What medication could be used in a patient with depression and a possible past history of manic episodes?

From the Guidelines

For a patient with depression and a possible past history of manic episodes, a mood stabilizer combined with an antidepressant would be the most appropriate treatment approach, with lithium or valproate being the preferred mood stabilizers, as recommended by the WHO guidelines 1. When considering treatment options, it is essential to prioritize mood stabilization to prevent manic episodes.

• Lithium, valproate (Depakote), or lamotrigine (Lamictal) are first-line mood stabilizers that can effectively treat both depressive symptoms and prevent manic episodes.
• According to the WHO guidelines 1, lithium or valproate should be used for the maintenance treatment of bipolar disorder, and treatment with lithium should be initiated only in those settings where personnel and facilities for close clinical and laboratory monitoring are available.
• When adding an antidepressant, selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily) or fluoxetine (20-80 mg daily) are often used, but they should only be initiated after mood stabilization is achieved, as recommended by the WHO guidelines 1.
• Alternatively, quetiapine (300-600 mg daily) or lurasidone (20-120 mg daily) can be used as monotherapy as they have both antidepressant and mood-stabilizing properties.
• Close monitoring for signs of mood switching is essential, especially during the first few weeks of treatment, as patients with both depression and a history of mania likely have bipolar disorder, and treating with antidepressants alone significantly increases the risk of triggering manic episodes, as noted in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1.
• The treatment should be continued for at least 6-12 months after symptom resolution, with gradual tapering if discontinuation is considered.

From the FDA Drug Label

Quetiapine fumarate tablet is indicated for the acute treatment of manic episodes associated with bipolar I disorder, both as monotherapy and as an adjunct to lithium or divalproex Quetiapine fumarate tablet is indicated as monotherapy for the acute treatment of depressive episodes associated with bipolar disorder. Efficacy was established in two 8-week monotherapy trials in adult patients with bipolar I and bipolar II disorder

Quetiapine could be used in a patient with depression and possible past history of manic episodes, as it is indicated for the treatment of depressive episodes associated with bipolar disorder and has established efficacy in patients with bipolar I and II disorder 2.

• It is essential to carefully evaluate the patient's diagnostic profile and consider the risks associated with medication treatment.
• Quetiapine may be used as monotherapy for the acute treatment of depressive episodes associated with bipolar disorder.

From the Research

Medication Options for Depression with Possible Past History of Manic Episodes

• Quetiapine is an option for patients with bipolar depression, as it has been shown to be effective in two pivotal trials (BOLDER I and II) with no increased risk of switching into mania 3.
• Lamotrigine may not be the best option, as it can induce manic episodes in some cases, particularly in patients with bipolar I disorder, manic predominant polarity, or a history of antidepressant manic switch 4.
• Aripiprazole, asenapine, carbamazepine, olanzapine, and ziprasidone have shown efficacy in acute-phase treatment of mixed mania/hypomania 5.
• Quetiapine and divalproex/valproate are also efficacious in treating mixed mania/hypomania, and combination therapies with these atypical antipsychotics and mood stabilizers can be considered in severe cases 5.
• Lithium and lamotrigine may be beneficial in preventing depressive relapse, but lithium's effectiveness may be reduced in patients with a history of multiple depressive or manic episodes 6.

Considerations for Treatment

• The patient's history of depressive and manic episodes should be taken into account when selecting a medication, as some medications may be more effective or have a higher risk of inducing manic episodes in certain patients 4, 6.
• Atypical antipsychotics, such as quetiapine and olanzapine, have been shown to have mood-stabilizing and antidepressant properties, making them a potential option for patients with bipolar disorder 3, 5, 7.