Bipolar depression is the most common and difficult-totreat
phase of BD. There is a high incidence of
subsyndromal symptoms in the disorder, which result in
residual functional impairment and erosion of quality of
life. Barriers due to stigma, acceptance, availability of
treatment and psychoeducation need to be overcome to
limit non-adherence to treatment and risk of relapse.48
The therapeutic benefits of any treatment choice need to
be balanced against risk,49 and a long-term outlook is
essential. In the context of a collaborative alliance between
the patient and clinicians, continuous monitoring is also
crucial. Pharmacotherapy should be integrated into a
personalised psychosocial and lifestyle package of
interventions that considers the person’s clinical profile
and preferences.50 The treatment recommendations
offered here are based on an evolving and incomplete
evidence base, and should be used in conjunction with
clinical judgement. Given that it is the predominant illness
phase of BD, and the extant literature is patchy, highquality
trials of bipolar depression should be a priority.