Atypical antipsychotics are also rated as first-line agents for combined treatment of psychotic depression. The experts were also asked about their preferred first-line medications when comorbidity is present. While there was consensus on most of the major clinical decisions in the guidelines, there was not a clear-cut consensus on some issues, including how frequently to monitor labs and what to do in situations where patients have gained a lot of weight, Sachs said. For weight gain associated with mood stabilizers, the experts prefer to continue the present medication and attempt weight loss through diet or exercise. No consensus exists on whether dose reduction is helpful.
Many experts also consider adding topiramate as an option.
There was only modest support, with either type of medication, for the use of appetite suppressants or thyroid hormone. There was also some caution among the experts about using some of the newer treatments, such as lamotrigine, gabapentin and topiramate. Doctors seem perfectly willing to consider omega-3, but it is not the first choice at any time for bipolar patients alone. The same is true for St. John's wort and many other alternatives. Sachs also pointed out that the expert consensus guidelines would be suitable for primary care physicians and other health care professionals involved in the care of patients who have bipolar disorder.