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References

322 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 2 Summary of drug choice The combination of olanzapine + fluoxetine is probably the most effective treatment available for bipolar depression but its use is constrained by the well-­known adverse effect profile of olanzapine. SSRIs other than fluoxetine may be effective but should probably be avoided unless clear individual benefit is obvious.54 Alternative first-­line choices are quetiapine, olanzapine, lurasidone, lamotrigine and cariprazine (and lumateperone in North America). These drugs differ substantially in adverse effect profile, tolerability and cost, each of which needs to be considered when prescribing for an individual. Lithium is also effective but supporting evidence is relatively weak. Second-­line drugs include ketamine and, increasingly, modafinil. Aripiprazole, risperidone, ziprasidone, tricyclics (with the exception of imipramine) and MAOIs (with the exception of tranylcypromine) are probably not effective and should not be used routinely.114 References

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