Prevention of rapid cycling:

Antidepressants may induce rapid cycling in some patients (eg, patients with bipolar II disorder and a cyclothymic temperament), even when given with lithium. The best strategy is preventive: limiting the use of antidepressants during the depressive phase. For an established case of rapid cycling, the physician must gradually discontinue all cycling antidepressants, stimulants, caffeine, benzodiazepines, and alcohol. Hospitalization may be required. Lithium (or divalproex) may be given with bupropion. Because borderline hypothyroidism also predisposes to rapid cycling (especially in women), augmenting mood stabilizers with hormones (eg, L-thyroxine 100 to 200 ?g/day po) often helps. Sometimes carbamazepine can also be useful. Some experts combine an anticonvulsant with lithium, trying to keep both drugs at 1/2 to 2/3 their usual dose. Nimodipine (90 mg bid), a calcium channel blocker, may also help in ultrarapid cycling (ie, cycling every few days), but it is not yet an established strategy.

Combining mood stabilizers is often necessary to obtain optimal results. However, avoiding carbamazepine-divalproex and divalproex-lamotrigine combinations is best because of additive toxic effects.

Phototherapy is a relatively new approach for patients with seasonal bipolar or bipolar II disorder (with autumn-winter depression and spring-summer hypomania). It is probably most useful as augmentation.