Q: Psychotherapy and Meds in BP I and BP II People : Is BP
II a Separate Disorder from BP I?
Hello Dr. Phelps,
Last year you wrote about a form of bipolar II psychotherapy that showed
promise for eliminating the need for medication. Have you heard more about
it? From my observation meds seem to be more effective in bipolar I
patients, and I suspect that BP2 is really a separate disorder that only looks
like BP1 because we know so little about mental illness and the brain in
general. So, in essence I think that prescribing BP1 drugs for BP2 is like
giving Nyquil to everyone who presents with a runny nose, be the underlying
problem a cold, allergy, or cocaine habit.
I enjoy your website very much.
Dear LW --
Thanks for the question. Several thoughts on that: first, at this point I
would say that the psychotherapy approaches for bipolar disorder seem to be
equally relevant in both Bipolar I and Bipolar II. For example, the
Barcelona research group recently reported their five-year data on their
approach, Psychoeducation, in Bipolar II. They showed that their education
intervention produced a significant difference between the psychoeducation group
and a "control treatment" (the same therapists spending the same amount of time,
but just running a support group, basically, not providing education or other
psychotherapy as such). That difference was quite large and, most
importantly, that difference was still there are five years later.
Unfortunately, the most widely practiced version of psychotherapy, "cognitive
behavioral therapy", when adapted for bipolar disorder, is probably better
suited for bipolar I. For example, the treatment manual by Monica Basco,
strikes me as formulated primarily for prevention of recurrences. People
with bipolar II are more likely to have continuous symptoms which require a
Anyway, I could go on about that. But it is probably
moot. Finding any of these bipolar-specific psychotherapies is still
difficult at this point, outside of the research centers that have been studying
them. Nevertheless, the treatment manuals for all of them are available
(see the bottom of my
psychotherapy for bipolar disorder
Secondly, is Bipolar II really a separate illness? Most mood researchers
seem to be increasingly of the opinion that "bipolar disorder" -- including
bipolar I and bipolar II -- is an umbrella term for a fairly wide variety of
conditions. Genetically it looks like there are many, many different genes
involved in bipolar disorder, that create all sorts of different patterns.
In addition, there is a great deal of overlap with conditions like ADHD, PTSD,
other anxiety disorders and syndromes that get lumped under the unfortunate term
"personality disorders".. Various people have various degrees of these
other conditions, as well as varying degrees of symptom intensity, and different
symptom mixtures. With all of those variations, it is rather amazing that
we can characterize anything very accurately. And yet, the term "bipolar
disorder" does -- in my opinion anyway -- capture often something that can lead
to effective treatments. So it is not as chaotic as it might look!
Finally, about the NyQuil. As you know, there are lots of medications we
use in the treatment of bipolar disorder (hopefully after making good use of the
non-medication approaches, for any form of this illness). People with
Bipolar II frequently do not need medications that can prevent manic symptoms;
their main problem is depression, and often they do not have a history of
destructive "hypomania". Under those circumstances, lamotrigine has
emerged as one of the most obvious candidates, because it lacks many of the side
effects and long-term risks of the rest of the "mood stabilizers".
However, I use it in Bipolar I quite frequently, alongside some of those other
medications. And for all of the rest of the mood stabilizers, whether a
patient has Bipolar I or Bipolar II doesn't really seem to determine which
particular medication is going to be most helpful. So in that respect, I
don't find that the subtype of bipolar disorder has much value in determining
which medication approach will be best.
Re-rereading your question, I fear I'm kind of talking around your question and
not really getting at. But I hope you will find something useful in all
Published October, 2008