Les recommandations professionnelles dans le traitement de la dépression bipolaire

Numerous guidelines for the treatment of bipolar disorder have been published in the recent years. A review focusing on recent international and French guidelines the last 5 years on the management of bipolar depression was conducted. The comparaison of guidelines showed differences in the choice of initial treatment : monotherapy (in first line : quetiapine and lamotrigine) or polypharmacotherapy (in first line : combination olanzapine / fluoxetine). All guidelines recommend in patients with inadequat response a therapeutic strategy in two steps. An initial clinical stage seeking the causes of poor therapeutic response and a second therapeutic stage trying to optimize the current treatment, to change treatment or to consider a co-therapy. In first line, the prophylactic drugs recommended are : lithium, valproate, quetiapine ; olanzapine, risperidone (and long-acting formulation) and aripiprazole mainly for the prevention of manic episodes ; lamotrigine limited to prevention of depressive episodes. The duration of treatment before patient reassessment and that of maintenance therapy are not consensual. The development of second-generation antipsychotics in bipolar depression is an interesting development for our therapeutic armamentarium and has been incorporated in recent guidelines.