Treatment for bipolar depression: New studies

Depression in bipolar disorder is a condition that lasts longer than mania and causes more suffering and disability. Because the symptoms of bipolar depression often combine despair with agitation and impulsiveness, it is an important cause of suicide. It also raises the risk of death from cardiovascular disease and other causes.

Bipolar depression is often difficult to diagnose, and even when correctly diagnosed, difficult to treat. In studies published in 2007, researchers have learned more about the limitations of drug treatments while finding evidence for the effectiveness of intensive psychotherapy.

Common drug treatments for acute bipolar depression are lithium and the anticonvulsant lamotrigine (Lamictal). To prevent depression from returning after recovery, clinicians may continue to prescribe these drugs and add others, including antipsychotic drugs. When depression does not respond to medications, electroconvulsive therapy (ECT) is an alternative—despite the bad press about it, ECT is a fairly safe and very effective treatment.

Fluoxetine (Prozac) and other antidepressants provide another option. Although the FDA has approved a combination of olanzapine and fluoxetine for bipolar depression, the effectiveness and safety of antidepressants in bipolar disorder are still disputed. Many experts fear that they can cause patients to switch from depression to mania.

Results from a study published in the New England Journal of Medicine in the spring of 2007 suggest that neither the hopes nor the fears are justified. Among 366 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) who were treated for six months with lithium and other mood stabilizers, adding either of two antidepressants — bupropion (Wellbutrin) or paroxetine (Paxil) — had no more effect on depression than adding a placebo. On the other hand, patients taking these drugs were no more likely to develop mania than patients taking a placebo.

This trial was conducted under more realistic conditions than most. The researchers included patients more characteristic of the general population. Subjects had different types of bipolar disorder, and some had additional diagnoses, such as anxiety or addictive disorders. The patients could continue any treatment they were already receiving and they were allowed to reject any antidepressant they did not want to take. In many studies, the outcome is judged by changes on a symptom rating scale; in this trial, recovery was defined as euthymia (absence of mood symptoms) for two months. The unusual study design may help to explain why the results contradict earlier research suggesting that antidepressants can be effective in bipolar depression.

Intensive psychotherapy, in contrast, got good marks in a study in the April 2007 issue of the Archives of General Psychiatry. Nearly 300 patients were divided into four groups. Three of the groups were given different kinds of intensive psychotherapy — up to 30 sessions in nine months. The fourth group received three sessions in six weeks of what the authors called collaborative care, that is, education about the illness and its treatment. All patients took mood stabilizers and some took antidepressant medication.

The intensive treatments were cognitive behavioral therapy, which concentrated on problem-solving, scheduling, stress management, and correction of self-defeating thoughts; interpersonal and social rhythm therapy, which addressed problems in personal relationships and disrupted social and biological routines; and family-focused therapy, which helped relatives to improve their communication with the patient, avoid creating stress that provokes symptoms, and develop plans to prevent relapse. Psychotherapy patients also received the equivalent of collaborative care — information about the disorder and the need to take medications, relapse prevention planning, and lessons in illness management.

The three intensive treatments were equally effective, and all three were more effective than collaborative care alone. Patients receiving intensive therapy recovered, on average, a month sooner, and they were about 60% more likely to be well in any given month of the study.

The authors point out that the advantage of intensive psychotherapy might have been due to more contact with a mental health professional rather than to any specific features of the treatments. They add that future research must consider costs and benefits. Intensive treatments are expensive, but so are the consequences of continued bipolar depression.

Have you had experience dealing with treatments for the depression that can occur in bipolar disorder?

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