Psychotherapy and Meds in BP I and BP II People:Is BP II a Separate Disorder from BP I?
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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 different approach.   

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 page).

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 this --


Dr. Phelps 

Published October, 2008


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