Patients not taking antimanic medication

Patients who are prescribed an antidepressant should also be prescribed an antimanic drug. Base the choice of antimanic drug on:

• decisions about future prophylactic treatment

• likely side effects

• whether the patient is a woman of child-bearing potential.

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When starting an antidepressant:

• explain the risks of switching to mania and the benefits of taking an adjunctive antimanic agent

• monitor carefully people who are unwilling to take an antimanic drug

• start the antidepressant treatment at a low dose and increase gradually if necessary.

 

Patients taking antimanic medication

Check the patient is taking the antimanic drug at the appropriate dose and adjust it if necessary.
 

Patients with mild depressive symptoms

Arrange a further assessment, normally within 2 weeks, if:

• The patient’s previous episodes of mild depression have not developed into chronic or more severe

depression, or

• A more severe depression is not likely.

If symptoms do not improve, follow the advice for moderate or severe depression.
 

Patients with moderate or severe depressive symptoms
Consider:

• prescribing an SSRI (but not paroxetine in pregnant women), or

• adding quetiapine, if the patient is already taking an antimanic drug that is not an antipsychotic.

For moderate depression, if there is no significant improvement after an adequate trial of drugs,
consider a structured psychological therapy focused on depressive symptoms, problem solving,
improving social functioning, and medication concordance.
 

 Do not use routinely:

• lamotrigine* as a single first-line drug in bipolar I disorder

•  transcranial magnetic stimulation*.

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Antidepressant treatment and risk monitoring
 Avoid antidepressants for patients who have:

•  rapid-cycling bipolar disorder

•  a recent hypomanic episode

•  recent functionally impairing rapid mood fluctuations.

Instead, consider increasing the dose of the antimanic drug or adding a second one (including
lamotrigine*).


Starting antidepressants
Address patients’ concerns about taking antidepressants; for example, craving and tolerance do
not occur.
When starting antidepressant treatment, tell patients:

• manic or hypomanic switching may occur

• onset of effect is not immediate, and improvement is gradual and fluctuating

• about the need to take medication as prescribed and the risk of discontinuation/withdrawal symptoms

• to look out for signs of akathisia, suicidal ideation (normally anyone under 30 should be reviewed

• within 1 week of initiation of treatment), and increased anxiety and agitation (particularly at the beginning of treatment)

• to seek help promptly if side effects are distressing.

• If a patient develops marked and/or prolonged akathisia or agitation while taking an antidepressant,urgently review the use of the drug.

• Take care when prescribing SSRIs to people – particularly older people – taking medication that can cause intestinal bleeding, such as non-steroidal anti-inflammatory drugs (NSAIDs). Consider using a gastroprotective drug.

Stopping antidepressants after an episode
If a patient is in remission from depressive symptoms, or symptoms have been significantly less for
8 weeks, consider stopping the antidepressant by reducing the dose gradually (particularly with
paroxetine and venlafaxine) over several weeks, while maintaining the antimanic medication.
Incomplete response to treatment for acute depression
If symptoms do not fully respond to an antidepressant, reassess for substance misuse, psychosocial
stressors, physical health problems, comorbid disorders such as anxiety or severe obsessional
symptoms, and poor adherence.

Then consider:

• increasing the dose of the antidepressant within ‘BNF’ limits

• individual psychological therapy focused on depressive symptoms

• switching to a different antidepressant, such as mirtazapine or venlafaxine

• adding quetiapine* or olanzapine, if the patient is not already taking them, or

• adding lithium if the patient is not already taking it.

 

If symptoms fail to respond to at least three adequate courses of antidepressant treatment, consider

referring to (or seeking advice from) a specialist in bipolar disorder.

 For persistent depressive symptoms in patients with no recent history of rapid cycling (including those
not taking an antidepressant), consider structured psychological therapy.

Concurrent depressive and psychotic symptoms
For concurrent depressive and psychotic symptoms, consider augmenting treatment with an
antipsychotic such as olanzapine, quetiapine or risperidone, or using electroconvulsive therapy
if depression is severe.