Treating Depression in the Context of Mania or Mania Risk in Youth

Abstract

Bipolar disorder (BD) is a heritable and episodic psychiatric disorder that is increasingly being recognized to take onset in childhood or adolescence. Youth with a parent or sibling with BD may also be at risk for mania, but frequently present with depression. In a busy clinical practice, treating depression in the context of mania or risk for mania can be obfuscated by a number of factors, including clinical heterogeneity and co-occurring conditions, changes in symptom presentation over the course of development, and treatment-emergent affective switching. In this review, we critically appraise recently published literature pertinent to the use of nonpharmacological and pharmacological strategies for the treatment of depression in youth with or at familial risk for BD. We used available data and extrapolate from adult studies to present reasonable treatment options in the context of a limited evidence base. Initial consideration of nonpharmacologic approaches such as psychotherapy, engaging in resilience-promoting strategies, and using omega-3 fatty acid supplementation is suggested given the low risk involved in implementation. Pharmacological treatment is guided by a combination of presenting symptoms, response to previous treatment trials or family history of previous responses, reported adverse effects, and patient and family preference. We conclude with a research update on emerging evidence-based treatment of bipolar I depression in youth. High-risk youth are more susceptible to developing antidepressant-induced mania (AIM), but the risks may be cautiously managed by starting at low doses, slow titrations, close monitoring for emerging adverse effects, and consideration of mood stabilizers and atypical antipsychotics with any emergence of persistent hypomania or mania that is not reversed by lowering or discontinuing antidepressant dosing.