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CLINICAL SYNTHESIS   |    
Psychopharmacology of Bipolar II Depression and Bipolar Depression with Mixed Features
Honor Hsin, M.D., Ph.D.; Trisha Suppes, M.D., Ph.D.
FOCUS 2014;12:136-145. doi:10.1176/appi.focus.12.2.136
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Author Information and CME Disclosure

Honor Hsin, M.D., Ph.D., Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine

Trisha Suppes, M.D., Ph.D., Director, Bipolar Disorders Research Program, VA Palo Alto Health Care System and Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University Medical Center, Palo Alto CA

Dr. Hsin Reports no competing interests. Dr. Suppes reports the following disclosures: Grant Funding or Medication for Clinical Grants: National Institute of Mental Health, Sunovian, Elan Pharma; Consultant: Sunovian, H. Lundbeck; Royalties: Compact Clinicals; Travel: Sunovian, H. Lundbeck, Omnia Prova Education Collaborative.

Address correspondence to Dr. Suppes, Director, Bipolar Disorders Research Program, VA Palo Alto Healthcare System, 3801 Miranda Ave M.S.C.: 151T, Palo Alto CA 94304; e-mail: tsuppes@stanford.edu

Abstract

The lifetime prevalence of bipolar disorder (BD) is estimated at 1%−2%, with significant rates of associated impairment in social and occupational functioning (1, 2). Although there have been important advancements in the treatment of BD over the last few decades, most of this work has centered on BD type I, from the management of pure manic or pure depressive episodes to the maintenance of mood stability. In this article we focus on the aspects of BD that are difficult to treat clinically and that lie outside most research to date, but nonetheless represent a significant illness burden: BD II depression and BD depression with mixed features (3). We review the latest evidence-based treatment strategies and recommendations for these conditions, as well as outstanding questions that require further investigation. BD II depression raises considerations distinct from BD I depression; current evidence is strongest for quetiapine in its acute treatment and lithium for long-term maintenance, although significant gaps in our treatment knowledge remain. The appropriate role for antidepressants is still not determined for BD II depression. Similarly, BD depression with mixed features conveys clinical significance distinct from other BD mood episodes, and evidence suggests that antidepressant use should be monitored more closely in this context. Further research is needed to improve our phenomenologic understanding of BD and to increase specificity in treatment approaches.

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Table 1.Bipolar II Depression Treatment Strategiesa
Table Footer Note

a Summary of evidence for acute and maintenance therapy of BD II depression. Strength of recommendation is indicated in the left-sided subcolumns for each main column: +, strongly recommend based on evidence; +/−, weakly recommend based on evidence; -, do not recommend based on evidence; 0, absent or little evidence available to make a recommendation; ?, limited or controversial evidence exists but not enough to make a recommendation. The primary sources of these recommendations are indicated in the corresponding right-sided subcolumns.

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Table 2.DSM–5 Specifiers for Bipolar and Related Disordersa
Table Footer Note

a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC APA 2013. Copyright © 2013, American Psychiatric Association. Used with permission.

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