Bipolar Major Depression in Adults - General Principles of Treatment - UpToDate

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Bipolar major depression in adults: General principles

of treatment
AUTHORS: William V Bobo, MD, MPH, Richard C Shelton, MD
SECTION EDITOR: Paul Keck, MD
DEPUTY EDITOR: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Mar 19, 2023.
INTRODUCTION
Bipolar disorder is marked by episodes of mania ( table 1) and hypomania ( table 2) and
nearly always includes episodes of major depression ( table 3) [1]. Observational studies
consistently show that depressive episodes predominate the clinical course of bipolar
disorder [2,3]. Compared with manic and hypomanic episodes, bipolar depressive episodes
and residual bipolar depressive symptoms account for a greater proportion of long-term
morbidity, impaired functioning, and risk of suicide [4,5].
As a result, improved treatment of bipolar major depression is a patient priority. In an

internet based survey from 11 countries, which asked patients with bipolar disorder (n =
1300) which aspects of care they would most like to see improved, better treatment of
depression was endorsed by the largest number (>40 percent) [6]. The second and third
leading aspects of care that patients would most like to see improved were avoiding weight
gain and preventing relapse of depressive episodes.
This topic reviews the general principles of treating bipolar major depression. Other topics
discuss choosing treatment for adults with bipolar major depression, the efficacy and
adverse effects of antidepressants and second generation antipsychotics for bipolar major
depression in adults, investigational approaches to treating bipolar major depression in
adults, choosing pharmacotherapy for adults with acute mania and hypomania, choosing
maintenance treatment for adults, and choosing pharmacotherapy for pediatric bipolar
major depression:
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/bipolar-major-depression-in-adults-general-principles-of-treatment/print?search… 1/23
● (See "Bipolar major depression in adults: Choosing treatment".)

● (See "Bipolar major depression in adults: Efficacy and adverse effects of
antidepressants".)
● (See "Bipolar major depression in adults: Efficacy and adverse effects of second-
generation antipsychotics".)
● (See "Bipolar major depression in adults: Investigational and nonstandard approaches
to treatment".)
● (See "Bipolar mania and hypomania in adults: Choosing pharmacotherapy".)
● (See "Bipolar disorder in adults: Choosing maintenance treatment".)
● (See "Pediatric bipolar major depression: Choosing treatment".)
DEFINITION OF BIPOLAR DISORDER
Bipolar disorder is a mood disorder that is characterized by periods of pathologic mood

elevation (mania or hypomania) [1]. Patients with bipolar I disorder experience manic
episodes ( table 1) and nearly always experience both hypomanic episodes ( table 2) and
major depressive episodes ( table 3). Bipolar II disorder is characterized by at least one
episode of hypomania ( table 2) and one or more major depressive episodes. In addition,
psychotic features such as delusions and hallucinations frequently accompany bipolar
depressive episodes, particularly in patients with bipolar I disorder [7].
Additional information about the clinical features and diagnosis of bipolar disorder, including
bipolar major depression, is discussed separately. (See "Bipolar disorder in adults: Clinical
features" and "Bipolar disorder in adults: Assessment and diagnosis".)
GENERAL PRINCIPLES
Initial assessment — Treatment of acute bipolar depressive episodes begins with a

psychiatric and general medical history, mental status and physical examination, and
focused laboratory and imaging studies as clinically indicated. Clinicians should assess
current and past:
● Depressive symptoms and episodes ( table 3), including suicidal ideation and
behavior
● Manic and hypomanic symptoms and episodes ( table 1 and table 2)
● Psychotic features such as delusions and/or hallucinations
● Substance abuse
● Treatment responses, including treatment-limiting adverse effects
● Patient preferences regarding treatment
Establishing a clear history of mania or hypomania meeting full diagnostic criteria is

essential. Additional information about assessing patients for bipolar disorder is discussed
separately. (See "Bipolar disorder in adults: Assessment and diagnosis", section on
'Assessment'.)
Goals — The goals of acute treatment for bipolar depressive episodes is remission, defined
as resolution of mood symptoms or improvement to the point that few symptoms of only
mild intensity persist, and restored functioning [8,9]. However, remission can require several
weeks or longer to occur; thus, a reasonable interim goal is response [8,9], defined as
stabilization of the patient’s safety with clinically significant reduction in the number and
severity of mood symptoms. Response includes resolution of suicidal ideation and psychotic
features, when present. In addition, improvement in depressive symptoms should occur
without precipitating treatment-emergent manic/hypomanic episodes or rapid cycling. In
many studies that use rating scales to monitor response to treatment, response is defined as
reduction of baseline symptoms ≥50 percent.
Setting — Hospitalization may be required for the safety and stabilization of patients with
severe bipolar depression accompanied by [10]:
● Suicidal ideation with a plan and intent to kill oneself. (See "Suicidal ideation and
behavior in adults".)
● Delusions or hallucinations that threaten the patient’s safety, such as command

auditory hallucinations involving suicide. (See "Psychosis in adults: Epidemiology,
clinical manifestations, and diagnostic evaluation".)
● Severe agitation. (See "Assessment and emergency management of the acutely

agitated or violent adult".)
● Loss of functioning such that patients can no longer adequately care for themselves –
As an example, patients may become dehydrated and malnourished due to refusal of
liquids and food.
Patients with acute but moderate bipolar depression (such as those with fleeting suicidal
ideation without suicidal intent or plan) can be treated in a partial hospitalization or intensive
outpatient treatment program. Otherwise, most patients with bipolar depression can be
managed as outpatients.
Pharmacotherapy — Choosing a specific medication regimen for acute episodes of bipolar I

or II major depression is discussed separately. (See "Bipolar major depression in adults:
Choosing treatment".)
In selecting pharmacotherapy for patients with bipolar major depression, clinicians should
understand that they are likely selecting a maintenance regimen as well, because
medications that successfully resolve acute bipolar episodes are generally continued [11,12].
Maintenance treatment of bipolar disorder is discussed separately. (See "Bipolar disorder in
adults: Choosing maintenance treatment".)
For patients with bipolar major depression who receive a second-generation antipsychotic as
monotherapy, efficacy is often comparable for low doses and high doses, whereas
discontinuation of treatment due to adverse effects may occur less often with low doses. As
an example, a meta-analysis of four randomized trials (n >1600 patients) compared fixed
doses of quetiapine 300 mg/day with quetiapine 600 mg/day and found that symptomatic
improvement, response (reduction of baseline symptoms ≥50 percent), and remission were
each comparable for the two groups [13]. However, discontinuation of treatment due to
adverse effects occurred less often with quetiapine 300 mg/day.
Nearly all of the high quality evidence that guides choosing a medication regimen consists of
randomized trials that compared an active drug with placebo. Few head-to-head trials have
compared different active drugs.
If patients respond poorly to a medication regimen that includes multiple drugs, we change
one medication at a time.
Duration of an adequate drug trial — Based upon literature reviews [14] and multiple
randomized trials [15], the duration of an adequate medication trial for patients with bipolar
I or II major depression is usually six to eight weeks. Nearly all of the studies were conducted
with outpatients.
However, in clinically urgent situations, such as inpatient hospitalization, it is typically not

feasible to wait six to eight weeks to determine if a drug trial has sufficiently relieved
symptoms. For these patients, if there is minimal improvement (eg, reduction of baseline
symptoms <20 percent) within the first few weeks (eg, two to three) of treatment with a
specific medication, it may be acceptable to decide that response is unlikely to occur [16,17].
Using absence of early improvement to predict nonresponse is supported by a study of four

randomized trials in which an active medication regimen was superior to placebo in bipolar I
or II major depression (n > 2000 patients) [18]. The active drugs consisted of lamotrigine,
olanzapine plus fluoxetine, or quetiapine; the trials lasted seven or eight weeks; early
improvement was defined as reduction of baseline symptoms ≥20 percent at week 2, and
response was defined as reduction of baseline symptoms ≥50 percent. The analyses pooled
the negative predictive values, which represented the probability that patients would not
respond at the end of the study if they had not demonstrated early improvement. The
pooled negative predictive value was high (74 percent) and the false positive rate was low (14
percent); these results were interpreted to mean that absence of early improvement was a
highly reliable predictor of subsequent nonresponse. By contrast, the presence of early
improvement did not reliably predict eventual response.
Monitoring — We recommend that clinicians monitor depressive symptoms, treatment

response and adverse effects, and adherence to treatment at each visit [16,19]. Assessment
frequency depends upon the severity of depressive symptoms, treatment setting, suicide
risk, presence of psychotic features and comorbid psychopathology, and functional
impairment. Hospitalized patients are assessed at least daily, and symptoms of suicidality or
psychosis may necessitate constant monitoring. Outpatients who have responded well to
treatment can be followed less frequently (typically every one to three weeks, depending
upon residual symptom severity) until they achieve remission. Once remission is achieved
and adequate medication tolerability and adherence are established, office visits can be
scheduled less frequently (eg, every one to six months), depending upon factors such as
prior course of illness, including the duration of the most recent depressive episode;
duration of current remission; and current level of psychosocial functioning.
Patients treated for bipolar major depression should also be monitored for symptoms of
hypomania and mania. The course of illness is such that depressed patients can
spontaneously develop concurrent symptoms of hypomania/mania (mixed features), or
switch from depression to hypomania/mania, despite the use of antimanic drugs such as
lithium, second-generation antipsychotics, and valproate. In addition, some patients may be
vulnerable to hypomania/mania induced by antidepressants. (See "Bipolar major depression
in adults: Efficacy and adverse effects of antidepressants", section on 'Risk of switching to
mania'.)
Measurement based care is the systematic and quantitative assessment of symptoms with
rating scales during treatment. Rating scales that can be used to monitor depressive
syndromes include the Patient Health Questionnaire – Nine Item (PHQ-9) ( table 4) [20] and
the Quick Inventory of Depressive Symptomatology – Self-Report 16 Item (QIDS-SR16)
( table 5) [21,22], which are self-report instruments that have good psychometric
properties and were developed for use in patients with unipolar major depression. Additional
information about these instruments is discussed separately. (See "Using scales to monitor
symptoms and treat depression (measurement based care)", section on 'Patient Health
Questionnaire - Nine Item'.)
Routine monitoring with rating scales may identify nonresponders, detect residual or
prodromal symptoms, and help patients recognize improvement; however, the use of rating
scales is not standard clinical practice. There is no evidence demonstrating that
measurement based care improves outcomes for bipolar major depression; this may be due
in part to the scarce literature.
For patients who are treated with second-generation antipsychotics, especially quetiapine or
olanzapine, we suggest monitoring metabolic parameters ( table 6) to help patients avoid
weight gain and the metabolic syndrome. (See "Second-generation antipsychotic
medications: Pharmacology, administration, and side effects", section on 'Metabolic
syndrome'.)
Nonadherence — Clinicians should assess patients with bipolar disorder for nonadherence
and address it when present [23]. (See "Bipolar disorder in adults: Managing poor adherence
to maintenance pharmacotherapy".)
Adjunctive psychotherapy — Although the cornerstone of treatment for bipolar major

depression is pharmacotherapy, we frequently prescribe adjunctive psychotherapy to:
● Educate patients about the illness, including symptoms, course of illness, treatment
options, and sequelae
● Enhance acceptance of the diagnosis and adherence to pharmacotherapy
● Ameliorate symptoms
● Address comorbid psychiatric disorders (eg, personality disorders or substance use

disorders)
● Promote self-management, which includes creating structure and adopting daily

routines, being physically active, monitoring symptoms, and avoiding potentially mood
destabilizing activities such as alcohol misuse and use of cannabis and other drugs
● Manage stress
● Address problems with relationships and work
● Develop a plan to cope with acute crises
Clinicians should educate and support all patients with bipolar major depression, as well as
family members, caregivers, and supportive others, when appropriate. Using psychotherapy
is consistent with recommendations in multiple treatment guidelines [9,19,23-27] and
reviews [28,29]. Nevertheless, not all patients with bipolar major depression need
psychotherapy, such as patients without comorbidity who are knowledgeable about bipolar
disorder and adhere to treatment [30].
We often select cognitive-behavioral therapy (CBT) for bipolar major depression because it
has been most widely studied, and in our experience is the most widely available. However,
the specific choice of psychotherapy depends upon individual patient needs and preferences,
as well as availability of services. As an example, patients with prominent dysfunctional
thoughts and difficulties performing tasks may benefit from CBT [31], whereas patients with
role disputes or role transitions may benefit from interpersonal psychotherapy [32], and
patients with families that are characterized by frequent conflicts, high expressed emotion,
and problems with communication and problem solving may benefit from family therapy
[33,34]. Another reasonable option is group psychoeducation, which is readily
comprehended by most patients and relatively easy to implement in most clinical settings.
Evidence supporting the use of psychotherapy for bipolar major depression includes a one-
year randomized trial that compared adjunctive intensive psychotherapy with brief
psychoeducation in patients with bipolar I or II major depression (n = 293) [35]. All patients
were treated with pharmacotherapy. Patients assigned to intensive psychotherapy received
CBT, family therapy, or interpersonal and social rhythm therapy on a weekly or biweekly
basis for up to 30 sessions (mean number = 14) over nine months. Brief psychoeducation
consisted of three sessions administered over six weeks. Recovery occurred in more patients
treated with intensive psychotherapy than psychoeducation (64 versus 52 percent). In
addition, functioning improved more with intensive psychotherapy. Study attrition for
intensive psychotherapy and psychoeducation was comparable (36 and 31 percent). No
statistically significant difference was observed in the rate of recovery among patients
treated with CBT, family therapy, or interpersonal and social rhythm therapy.
Multiple randomized trials specifically support using CBT for bipolar major depression. As an
example, a meta-analysis of four randomized trials (n = 305 patients) found that
improvement of depressive symptoms was superior with adjunctive CBT than usual care, and
the clinical effect was small to moderate [24,36].
Psychotherapy (eg, group psychoeducation or interpersonal social rhythm therapy) can also
be effective for maintenance treatment of bipolar disorder [37]. (See "Bipolar disorder in
adults: Psychoeducation and other adjunctive maintenance psychotherapies".)
Comorbidity — Bipolar disorder is frequently accompanied by general medical and/or

psychiatric comorbidity. (See "Bipolar disorder in adults: Clinical features", section on
'Comorbidity'.)
For patients with bipolar major depression and comorbidity (eg, substance use disorders),
we suggest that clinicians attempt to treat both disorders concurrently [10,19,23,38].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Bipolar disorder".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, “The Basics” and “Beyond the
Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (See "Patient education: Bipolar disorder (The Basics)" and "Patient
education: Coping with high drug prices (The Basics)".)
● Beyond the Basics topics (See "Patient education: Bipolar disorder (Beyond the Basics)"
and "Patient education: Coping with high prescription drug prices in the United States
(Beyond the Basics)".)
SUMMARY
● Treatment of acute bipolar depressive episodes begins with a psychiatric and general
medical history, mental status and physical examination, and focused laboratory and
imaging studies as clinically indicated. (See 'Initial assessment' above.)
● Hospitalization may be required for the safety and stabilization of severe bipolar
depression, such as patients with suicidal ideation and behavior. Patients with
moderate bipolar depression can be treated in a partial hospitalization or intensive
outpatient treatment program. Most patients with bipolar depression can be managed
in outpatient clinics. (See 'Setting' above.)
● In selecting pharmacotherapy for patients with bipolar major depression, clinicians

should understand that they are likely selecting a maintenance regimen as well. For
patients who receive a second-generation antipsychotic as monotherapy, efficacy is
often comparable for low doses and high doses, whereas discontinuation of treatment
due to adverse effects may occur less often with low doses. (See 'Pharmacotherapy'
above.)
● The duration of an adequate medication trial for outpatients with bipolar I or II major
depression is usually six to eight weeks. However, in clinically urgent situations, if there
is minimal improvement within the first few weeks of treatment, it may be acceptable
to decide that response is unlikely to occur. (See 'Duration of an adequate drug trial'
above.)
● Clinicians should monitor depressive symptoms, treatment response and adverse

effects, and adherence to treatment at each visit. (See 'Monitoring' above.)
● Although the cornerstone of treatment for bipolar major depression is

pharmacotherapy, we often prescribe adjunctive psychotherapy. (See 'Adjunctive
psychotherapy' above.)
● For patients with bipolar major depression and comorbidity, we suggest that clinicians
attempt to treat all of disorders concurrently. (See 'Comorbidity' above.)
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REFERENCES
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Topic 115480 Version 7.0
GRAPHICS
DSM-5-TR diagnostic criteria for manic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least one week and present
most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable) are present to a significant degree and
represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (eg, feels rested after only three hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (ie, purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (eg,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent harm to self or others, or there are
psychotic features.
D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a
medication, other treatment) or to another medical condition.
NOTE: A full manic episode that emerges during antidepressant treatment (eg, medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
NOTE: Criteria A through D constitute a manic episode. At least one lifetime manic episode is required
for the diagnosis of bipolar I disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).
American Psychiatric Association. All Rights Reserved. Note: These diagnostic criteria remain unchanged in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, American Psychiatric Association 2022.
Graphic 91106 Version 8.0
DSM-5-TR diagnostic criteria for hypomanic episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least four consecutive days and
present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable) have persisted, represent a noticeable
change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (eg, feels rested after only three hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (eg,
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by
definition, manic.
F. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a
medication, or other treatment).
NOTE: A full hypomanic episode that emerges during antidepressant treatment (eg, medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of
that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is
indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation
following antidepressant use) are not taken as sufficient for a diagnosis of a hypomanic episode,
nor necessarily indicative of a bipolar diathesis.
NOTE: Criteria A through F constitute a hypomanic episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013).
American Psychiatric Association. All Rights Reserved. Note: These diagnostic criteria remain unchanged in the Diagnostic and
DSM-5-TR diagnostic criteria for bipolar major depression
A. Five (or more) of the following symptoms have been present during the same two-week period and
represent a change from previous functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report
(eg, feels sad, empty, hopeless) or observations made by others (eg, appears tearful). (NOTE:
In children and adolescents can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another
medical condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a
serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. This decision inevitably requires the exercise of clinical judgement based
on the individual's history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
Specify:
With anxious distress
With mixed features
With rapid cycling
With melancholic features

With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American
Psychiatric Association. All Rights Reserved. Note: The original diagnostic criteria remain unchanged in the Diagnostic and
PHQ-9 depression questionnaire
Name: Date:
Over the last 2 weeks, how often have you been Not at Several More Nearly
bothered by any of the following problems? all days than every
half day
the
days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too 0 1 2 3

much
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, 0 1 2 3

or that you have let yourself or your family down
Trouble concentrating on things, such as reading the 0 1 2 3

newspaper or watching television
Moving or speaking so slowly that other people could 0 1 2 3

have noticed? Or the opposite, being so fidgety or
restless that you have been moving around a lot
more than usual.
Thoughts that you would be better off dead, or of 0 1 2 3

hurting yourself in some way
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
If you checked off any problems, how difficult Not Somewhat Very Extremel
have these problems made it for you to do your difficult difficult difficult difficult
work, take care of things at home, or get along at all
___ ___ ___
with other people? ___
PHQ: Patient Health Questionnaire.
Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer,
Inc. No permission required to reproduce, translate, display or distribute.
The Quick Inventory of Depressive Symptomatology
Name or ID: ________________________________ Date: _____________
Check the one response to each item that best describes you for the past seven days.
During the past seven days...
1. Falling asleep
____ 0 I never take longer than 30 minutes to fall asleep.
____ 1 I take at least 30 minutes to fall asleep, less than half the time.
____ 2 I take at least 30 minutes to fall asleep, more than half the time.
____ 3 I take more than 60 minutes to fall asleep, more than half the time.
2. Sleep during the night
____ 0 I do not wake up at night.
____ 1 I have a restless, light sleep with a few brief awakenings each night.
____ 2 I wake up at least once a night, but I go back to sleep easily.
____ 3 I awaken more than once a night and stay awake for 20 minutes or more, more than half
the time.
3. Waking up too early
____ 0 Most of the time, I awaken no more than 30 minutes before I need to get up.
____ 1 More than half the time, I awaken more than 30 minutes before I need to get up.
____ 2 I almost always awaken at least one hour or so before I need to, but I go back to sleep
eventually.
____ 3 I awaken at least one hour before I need to, and can't go back to sleep.
4. Sleeping too much
____ 0 I sleep no longer than 7-8 hours/night, without napping during the day.
____ 1 I sleep no longer than 10 hours in a 24-hour period including naps.
____ 2 I sleep no longer than 12 hours in a 24-hour period including naps.
____ 3 I sleep longer than 12 hours in a 24-hour period including naps.
5. Feeling sad
____ 0 I do not feel sad.
____ 1 I feel sad less than half the time.
____ 2 I feel sad more than half the time.
____ 3 I feel sad nearly all of the time.
Please complete either 6 or 7 (not both).
6. Decreased appetite
____ 0 There is no change in my usual appetite.
____ 1 I eat somewhat less often or lesser amounts of food than usual.
____ 2 I eat much less than usual and only with personal effort.
____ 3 I rarely eat within a 24-hour period, and only with extreme personal effort or when others
persuade me to eat.
OR
7. Increased appetite
____ 0 There is no change from my usual appetite.
____ 1 I feel a need to eat more frequently than usual.
____ 2 I regularly eat more often and/or greater amounts of food than usual.
____ 3 I feel driven to overeat both at mealtime and between meals.
Please complete either 8 or 9 (not both).
8. Decreased weight (within the last two weeks)
____ 0 I have not had a change in my weight.
____ 1 I feel as if I have had a slight weight loss.
____ 2 I have lost 2 pounds or more.
____ 3 I have lost 5 pounds or more.
OR
9. Increased weight (within the last two weeks)
____ 0 I have not had a change in my weight.
____ 1 I feel as if I have had a slight weight gain.
____ 2 I have gained 2 pounds or more.
____ 3 I have gained 5 pounds or more.
10. Concentration/decision making
____ 0 There is no change in my usual capacity to concentrate or make decisions.
____ 1 I occasionally feel indecisive or find that my attention wanders.
____ 2 Most of the time, I struggle to focus my attention or to make decisions.
____ 3 I cannot concentrate well enough to read or cannot make even minor decisions.
11. View of myself:
____ 0 I see myself as equally worthwhile and deserving as other people.
____ 1 I am more self-blaming than usual.
____ 2 I largely believe that I cause problems for others.
____ 3 I think almost constantly about major and minor defects in myself.
12. Thoughts of death or suicide
____ 0 I do not think of suicide or death.
____ 1 I feel that life is empty or wonder if it's worth living.
____ 2 I think of suicide or death several times a week for several minutes.
____ 3 I think of suicide or death several times a day in some detail, or I have made specific plans
for suicide or have actually tried to take my life.
13. General interest
____ 0 There is no change from usual in how interested I am in other people or activities.
____ 1 I notice that I am less interested in people or activities.
____ 2 I find I have interest in only one or two of my formerly pursued activities.
____ 3 I have virtually no interest in formerly pursued activities.
14. Energy level
____ 0 There is no change in my usual level of energy.
____ 1 I get tired more easily than usual.
____ 2 I have to make a big effort to start or finish my usual daily activities (for example, shopping,
homework, cooking, or going to work).
____ 3 I really cannot carry out most of my usual daily activities because I just don't have the
energy.
15. Feeling slowed down
____ 0 I think, speak, and move at my usual rate of speed.
____ 1 I find that my thinking is slowed down or my voice sounds dull or flat.
____ 2 It takes me several seconds to respond to most questions and I'm sure my thinking is
slowed.
____ 3 I am often unable to respond to questions without extreme effort.
16. Feeling restless
____ 0 I do not feel restless.
____ 1 I'm often fidgety, wringing my hands, or need to shift how I am sitting.
____ 2 I have impulses to move about and am quite restless.
____ 3 At times, I am unable to stay seated and need to pace around.
Reproduced with permission from the UT Southwestern Medical Center at Dallas. For more information, please visit www.ids-
qids.org. Copyright © 2011. All rights reserved.
Monitoring for metabolic side effects of antipsychotic drugs
At
least
4 8 12
Baseline Quarterly Annually every
weeks weeks weeks
5
years
Personal or X X
family history
Weight (body X X X X X
mass index)
Waist X X X
circumference
Blood pressure X X X
Fasting plasma X X X
glucose
Fasting lipid X * X X
profile
* For patients taking olanzapine, quetiapine, clozapine.
Copyright © 2004 American Diabetes Association. From Diabetes Care, Vol. 27, 2004: 596-601. Reproduced with permission.

Bipolar Major Depression in Adults - General Principles of Treatment - UpToDate

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23/2/24, 14:03 Bipolar major depression in adults: General principles of treatment - UpToDate

Official reprint from UpToDate®

Bipolar major depression in adults: General principles

Literature review current through: Jan 2024.

As a result, improved treatment of bipolar major depression is a patient priority. In an

● (See "Bipolar major depression in adults: Choosing treatment".)

DEFINITION OF BIPOLAR DISORDER

Bipolar disorder is a mood disorder that is characterized by periods of pathologic mood

Initial assessment — Treatment of acute bipolar depressive episodes begins with a

Establishing a clear history of mania or hypomania meeting full diagnostic criteria is

● Delusions or hallucinations that threaten the patient’s safety, such as command

● Severe agitation. (See "Assessment and emergency management of the acutely

Pharmacotherapy — Choosing a specific medication regimen for acute episodes of bipolar I

However, in clinically urgent situations, such as inpatient hospitalization, it is typically not

Using absence of early improvement to predict nonresponse is supported by a study of four

Monitoring — We recommend that clinicians monitor depressive symptoms, treatment

Adjunctive psychotherapy — Although the cornerstone of treatment for bipolar major

● Enhance acceptance of the diagnosis and adherence to pharmacotherapy

● Address comorbid psychiatric disorders (eg, personality disorders or substance use

● Promote self-management, which includes creating structure and adopting daily

● Address problems with relationships and work

● Develop a plan to cope with acute crises

Comorbidity — Bipolar disorder is frequently accompanied by general medical and/or

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● In selecting pharmacotherapy for patients with bipolar major depression, clinicians

● Clinicians should monitor depressive symptoms, treatment response and adverse

● Although the cornerstone of treatment for bipolar major depression is

Use of UpToDate is subject to the Terms of Use.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

6. McIntyre RS. Understanding needs, interactions, treatment, and expectations among

Bull 2007; 40:7.

14. Pacchiarotti I, Mazzarini L, Colom F, et al. Treatment-resistant bipolar depression:

26. Kendall T, Morriss R, Mayo-Wilson E, et al. Assessment and management of bipolar

DSM-5-TR diagnostic criteria for manic episode

Graphic 91106 Version 8.0

DSM-5-TR diagnostic criteria for hypomanic episode

Graphic 91107 Version 7.0

DSM-5-TR diagnostic criteria for bipolar major depression

NOTE: Criteria A through C represent a major depressive episode.

With melancholic features

Graphic 91398 Version 10.0

PHQ-9 depression questionnaire

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure, 0 1 2 3

Trouble concentrating on things, such as reading the 0 1 2 3

Moving or speaking so slowly that other people could 0 1 2 3

Thoughts that you would be better off dead, or of 0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

15 to 19: moderately severe

PHQ: Patient Health Questionnaire.

Graphic 59307 Version 12.0

The Quick Inventory of Depressive Symptomatology

Name or ID: ________________________________ Date: _____________

During the past seven days...

____ 0 I never take longer than 30 minutes to fall asleep.

2. Sleep during the night

Total _ = _ + _ + _ + ___

Name or ID: ____________________ Date: _