The Expert Consensus Guidelines
for treating depression in bipolar disorder

Frances AJ, Kahn DA, Carpenter D,
Docherty JP, Donovan SL
Department of Psychiatry,
Duke University Medical Center,
Durham, NC 27710, USA.
J Clin Psychiatry 1998; 59 Suppl 4:73-9


We present expert consensus guideline recommendations for the treatment of bipolar depression. These were arrived at through the statistical aggregation of the survey responses of 61 leading clinical researchers to eight questions about the key decision points in the management of bipolar depression. The experts' first-line recommendation for treating psychotic depression in bipolar disorder is to provide a combination of mood stabilizer, antidepressant, and neuroleptic medication. For severe, but nonpsychotic bipolar depression, the experts recommend the combination of a mood stabilizer and an antidepressant. For milder bipolar depression, a mood stabilizer and an antidepressant together or a mood stabilizer alone would be first line. The experts' antidepressant dose and dosing schedule recommendations are equivalent for unipolar and bipolar depression, but the experts recommend a faster discontinuation of antidepressants during the maintenance phase in bipolar patients--probably to reduce the risk of rapid cycling. Among the antidepressants, the experts prefer bupropion and the serotonin reuptake inhibitors as first line. They also believe that bupropion is least likely among antidepressants to cause switches to mania. Among mood stabilizers, the experts rate lithium as most likely to have a direct antidepressant effect.
Bipolar II
Dysphoric mania
Bipolar disorders
Bipolar depression
Bipolar versus unipolar
Social phobia and bipolarity
Antidepressant-induced mania
Melancholic bipolar depression
Bipolar depression: undertreatment
Bipolar depression and mixed states
Mood-lifting opioid analgesics for bipolars
Relationship of major depressive disorder to bipolar disorder
Olanzapine-fluoxetine combination (Symbyax) for depression

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