Monotherapy for bipolar depression in adults and young people
See Overview of pharmacotherapy for bipolar depression in adults and young people for a discussion of the choice between monotherapy or combination therapy for bipolar depression, drug choice and use in specific populations (eg pregnant people, young people).
When using an antipsychotic, slower dose escalation may be required for people who are antipsychotic naive, to reduce the likelihood of antipsychotic adverse effects.
For monotherapy treatment of bipolar depression, use:
1 cariprazine 1.5 mg orally, daily; depending on clinical response and tolerability, the dose may be increased after 2 weeks to 3 mg daily. Maximum daily dose of 3 mg daily. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is requiredRANZCP 2020 guideline bipolar disorder, depressive episode cariprazine cariprazine cariprazine
OR
1 lamotrigine 25 mg orally, at night for 2 weeks; increase to 50 mg at night for 2 weeks; increase to 100 mg at night for 1 week; increase to 200 mg at night. Maximum daily dose of 400 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required bipolar disorder, depressive episode lamotrigine lamotrigine lamotrigine
OR
1 lithium carbonate immediate-release 500 to 750 mg orally, daily, in 2 or 3 divided doses or as a single dose at night—divided doses may improve tolerability whereas once-daily dosing may improve adherence. After 5 to 7 days of treatment, determine lithium blood concentration. Target a concentration of 0.6 to 0.8 mmol/L, depending on clinical response and tolerability; concentrations of 0.4 to 1.0 mmol/L may be effective in some patients. A lower lithium concentration (0.4 to 0.6 mmol/L) may be required in patients 60 years or older because of poorer tolerability. Adjust daily dose in increments of 250 to 500 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required1234 bipolar disorder, depressive episode, monotherapy lithium lithium lithium
OR
1 lithium carbonate modified-release 450 to 675 mg orally, daily, in 2 divided doses or as a single dose at night—divided doses may improve tolerability whereas once-daily dosing may improve adherence. After 5 to 7 days of treatment, determine lithium blood concentration. Target a concentration of 0.6 to 0.8 mmol/L, depending on clinical response and tolerability; concentrations of 0.4 to 1.0 mmol/L may be effective in some patients. A lower lithium concentration (0.4 to 0.6 mmol/L) may be required in patients 60 years or older because of poorer tolerability. Adjust daily dose in increments of 225 to 450 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required1234 lithium lithium lithium
OR
1 lurasidone 20 mg orally, daily; titrate to response and tolerability. Maximum daily dose of 120 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required bipolar disorder, depressive episode, monotherapy lurasidone lurasidone lurasidone
OR
1 olanzapine 5 mg orally, daily; titrate to response and tolerability. Maximum daily dose of 20 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required bipolar disorder, depressive episode, monotherapy olanzapine olanzapine olanzapine
OR
1 quetiapine immediate-release 50 mg orally, at night on the first day; increase to 100 mg at night on the second day; increase to 200 mg at night on the third day; increase to 300 mg at night on the fourth day; then titrate to response and tolerability. Maximum daily dose of 600 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required bipolar disorder, depressive episode, monotherapy quetiapine quetiapine quetiapine
OR
1 quetiapine modified-release 50 mg orally, at night on the first day; increase to 100 mg at night on the second day; increase to 200 mg at night on the third day; increase to 300 mg at night on the fourth day; then titrate to response and tolerability. Maximum daily dose of 600 mg. Continue for at least 6 to 12 months to prevent relapse, then assess if prophylaxis is required. quetiapine quetiapine quetiapine
Response to treatment usually becomes apparent after at least 1 week (except for lamotrigine, which takes longer given the slower dose titration); full benefit may take 4 to 6 weeks, or even longer. If there is no response to monotherapy within this timeframe, see Nonresponse to treatment for bipolar depression
If there is an acceptable response, continue treatment for at least 6 to 12 months to prevent relapse, then assess if prophylaxis of bipolar disorder is required.