Vladimir Maletic, MD, MS: Andy, you mentioned that use of antipsychotics. What are the scenarios where use of antipsychotics first-generation, and particularly second-generation, would be indicated as opposed to starting with the mood stabilizing age? Are there any clinical scenarios that influence your decisions?

Andrew Cutler, MD: Absolutely. First, I’d like to try to start with an FDA-approved medication because then there’s evidence of both efficacy and safety. What’s interesting is when you poll audiences, they get this question wrong all the time, but what are the approved medications for bipolar depression? There’s 5 of them, and all 5 are atypical antipsychotics. Lithium, divalproex, carbamazepine, and lamotrigine are not approved for acute bipolar depression. That’s a situation where I’m absolutely going to reach for 1 of the FDA-approved atypical antipsychotics. Some of the antipsychotics are not approved yet for mania, but all antipsychotics in my mind are going to work for mania. Chlorpromazine in 1974 was FDA approved to treat mania, and antipsychotics can treat mania. I may have reached for an antipsychotic for mania, but my whole thinking has changed. I still like lithium and lamotrigine— divalproex hasn’t worked as well for depression for me—and so I reserve that for somebody with a real troublesome mania or frequent manias. It’s a good anti-manic if you will. I tend to use the atypical antipsychotics, especially because, while you’re right, it’s a funny quirk of the DSM [American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders] that you can be diagnosed with bipolar I with only mania. Most patients have recurrent depressions, and the depressions last longer, and the degree of impairment correlates more with a depressive state than with the manic state. I tend to lean towards using something that’s going to help with a depressed phase, perhaps prevent depression like lamotrigine, which can help prevent depression. It stabilizes mood from below. Those are some of the thoughts. I have certain ones of these approved atypicals that I lean more towards than others. If we talk specifically about the situation of anxiety, quetiapine has been a go-to medication for that if I can adjust the dose and try to minimize the weight in metabolic issues, for instance.

Transcript edited for clarity