Bipolar depression and polarity-safe treatment — structured clinical viva

This is bipolar depression on antidepressant monotherapy, which is a polarity-safety problem even in bipolar II. Assessment must cover suicide risk in detail (intent, plan, means, protective factors, mixed features such as racing thoughts or decreased sleep need, alcohol), current hypomanic symptoms, medication adherence, thyroid status, substance use, and psychosocial stressors. Passive death wishes still require a safety plan and follow-up intensity decision; admission if risk escalates or support is inadequate.^[4]

Do not simply escalate the SSRI. STEP-BD showed adjunctive antidepressants did not outperform mood stabiliser plus placebo for durable recovery in bipolar depression; monotherapy is even harder to defend.^[1] Plan a switch toward polarity-safe treatment: e.g. taper sertraline while introducing quetiapine titrated toward 300–600 mg at night with metabolic monitoring (BOLDER evidence includes bipolar II depression), or consider lurasidone 20–120 mg with food where available, lithium, or carefully titrated lamotrigine for longer-term depression prevention.^[2][3][4]

Explain metabolic, sedation, and rash (lamotrigine) risks; agree review timing; involve supports with consent; document early warning signs for switch into hypo/mania if any antidepressant cover remains briefly during transition.^[4]