What are the VA/DoD guidelines for monotherapy in the treatment of bipolar affective disorder (manic-depressive illness)?

Updated: May 30, 2019
  • Author: Stephen Soreff, MD; Chief Editor: Glen L Xiong, MD  more...
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The VA/DoD considers first-line monotherapy in adult patients with bipolar depression to include quetiapine, lamotrigine, or lithium. [3] Cautiously consider olanzapine monotherapy due to its adverse effects. Second-line pharmacotherapy includes the combination of olanzapine/fluoxetine owing to its side-effect profile of weight gain, diabetes risk, and hypertriglyceridemia. [3]

Although the VA/DoD found insufficient evidence for or against the use of valproate, carbamazepine, topiramate, risperidone, ziprasidone, or clozapine for managing bipolar depression, it did advise against aripiprazole monotherapy in patients with acute bipolar depression, except in cases in which there was [3] : (1) a previous good response during depression without a switch to mania or (2) a history of treatment of refractory depression.

A post hoc analysis of older adults (aged >55 years) showed lurasidone was significantly more effective than placebo as monotherapy. Adjunctive therapy with lurasidone was not associated with significant improvement. Both monotherapy and adjunctive therapy with lurasidone were safe and well tolerated in this older adult population. [87]

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