27 - Management commentary  pp. 278-281

Management commentary

By Michael E. Thase

Image View Previous Chapter Next Chapter

Across the past decade there has been a rather dramatic increase in interest in Bipolar II Disorder. Once viewed as a relatively minor and unreliably diagnosed variant of the ‘real’ illness, BP II and other depressions grouped within the so-called ‘softer’ end of the bipolar spectrum are now considered by some experts as the more prevalent forms of manic depressive illness (see, for example, Angst and Cassano, 2005). Not only is BP II much more common than previously appreciated, there is good evidence that the depressive episodes – which can consume one half of an afflicted adult's lifetime (Judd et al., 2003) – can have devastating effects on psychosocial vocational functioning that at least match those of the ‘major’ form of the illness (Judd et al., 2005). Such findings underscore the more pernicious and protracted nature of the depressive episodes of bipolar disorder, as well as the need for better antidepressant therapies for people who experience hypomanic episodes.

As people with BP II almost never seek treatment for the hypomanic episodes, clinicians often do not make the diagnosis of BP II until after the patient has received some sort of antidepressant therapy for some duration. Once the diagnosis is made, he or she must answer only one fundamental question when fashioning a treatment: ‘Is the risk of a treatment-emergent affective switch (TEAS) sufficiently high to warrant the use of a mood stabiliser?

Angst, J. and Cassano, G. (2005). The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar Disorders, 7 (Suppl. 4), S4–12.
Calabrese, J. R., Bowden, C. L., Sachs, G. S. et al. (1999). A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with Bipolar I depression. Lamictal 602 Study Group. Journal of Clinical Psychiatry, 60, 79–88.
Calabrese, J. R., Keck, P. E. Jr., Macfadden, W. et al. (2005). A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of Bipolar I or II depression. American Journal of Psychiatry, 162, 1351–60.
Frye, M. A., Ketter, T. A., Kimbrell, T. A. et al. (2000). A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders. Journal of Clinical Psychopharmacology, 20, 607–14.
Goodwin, G. M., Bowden, C. L., Calabrese, J. R. et al. (2004). A pooled analysis of two placebo-controlled 18-month trials of lamotrigine and lithium maintenance in Bipolar I Disorder. Journal of Clinical Psychiatry, 65, 432–41.
Judd, L. L., Akiskal, H. S., Schettler, P. J. et al. (2003). A prospective investigation of the natural history of the long-term weekly symptomatic status of Bipolar II Disorder. Archives of General Psychiatry, 60, 261–9.
Judd, L. L., Akiskal, H. S., Schettler, P. J. et al. (2005). Psychosocial disability in the course of Bipolar I and II disorders: a prospective, comparative, longitudinal study. Archives of General Psychiatry, 62, 1322–30.
Kupfer, D. J., Pickar, D., Himmelhoch, J. M. and Detre, T. P. (1975). Are there two types of unipolar depression? Archives of General Psychiatry, 32, 866–71.
Nierenberg, A. A., Ostacher, M. J., Calabrese, J. R. et al. (2006). Treatment-resistant bipolar depression: a STEP-BD equipoise randomized effectiveness trial of antidepressant augmentation with lamotrigine, inositol, or risperidone. American Journal of Psychiatry, 163, 210–16.
Post, R. M., Altshuler, L. L., Leverich, G. S. et al. (2006). Mood switch in bipolar depression: comparison of adjunctive venlafaxine, bupropion and sertraline. British Journal of Psychiatry, 189, 124–31.
Thase, M. E. (2006). Pharmacotherapy of bipolar depression: an update. Current Psychiatry Reports, 8, 478–88.
Thase, M. E., Macfadden, W., Weisler, R. H. et al. for the BOLDER II Study Group (2006). Efficacy of quetiapine monotherapy in Bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study). Journal of Clinical Psychopharmacology, 26, 600–9.
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.
Vieta, E., Martinez-Aran, A., Goikolea, J. M. et al. (2002). A randomized trial comparing paroxetine and venlafaxine in the treatment of bipolar depressed patients taking mood stabilizers. Journal of Clinical Psychiatry, 63, 508–12.