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.This algorithmshould be utilized in conjunction with the primary treatment algorithm formania/hypomania.If a patient reports symptoms of depression significant enough towarrant intervention, the clinician is directed to utilize this algorithm as a concomitanttreatment strategy, in addition to any stage of treatment within the mania/hypomaniaalgorithm.As with any algorithm, if insufficient response in depressive symptoms isachieved, the clinician should continue through the algorithm until satisfactory symptomreduction is achieved.It is important to consider carefully the addition of anantidepressant to a bipolar patient s medication regimen.If the patient presents with a pure bipolar major depressive episode, without mood lability or hypomania, thedecision is relatively clear, as the degree of suffering will justify initiating anantidepressant.However, many patients will have significant depressive symptoms, butalso periods of dysphoric hypomania, mood lability, irritability, and other complicatedstates.Patients may need both a mood stabilizer and an antidepressant.The balancing of Atlas of bipolar disorders 124optimizing mood stabilizers, possibly adding lithium, or adding an antidepressant, mustbe done on a case-by-case basis.The algorithm to treat bipolar depression assumes that antidepressants will only beused in conjunction with a moodstabilizing medication, because of the risk of inducingmanic symptoms.It may be necessary to adjust the mood stabilizer during treatment (i.e.increasing the dose with development of irritability or mood lability).In some cases itmay be clinically indicated to switch or combine mood stabilizers (i.e.if an effectiveantidepressant is found and continued need for the medication is provided, but the drug isassociated with mild mood lability).It is expected that the physician will continue toutilize recommendations of the hypomania/mania algorithm even when prescribingantidepressant treatment.Selection of a specific antidepressant medication should be made based on individualfactors such as the expected sideeffect profile, potential toxicity, concomitant medicalproblems, and medications.The initial algorithm stages focus on anti-depressantmonotherapy with medications associated with favorable risk-benefit ratios and for whichthere is evidence of efficacy in bipolar patients.Stage The first stage includes initiating and/or optimizing mood-stabilizing medications.The1 recommendation is that all patients diagnosed with bipolar I disorder be prescribedantimanic medications, using the algorithm for treatment of mania/hypomania.Thecommittee made explicit the recommendation that optimizing mood-stabilizing medicationsmight mean either an increase or a decrease in dosing, although no data are available todirect tactics clearly on this issue.Stage Patients entering Stage 2 of the algorithm should have a major depressive episode of2 sufficient severity to merit medication treatment.Stage 2 includes the addition of a selectiveserotonin reuptake inhibitor (SSRI), bupropion SR, or lamotrigine to existing medications.The SSRI options are open, and include fluoxetine, paroxetine, sertraline, fluvoxamine, andcitalopram.Bupropion SR is an additional option (the committee recommended thesustained-release version of bupropion, due to improved tolerability).While there is a riskof rash with lamotrigine, there are positive Level A data in support of its efficacy fortreatment of bipolar depression.Stage At this point, the algorithm begins to rely more heavily on clinical consensus and expert3 opinion, as there are only limited data on treatment of bipolar depression following failurein Stage 2.The algorithm development philosophy was that when there are several optionsavailable, with little or no empirically derived reason to rank them, choices should beoffered so that the clinician and patient can choose what is best for that individual.Therefore, Stage 3 offers the clinician and patient several options, including addition oflithium, switching to an alternative antidepressant medication (adding venlafaxine andnefazodone as additional options), or adding from Stage 2 options a second antidepressantor lamotrigine.If Stage 2 treatment was unsuccessful primarily because of intolerable side-effects, consider selecting an antidepressant from a different class with a contrasting side-effect profile (e.g.if the patient experienced sexual dysfunction on an SSRI, considerbupropion SR or nefazodone).Stage This stage includes the combination of two antidepressant medications.This includes4 selection from the SSRI group, bupropion SR, and lamotrigine.In choosing anantidepressant combination, it is recommended to use medications from different classes(i.e.not two SSRIs).The goal of combination antidepressant regimens is to combinemedications to enhance clinical response.In general, because of the potential for druginteractions, anti depressant combination treatment should be used carefully, and patients Treating bipolar disorders 125monitored closely.Stage This stage includes changing the antidepressant medication to an MAOI, or adding an5 atypical antipsychotic medication.Because of potential health risks and the need to followspecial dietary restrictions and avoid certain medications, MAOIs are located in Stage 5,after medications and medication combinations with fewer Level A and B data.Diet-restriction guidelines should be provided to all patients receiving MAOI medications.Stage Recommendations at this stage include using the alternative not used in Stage 5, ECT, or6 Other.The Other category is exploratory, and includes a number of options to beconsidered in addition to partially effective medication combinations.It includes inositol,dopamine agonists, stimulant medications, thyroid, conventional Atlas of bipolar disorders 126Algorithm 3antipsychotics, tricyclic antidepressants, omega 3, acupuncture and hormones.Consultation withthe module director, Dr Suppes, is available if a clinician is considering treatment from Stage 7for a patient who achieved no or partial response to all other algorithm options.Reproduced with permission from reference 25Algorithm 4 Algorithm for adult mania/hypomania.This is the primary treatmentalgorithm [ Pobierz całość w formacie PDF ]