Making optimal use of combination pharmacotherapy in bipolar disorder

Because patients with bipolar disorder often do not respond sufficiently to treatment with 1 mood stabilizer, psychiatrists frequently employ combination therapy and add antipsychotics, antiepileptics, or antidepressants to mood stabilizers. Combination therapy can be more effective than monotherapy in controlling breakthrough or treatment-resistant episodes. For example, atypical antipsychotics have been shown to be effective adjunctive treatments for mania and for patients with psychotic symptoms during a depressive episode, while the combination of a mood stabilizer and lamotrigine or an antidepressant has been found to control bipolar depression. The American Psychiatric Association guideline for the treatment of bipolar disorder recommends optimizing individual medications before switching to combination therapy. Selecting a combination treatment regimen with an acceptable side effect profile is critically important because patients may discontinue therapy they cannot tolerate. Agents should be added carefully, with continued monitoring of adverse effects. Physicians should give patients only as much medication as needed.