Sequential Multiple Assignment Randomized Trial for Bipolar Depression

Prior treatment

• Currently taking the study medications or a history of serious adverse events to any of the study medications, to the extent that as determined by site PI, another trial would not be clinically indicated

Other illness

• Meets current criteria for a manic episode, rapid cycling within the past year (history of 4 or more mood episodes per year)
• History of schizophrenia or other nonaffective psychosis
• Current substance use disorder that will interfere with participation in the study
• A history of non-response for depressive episodes, to any of the study medications, when given at adequate doses for at least 6 weeks

Other

• Current acute suicidal risk that requires inpatient treatment
• Pregnancy or breastfeeding

• Aged between 18 years to 75 years
• Meets criteria for DSM-V Bipolar I or II disorder with a history of manic or hypomanic episodes and current major depressive episode lasting at least 2 weeks
• Can be managed as an outpatient and participate in the study
• Willing to be randomized; able to perform study assessments
• Women of childbearing potential must agree to use adequate contraception (e.g. oral contraceptives, intrauterine device, barrier methods, or total abstinence; Depo Provera is acceptable if it is started 3 months prior to enrollment), and inform staff of their plans to conceive.