PsychoTropical Research - Dr Ken Gillman, Serotonin Syndrome, Mirtazapine, Dual Action Drugs. Bipolar Disorder - Consensus treatment guidelines.

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Bipolar Disorder - Consensus treatment guidelines

Bipolar Disorder - Consensus treatment guidelines

Date Created: 16/10/1999   Last Modified: 004/01/2003   Last Checked: 04/01/2003

Current opinion among experts, and some evidence, suggests that different treatment strategies are likely to be appropriate for depression when it occurs in the context of a possible or known Bipolar Disorder.

Advances and changes are especially rapid in this area. It will be fascinating to see if any of the 'newer' anti-epileptics turn out to be antidepressants that are better for Bipolar Disorder; indications are that lamotrigine may be such a drug although it has not yet been approved officially.

Current consensus suggests the first-line strategy for treating psychotic depression in bipolar disorder is to give a combination of a mood stabilizer, antidepressant, and neuroleptic. For severe non-psychotic bipolar depression a combination of a mood stabilizer and antidepressant.

Monoamine oxidase inhibitors, particularly tranylcypromine, are widely regarded as appropriate in bipolar cases. There is evidence that tranylcypromine is especially effective for 'anergic' symptoms in Bipolar Disorder.

The experts' antidepressant choice for treatment of both severe and moderate degrees of depression was:--

  • =1- bupropion * or an SSRI
  • 2-MAOI
  • 3- venlafaxine
  • =4-TCA and nefazodone

* Bupropion may have a lesser risk of causing a switch to mania; this view comes from American experience but does not seem to accord well with other views.

*** Of this particular large group of 'experts' 40% of them considered an MAOI was a first line treatment for severe or moderately severe depression in Bipolar Disorder.

In cases of milder bipolar depression the first choice may be a mood stabilizer and an antidepressant together, or mood stabilizer alone. Faster reduction and cessation of antidepressants after remission in bipolar patients may reduce the risk of rapid cycling.

Current opinion among experts is that Bipolarity, either established or suspected (eg because of family history), makes specialist referral strongly indicated. (I would say almost mandatory).