8 Controversies in Bipolar Disorder Addressed

Nassir Ghaemi, MD, MPH; Stephen M. Strakowski, MD


June 30, 2016

Controversy 4: Treating Type I vs Type II

Should the treatment of bipolar II disorder differ from that of bipolar I disorder?

Dr Ghaemi: Some experts make a big deal about the difference between bipolar I and bipolar II disorder, accepting that antidepressants are ineffective in the former but asserting that they are effective and safe in the latter. Some randomized trials report benefit and safety in bipolar II disorder, but there are others that report inefficacy.

I'm open to the notion that some patients with bipolar II disorder may benefit from low-dose antidepressants, in the short term especially, but I'm doubtful they are helpful in most patients—even those with type II illness. However, if someone has very mild bipolar II disorder, with rare and infrequent hypomanic episodes, they may have some benefit with some low-dose antidepressants.

Dr Strakowski: The diagnosis of bipolar II disorder is one of the least reliable in psychiatric practice because hypomania is infrequently witnessed, so that clinicians end up almost exclusively relying on reporting; here, individuals with chronic depression that waxes and wanes will often be mistakenly told they have "mood swings" and receive an erroneous diagnosis of bipolar II disorder. These patients are almost certainly manageable with antidepressants.

On the other hand, Amsterdam and Brunswick[5] and others have completed work in more carefully defined bipolar II disorder suggesting that SSRI monotherapy may be effective in some of these patients; this research also suggests that bipolar II disorder, at least in some individuals, may be more similar to recurrent major depression than bipolar I disorder.

Because the jury is still out on these issues, my recommendation in patients with bipolar II disorder is to first very carefully review evidence for the diagnosis—and then, when convinced that the diagnosis is probably correct, try to gain improvement through optimizing mood stabilizers before considering antidepressants.


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