Several special aspects that differentiate treatment of depressive episodes during manic-depressive disorder should be noted. First, lithium appears to be an effective antidepressant in depressive episodes during manic-depressive disorder (see Tables 4.5 and 4.9), whereas the evidence is equivocal for its efficacy in unipolar depression (Fieve, Platman, & I'lutchik, 1968; Goodwin et al, 1972).
Second, it should be kept in mind that all somatic antidepressant treatments are potentially pro-manic, with the probable exception of lithium. These two facts indicate that lithium should be the first-line treatment for unmedicated persons with manic-depressive disorder in the depressed phase.
Third, although there are few data indicating that depression during manic-depressive disorder responds preferentially to any particular drug, there is evidence as noted above that persons with manic-depressive disorder who have hypersomnolent, anergic depressive episodes may respond to monoamine oxidase inhibitors better than to tricyclics (Himmelhoch, Thase, Mallinger, & Fuchs, 1991; Thase, Mallinger, McKnight, & Himmelhoch, 1992), In this regard, it should also be noted that ECT may be more effective than tricyclic
(reviewed in Zornberg & Pope, 1993). Thus, these modalities cannot be ignored as potential agents in treating manic-depressive disorder and should not be relegated to "last chance" status. Increasing education and comoni-toring during group psychotherapy can improve compliance and make MAOIs more practically useful and ECT more acceptable when indicated.
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