Drugs approved for Bipolar Depression

Question 1

second generation antipsychotics

Answer 1

First choices (for bipolar depression):

1. olanzapine-fluoxetine combination (symbyax)
2. quetiapine (seroquel XR)
3. Lurasidone (Latuda)

second choices:

1. other SGAs
2. lithium,
3. SSRIs
4. SNRIs
5. ECT

Antidepressants are only used with a mood stabilizer.

Question 2

Bipolar Depression prescribing ala Stahl

Answer 2

5HT/DA (atypical) blocker plus lamotrigine

Question 3

Bipolar Depression prescribing ala Schwartz

Answer 3

1. atypical antipsychotics (olanzapine/fluoxetine- symbyax) or quetiapine (seroquel XR), or Lurasidone (latuda).
2. lithium
3. antidepressants (off-label)
   a. SSRIs- fluoxetine, sertraline, paroxetine, escitalopram
   b. NDRI- bupropion

Question 4

Bipolar Depression prescribing per APA

Answer 4

1. lithium or lamotrigine
2. lithium plus an antidepressant
3. ECT (SI, psychosis)
4. interpersonal therapy or CBT

Question 5

Bipolar maintenance

Answer 5

1. Lithium- is better for mania than for depression.
2. lamotrigine- better for depression than mania.
3. atypical antipsychotics (also called SGAs and 5HT/DA)- are generally better with mania than depression.
4. valproic acid and carbamazepine are used if there is a history of rapid cycling.

Question 6

Olanzapine-Fluoxetine (Symbyax)

Answer 6

1. Approved for bipolar mania, treatment-resistant unipolar depression, bipolar depression, and schizophrenia.
2. 5HT2a, D2, and 5HT2c antagonist actions

Question 7

Quetiapine (Seroquel)

Answer 7

1. 5HT2a, 5HT2c, and a2 antagonism actions
2. 5HT1a agonist actions
3. D2 antagonism action
4. approved for bipolar mania, bipolar depression

Question 8

Importance of D3 antagonism (theoretical)

Answer 8

Antagonism/partial agonism of D3 receptors in the ventral tegmental area can increase dopamine release in the prefrontal cortex. Because there are no D3 receptors in the prefrontal cortex, D3 antagonists/partial agonists have no effect there. Dopamine is free to stimulate D1 receptors, hypothetically improving symptoms of depression (Stahl, 2021 p. 345).