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The Expert Consensus Guidelines for Treating Depression in Bipolar Disorder

Allen J. Frances, M.D., David A. Kahn, M.D., Daniel Carpenter, Ph.D., John P. Docherty, M.D., and Stacy L. Donovan

Published: October 1, 1998

Article Abstract

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 clinicalresearchers 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 providea combination of mood stabilizer, antidepressant, and neuroleptic medication. For severe, butnonpsychotic bipolar depression, the experts recommend the combination of a mood stabilizer and anantidepressant. For milder bipolar depression, a mood stabilizer and an antidepressant together or amood stabilizer alone would be first line. The experts’ antidepressant dose and dosing schedule recommendationsare equivalent for unipolar and bipolar depression, but the experts recommend a fasterdiscontinuation of antidepressants during the maintenance phase in bipolar patients—probably to reducethe risk of rapid cycling. Among the antidepressants, the experts prefer bupropion and the serotoninreuptake inhibitors as first line. They also believe that bupropion is least likely among antidepressantsto cause switches to mania. Among mood stabilizers, the experts rate lithium as most likely tohave a direct antidepressant effect.

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Volume: 59

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