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Bipolar Disorder: Avoidance of antidepressant monotherapy in BD I


This measure assesses the percentage of patients with BD I symptoms and behaviors who received monotherapy with an antidepressant agent during the first 12 weeks of treatment.

Clinical Rationale:

Goals of Acute Treatment:

  • Avoidance of mood destabilization and precipitating a manic or hypomanic episode (1,2)
  • Remission of symptoms with a return to usual levels of psychosocial functioning (1)

Initial Treatment Recommendations

  • Prescription of antidepressants in the absence of a mood stabilizer is not recommended for bipolar I patients (1)
  • Due to the risks of mania induction and cycle acceleration, antidepressant monotherapy is not recommended an appropriate maintenance treatment for patients with BD I, most recent episode depressed (2)
  • In addition to recommendations to avoid antidepressant monotherapy in BD I,
    the 2004 Consensus Guidelines(3)  and the TMAP guidelines (2) provide cautionary  guidance regarding the  inclusion of an antidepressant in combination with additional pharmacotherapy (mood stabilizing agent or antipsychotic agent) in the treatment regimen for a patient with bipolar depression with a history of rapid cycling or antidepressant-induced mania

Denominator Population:

Patients diagnosed with Bipolar I Disorder
(any type of episode)

Data Sources:

  • Administrative data
  • Medical Record

Numerator Population:

Patients who receive only antidepressant monotherapy during the first 12 weeks following initiation of pharmacotherapy treatment

Data Source:

  • Medical Record
  • If available, administrative data that indicates specific pharmacotherapy

Initial Case-finding Guidance:

Patients with diagnosis of Bipolar I Disorder
ICD9CM or DSM IVTR: 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7


  1. Practice Guideline for the Treatment of Patients with Bipolar Disorder (2002 Revision); American Psychiatric Association; Am J Psychiatry 159:4, April 2002 Supplement ;    Also, Guideline Watch (2006) Update, Hirschfeld, RM, American Psychiatric Association, 2006
  2. Suppes T, Dennehy E, Hirschfeld R, Altshuler L, Bowden D, Calabrese J, Ketter T, Sachs G, Swann A, The Texas Implementation of Medication Algorithms: Update to the Algorithms for Treatment of Bipolar I Disorder, J Clin Psychiatry 2005; 66:870-886
  3. Keck PE, Perlis R, Otto M, Carpenter D, Ross R, Docherty J, Treatment of Bipolar Disorder 2004; The Expert Consensus Guideline Series, Postgraduate Medicine – A Special Report, December 2004

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