Synopsis
Recognise depression within a bipolar course, retrieve lifetime evidence of activation before choosing treatment, exclude important medical and substance mimics, and manage current severity without waiting for perfect retrospective certainty.
- Bipolar depression can look identical to unipolar depression in cross-section; diagnosis depends on the lifetime course, not a special depressive symptom checklist.
- Ask every depressed adult about previous overactivity, disinhibition, elevated or irritable mood, reduced sleep need, increased speech, projects, spending and treatment-related activation.
- NICE advises considering specialist assessment when previous overactivity or disinhibition lasted four days or more and urgent referral for suspected mania, severe depression or danger.
Key red flags
Suicidal preparation, access to lethal means, recent self-harm, severe hopelessness or an agitated mixed state requires immediate individual formulation and intervention.
Investigation priorities
Map depressive, elevated, irritable and mixed periods, inter-episode recovery, duration, triggers and functional consequences.
Management branches
Current depression is accompanied by previous activation, disinhibition or reduced sleep need.
- Establish current severity, suicide risk, psychosis and mixed features and provide urgent care first when danger or severe illness is present.
- Build a lifetime timeline using behavioural examples, records and consented collateral and review substances, medicines and medical explanations.
Key medicines
Quetiapine immediate-releaseFor bipolar depression, take 50 mg at bedtime on day one, 100 mg on day two, 200 mg on day three and 300 mg on day four; the recommended daily dose is 300 mg.
LamotrigineWhen not taking valproate or enzyme-inducing medicines, use 25 mg once daily for weeks one and two, 50 mg daily for weeks three and four, then increase gradually toward 200 mg daily according to the product schedule.