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His primary care physician diagnosed major depressive disorder last December and began the first of a series of antidepressant medications that eventually included fluoxetine, mirtazapine, and bupropion. A careful patient history is critical; on closer questioning, Mr Smith revealed what appears to have been a previous manic episode, as well as several potential signs of bipolar depression. It is far from uncommon for patients such as Mr Smith to receive multiple courses of standard antidepressant medications.2 Unfortunately, there are real risks associated with using these medications for bipolar depression.
Some studies suggest that there may be other, less concrete effects of prolonged depression in bipolar patients as well.

Only 1 medication and 1 medication combination are approved by the FDA to treat depression in patients with bipolar disorder. He reports numerous episodes of depression that began when he was young and a possible family history of bipolar disorder.
Standard antidepressants may precipitate manic episodes in a minority of bipolar patients and may be ineffective.7 A delayed diagnosis may prolong depression and further affect the patient’s ability to function effectively at home and at work.
Treatment choices in psychiatry are rarely straightforward, and bipolar depression is no exception to this general rule.

The number of FDA-approved medications for bipolar mania has literally tripled over the past decade while the pharmacopeia available for bipolar depression remains quite limited (Table 2).

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