolar disorder in adults and young people.

Electroconvulsive therapy (ECT)  is reserved for acutely depressed patients or urgent situations (eg depressive stupor, psychotic symptoms, substantive suicidal thoughts).

Optimised multimodal therapy and an adequate duration of drug therapy can prevent recurrent episodes, which are associated with worse long-term outcomes. Poor treatment adherence can lead to relapse or recurrent episodes; check blood drug concentrations where relevant23. Other common causes of recurrence or relapse include substance abuse, stressful life events or sleep issues. If relapse occurs, treat according to the mood episode and consider the need for prophylaxis of bipolar disorder, in consultation with the patient’s psychiatrist.

See also the additional considerations:

1 If involuntary treatment is required, it must be undertaken in accordance with relevant mental health legislation—see the Royal Australian and New Zealand College of Psychiatrists website.Return
2 A list of Australian laboratory test databases is available at the Australasian Association for Clinical Biochemistry and Laboratory Medicine (AACB) ‘Testing for health’ website.Return
3 For information on therapeutic reference ranges of psychotropics, see Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, et al. Consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology: update 2017. Pharmacopsychiatry 2018;51(1-02):9-62. [URL]Return