Depression in bipolar disorder (BD) is the major residual psychiatric morbidity with available treatments, accounting for three-quarters of the 40–50% long-term time-ill |
Unresolved morbidity, and especially depression, is associated with excess medical morbidity, including metabolic syndrome and cardiovascular disease, with increased mortality |
Suicide risk in BD is similar in types I and II BD, greater than in most other psychiatric disorders, ca. 20-times above general population rates, and strongly associated with depression, especially with agitation (mixed-dysphoric states), and in the days–weeks following hospital discharge |
Predicting suicide in BD clinically is limited regarding individuals and timing |
Treatments proposed to prevent suicidal behavior in BD include lithium, clozapine, and possibly ketamine and psychotherapies, which all require further study |
Therapeutics of bipolar depression is far less well developed than for nonbipolar major depression, probably reflecting lack of recognition of differences between bipolar and unipolar depression |
The short-term value and safety of antidepressant treatment for bipolar depression remains controversial, and long-term value remains virtually untested; it is best avoided with ongoing dysphoric agitation or mixed features |
Some modern antipsychotics are effective in bipolar depression short-term; lithium and lamotrigine have modest prophylactic value long-term but are not adequately tested short-term; other anticonvulsant mood-stabilizers have very limited evidence of short- or long-term efficacy in bipolar depression |
All available treatments for bipolar depression have risks of adverse metabolic or neurological effects; valproate and carbamazepine are also highly teratogenic |