19 - Management commentary  pp. 240-243

Management commentary

By Eduard Vieta

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Bipolar II Disorder is a significant public health problem, and there is a dearth of studies of effective treatment modalities for this specific condition. Literally, the evidence base for most of what we use to treat BP II comes from extrapolation of what we have learned from trials on BP I, unipolar depression, schizophrenia, and even epilepsy. Among several reasons, the two principal ones for this phenomenon are the relative ‘youth’ of the diagnostic category and the absence of a specific regulatory indication for marketing approval. Hence, in the practical absence of solid scientific grounds (El-Mallakh et al., 2006), opinion-based articles like the one by Parker become crucial to assist routine clinical care. I now offer some personal views.

Validity and reliability of the diagnosis of BP II Disorder

There is some evidence supporting BP II as a valid diagnostic category, but its reliability is relatively low (Vieta and Suppes, 2007). This is one of the major sources of both under-diagnosis and misdiagnosis (Akiskal, 2002). Most difficulties come from the frequently egosyntonic, pleasurable and transient nature of hypomania, which makes it very difficult to diagnose retrospectively. If this was a truly mild condition, nobody would care about under-diagnosis and misdiagnosis, but unfortunately, in my view, it is not mild. It only appears so when considered or observed cross-sectionally, but, in the long run it is associated with significant suffering, impairment and suicide (Vieta et al., 1997).

Akiskal, H. S. (2002). Towards a new classification of bipolar disorders. In Bipolar Disorders. Clinical and Therapeutic Progress, ed. E. Vieta, pp. 185–215. Madrid: Panamericana.
Altshuler, L. L., Suppes, T., Black, D. O. et al. (2006). Lower switch rate in depressed patients with Bipolar II than Bipolar I Disorder treated adjunctively with second-generation antidepressants. American Journal of Psychiatry, 163, 313–15.
Colom, F. and Vieta, E. (2006). Psychoeducation Manual for Bipolar Disorder. New York: Cambridge University Press.
Coryell, W., Keller, M., Endicott, J. et al. (1989). Bipolar II illness: course and outcome over a five-year period. Psychological Medicine, 19, 129–41.
El-Mallakh, R., Weisler, R. H., Townsend, M. H. and Ginsberg, L. D. (2006). Bipolar II Disorder: current and future treatment options. Annals of Clinical Psychiatry, 18, 259–66.
Ghaemi, S. N., Hsu, D. J., Soldani, F. and Goodwin, F. K. (2003). Antidepressants in bipolar disorder: the case for caution. Bipolar Disorders, 5, 421–33.
Parker, G., Tully, L., Olley, A. and Hadzi-Pavlovic, D. (2006). SSRIs as mood stabilizers for Bipolar II Disorder? A proof of concept study. Journal of Affective Disorders, 92, 205–14.
Suppes, T., Hirschfeld, R. M., Vieta, E. et al. (2007). Quetiapine for the treatment of Bipolar II depression: analysis of data from two randomized, double-blind, placebo-controlled studies. World Journal of Biological Psychiatry (in press).
Tohen, M., Vieta, E., Calabrese, J. et al. (2003). Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of Bipolar I depression. Archives of General Psychiatry, 60, 1079–88.
Torrent, T., Martinez-Aran, A., Daban, C. et al. (2006). Cognitive impairment in Bipolar II Disorder. British Journal of Psychiatry, 189, 254–9.
Vieta, E. (2003). Case for caution, case for action. Bipolar Disorders, 5, 434–5.
Vieta, E. and Suppes, T. (2007). International Society for Bipolar Disorders Diagnostic Task Force on Bipolar II Disorder. Bipolar Disorders (in press).
Vieta, E., Colom, F., Martínez-Arán, A. et al. (2000). Bipolar II Disorder and comorbidity. Comprehensive Psychiatry, 41, 339–43.
Vieta, E., Colom, F., Martínez-Arán, A., Benabarre, A. and Gastó, C. (1999). Personality disorders in Bipolar II patients. Journal of Nervous and Mental Disease, 187, 245–8.
Vieta, E., Gastó, C., Colom, F. et al. (2001). The role of risperidone in Bipolar II: an open six-month study. Journal of Affective Disorders, 67, 213–19.
Vieta, E., Gastó, C., Otero, A., Nieto, E. and Vallejo, J. (1997). Differential features between Bipolar I and Bipolar II disorder. Comprehensive Psychiatry, 38, 98–101.
Zarate, C. A. Jr., Payne, J. L., Singh, J. et al. (2004). Pramipexole for Bipolar II depression: a placebo-controlled proof of concept study. Biological Psychiatry, 56, 54–60.