Why the jury's still out on bipolar II treatment
Published: 5 April, 2019
Euphoria, an abundance of energy and creativity, enhanced risk-taking behaviours and libido, little need for sleep, excessive spending and feeling bulletproof. These are all symptoms of bipolar disorder I disorder – but they’re also symptoms of the condition’s lesser known relative, bipolar II.
Bipolar II is a serious mental disorder that impacts up to 5 per cent of the population – a significantly greater number than the 1 per cent of people diagnosed with bipolar I. But, despite the toll it takes on thousands of Australians and their families, it remains an elusive and challenging condition.
According to Gordon Parker AO, Scientia Professor of Psychiatry at the University of New South Wales and the former Executive Director and Founder of the Black Dog Institute, a lack of reliable data about bipolar II has resulted in a confused approach across the medical profession when it comes to treatment and management – and it’s putting patients at risk.
Here’s what it looks like
But first, the basics: Both bipolar I and II are characterised by significant fluctuations in mood, ranging from extremely high to very depressed. During lows, people fail to find pleasure in life, lack energy, and experience impaired concentration, as well as changes to appetite and weight. Many feel suicidal.
However, while both conditions share a number of symptoms, according to Professor Parker, there’s one major feature that sets them apart.
“What distinguishes bipolar I from bipolar II is that during the high states, people with bipolar I experience psychotic symptoms of delusions or hallucinations, and, in about 40 per cent of cases, they can be psychotic during their depressed phases,” he says.
“For those with a bipolar II condition, the individual is never psychotic when they’re high or depressed and that’s the key distinguishing feature, in my view.”
Not just ‘bipolar lite’
That bipolar II is a standalone condition is a view shared by the majority of mental health professionals – but not by all. A proportion still doubt that bipolar II exists at all or consider it a ‘milder’ version of the better-known bipolar I.
It’s an assumption that Professor Parker sees as inherently risky.
“What we know is that the suicide rate for bipolar II is just as high – and in some studies, higher – than bipolar I,” he says.
“It’s unwise to position it as a milder condition or something not to worry about, and I think the reason why it puts people at suicide risk is they go from a high to a depressed state very, very rapidly and precipitously.”
No singular approach to treatmentIf practitioners do not believe in bipolar II, or if they have a limited understanding of its unique features, patients risk being incorrectly diagnosed. Instead, many receive a diagnosis of a bipolar I disorder, or of a borderline personality disorder, or of ADHD, or simply of ‘depression’, resulting in treatment plans that don’t adequately address their underlying symptoms.
Even when a patient is correctly diagnosed with bipolar II, there’s no such thing as a standard approach to treatment. In a recent examination of nine different treatment guidelines from official organisations and professional bodies, Parker discovered minimal consensus on management strategies.
As most bipolar patients present with depressive symptoms, the result is that some clinicians may prescribe antidepressants, while others – like Parker – prefer mood stabilisers. It’s a debate that’s highlighted in Parker’s latest book, Bipolar II Disorder: Modelling, Measuring and Managing (Third Edition).
But despite the variety of treatment approaches available, there’s very little hard evidence available to recommend one over another. These issues stem from a lack of quality data on bipolar II, which was only formally classified as a standalone condition approximately 40 years ago.
Since then, there have been few studies of treatments for pure bipolar II patient populations, Parker says. Most studies combine bipolar I and II patients, despite their very real need for different treatment approaches. As a result, some clinicians take the same treatment approach for both bipolar I and II conditions, which Parker describes as akin to treating type 1 and 2 diabetes equivalently.
“Most of the treatments we have for bipolar disorder have been developed in studies involving bipolar I patients, and they often involve very heavy-duty medications that are unlikely to be suitable for patients with bipolar II,” Parker says.
“I think it’s really important that we accept that bipolar I and II are different states and that they are unlikely to benefit from the same medication. The problem is we haven’t got disorder-specific informing studies to support a consistent treatment approach and therefore we have lots of variation across practitioners as a consequence.”
What clinicians do agree on is that combining medication and non-pharmaceutical treatment approaches is integral to managing all bipolar conditions, including bipolar II. Non-pharmaceutical treatments can include therapy, both for the condition itself and for underlying issues that can make symptoms worse, such as substance abuse, while self-management strategies like mood charting, stay-well plans and corrective strategies to identify patterns and triggers are also intrinsically valuable.
“For example, if you suddenly don’t need to sleep, this could be an early warning sign of a high having emerged,” Parker says.
“Awareness of such signals allows corrective strategies. For example, an individual recognising that they go high every spring time and spend lots of money might hand their credit card over to their partner for that high-risk period.”
Don’t ignore the warning signs
While approaches to bipolar II treatment and management are still evolving, it’s important to seek help if you or someone you care about is exhibiting symptoms of the condition. Instead, speak to a partner, parent or close friend about your concerns, and also make an appointment with a general practitioner – specifically, a GP with an interest in mental health issues.
Now for the good news
While bipolar II disorder remains a challenging condition to diagnose and treat, there’s reason to be optimistic – some of Parker’s recent research has quantified that a very high percentage of patients who take a mood stabiliser and follow a stay-well plan have their condition brought under control. With the right treatment, patients with bipolar disorder can continue to work and flourish in their life.
You can read more about bipolar disorder here.
If you or someone you know is in crisis please call one of the following national helplines:
LIFELINE COUNSELLING SERVICE - 13 11 14
SUICIDE CALL BACK SERVICE 1300 659 467 (cost of a local call)