Efficacy Vs Tolerability in Bipolar Depression

1. Recall BP II and mid-spectrum bipolarity are 2-3 times more prevalent than BP I (depending on how you count)

2. Thus, depression is the main target for most patients with bipolarity; a minority will require anti-manic prophylaxis as well

Efficacy

Olanzapine-fluoxetineHighest metabolic risk

QuetiapineMetabolic risk substantial;side effects nearly universal
(often somnogenic is helpful)

LurasidoneMetabolic risk not zero; high cost

Tolerability

LamotrigineLowest long-term risks;
no side effects for most

Low-dose lithiumPrimarily adjunctive; see previous review for PT

Sleep-regulating psychotherapyBipolar-specific CBT-I adjunctive; IP/SRT under study as monotherapy*

CBT-I, cognitive behavioral therapy for insomnia; IP/SRT, interpersonal and social rhythm therapy.

*Efficacy equal to that of quetiapine in a pilot trial by Swartz et al[3] (neither was very good, unfortunately, but still, they were equal).