Antipsychotic choice for bipolar depression
When choosing an antipsychotic for bipolar depression, discuss the following with the patient and, if they consent, their family, carers or significant others:
- the purpose of antipsychotic therapy and its place in multimodal treatment
- which antipsychotic adverse effects are acceptable to the patient and how these effects are monitored, prevented and addressed
- the importance of treatment adherence; poor adherence is a cause of relapse.
Antipsychotic choice must balance efficacy and tolerability (consider both short- and long-term adverse effects). Choice should be guided by the adverse effect profile and whether these are acceptable to the patient. Metabolic disturbance is associated with antipsychotic treatment, particularly olanzapinePillinger 2020. Young people in particular are at risk of antipsychotic adverse effects including extrapyramidal adverse effects, effects due to elevated blood prolactin concentration, and weight gain. Consider the cost and accessibility of drugs to patients (see also Off-label prescribing for psychiatric disorders.
Establish baseline values of parameters that can be affected by antipsychotic therapy—see Baseline parameters potentially affected by antipsychotic therapy. Dosage should be guided by response to therapy and tolerability (regularly monitor for adverse effects). Slower dose escalation may be required for people who are antipsychotic naive, to reduce the likelihood of antipsychotic adverse effects.
If adverse effects are suspected, lower the dose or switch to another drug with a lower propensity for adverse effects—see Switching antipsychotics.