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Feature Article

Managing bipolar II disorder in the community

Gordon Parker
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© MURATGUNGUT/SHUTTERSTOCK
© MURATGUNGUT/SHUTTERSTOCK

Abstract

Bipolar II disorder has a significant prevalence and presents considerable risks in terms of impairment, social indiscretion and suicide. It can be readily diagnosed if appropriate criteria are respected, and its management involves a triad of medication, development of a wellbeing plan and psychoeducation. Most people with the condition can be primarily managed by their GP and do well.

Key Points

  • Bipolar II disorder has a significant prevalence and presents considerable risks for the patient.
  • Of late, Australian GPs have successfully taken up the assessment and management of patients with depression.
  • Therefore, there is a strong argument for GPs to feel comfortable about diagnosing and initially managing those with a bipolar II condition as well.
  • Management of bipolar II disorder involves a triad of medication, development of a wellbeing plan and psychoeducation.

This article is an abstract of a more detailed monograph that focuses on several issues addressed here and reflects the author’s interpretation of the literature and clinical observations in managing patients with bipolar II disorder over time.1

Types of bipolar disorder

The bipolar disorders are marked by distinct oscillations in mood states. There are three principal bipolar disorders. Bipolar I and II have a base of hypomanic or manic features during the elevated phase and generally share melancholic features in the depressive phase. However, people with a bipolar I disorder are psychotic when ‘high’ and a small percentage of these patients have episodes of psychotic depression during the depressed phase.

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People with bipolar II disorder are never psychotic in the manic phase and very rarely so in the depressed phase. Bipolar III disorder is an applicable diagnosis when a patient develops hypomanic or manic symptoms after the introduction, rapid increase in dose or rapid cessation of an antidepressant, but these symptoms can also occur in response to a number of other drugs. It is likely that in a certain percentage of such cases the exposure drug has brought out a bipolar condition in someone who is so predisposed but in many other instances it is an iatrogenic reaction.

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Community estimates in western countries generally quantify a lifetime risk of a bipolar II disorder at around 0.5% but, in the author’s opinion, the true rate is closer to 3%, with the lower figure reflecting limitations to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria as detailed below.

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The author believes that Australian GPs have taken up the assessment and management of depression well in the past two decades, and there is a strong argument for them to feel comfortable about diagnosing and initially managing those with a bipolar II condition as well.

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© MURATGUNGUT/SHUTTERSTOCK
© MURATGUNGUT/SHUTTERSTOCK
Professor Parker is Scientia Professor of Psychiatry at the University of New South Wales, Sydney, a consultant psychiatrist at the Prince of Wales Hospital, Sydney, and accredited psychiatrist at the Gordon Private Hospital, Sydney, NSW.