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Objective The risk-benefit profile of antidepressant medications in bipolar disorder is controversial. When conclusive evidence is lacking, expert consensus can guide treatment decisions. The International Society for Bipolar Disorders (ISBD) convened a task force to seek consensus recommendations on the use of antidepressants in bipolar disorders. Method An expert task force iteratively developed consensus through serial consensus-based revisions using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new or reworded items and items that needed to be rerated. This process resulted in the final ISBD Task Force clinical recommendations on antidepressant use in bipolar disorder. Results There is striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder. Few well-designed, long-term trials of prophylactic benefits have been conducted, and there is insufficient evidence for treatment benefits with antidepressants combined with mood stabilizers. A major concern is the risk for mood switch to hypomania, mania, and mixed states. Integrating the evidence and the experience of the task force members, a consensus was reached on 12 statements on the use of antidepressants in bipolar disorder. Conclusions Because of limited data, the task force could not make broad statements endorsing antidepressant use but acknowledged that individual bipolar patients may benefit from antidepressants. Regarding safety, serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors. The frequency and severity of antidepressant-associated mood elevations appear to be greater in bipolar I than bipolar II disorder. Hence, in bipolar I patients antidepressants should be prescribed only as an adjunct to mood-stabilizing medications.

It is commonly suggested that a female preponderance in depression is universal and substantial. This review considers that proposition and explanatory factors. The view that depression rates are universally higher in women is challenged with exceptions to the proposition helping clarify candidate explanations. 'Real' and artefactual explanations for any such phenomenon are considered, and the contribution of sex role changes, social factors and biological determinants are overviewed. While artefactual factors make some contribution, it is concluded that there is a higher order biological factor (variably determined neuroticism, 'stress responsiveness' or 'limbic system hyperactivity') that principally contributes to the gender differentiation in some expressions of both depression and anxiety, and reflects the impact of gonadal steroid changes at puberty. Rather than conclude that 'anatomy is destiny' we favour a diathesis stress model, so accounting for differential epidemiological findings. Finally, the impact of gender on response to differing antidepressant therapies is considered briefly.

SummaryUsing a reliable and valid measure of reported parental care and overprotection (the Parental Bonding Instrument) patients with two types of depressive disorder were compared with a control group, and the relationships to depressive experience examined in a non-clinical group as well. Bipolar manic-depressive patients scored like controls whereas neurotic depressives reported less parental care and greater maternal overprotection. Depressive experience in the non-clinical group was negatively associated with low parental care and weakly associated with parental overprotection.