For those patients experiencing breakthrough episodes of depression, the addition of an antidepressant should be considered (although antidepressants can occasionally flip the person into a high or a ‘mixed state’). For breakthrough hypomanic episodes that do not respond to nondrug strategies, an atypical antipsychotic can be useful when prescribed at a low dose and is usually only required for a brief period.
A stay-well plan
With respect to nondrug strategies, the development of a stay-well plan is central in managing bipolar II disorder. In essence, the patient is trained to use a daily mood chart to identify their early warning signs and triggers for depressive or hypomanic episodes, and to develop a plan for preventing the episode getting out of control and creating ‘collateral damage’. Early warning signs include sleep disruption, the person becoming energised or showing other hypomanic symptoms, increasing their level of alcohol and/or drugs (many of which fuel highs) or being unusually argumentative.
The patient should also be encouraged to develop a wellbeing plan, which is best undertaken when their mood is stable and in conjunction with a relative or friend whom they trust. The plan includes the patient accepting that the other person can alert them to the risk of a mood swing being observed and agreeing that certain actions can be employed when early warning signs and risk factors are in play, especially if the patient’s mood state advances to being noncompliant.
There are a number of psychological therapies that are advocated for treating patients with bipolar disorder including cognitive behavioural therapy, interpersonal and social rhythm therapy, and family-focused therapy, but these generally involve ‘fitting’ the patient to such a psychological treatment or paradigm, which is usually more relevant for the nonbiological depressive and anxiety states. Thus, it is more effective to implement a program in which the therapist (generally a skilled psychologist with extensive experience in managing bipolar disorder) works with the patient or, ideally, a group of patients, with bipolar II disorder to provide them with education about the condition, focusing on triggers, early warning signs, treatment options and psychological strategies that may be specifically beneficial.
GPs should feel comfortable in diagnosing and initiating management for people with a bipolar II disorder. If the patient does not respond well to the first treatment choice, then referral to a psychiatrist with skills in managing bipolar disorder would be the next step. Such management is extremely rewarding as many patients state their appreciation for ‘getting their life back’. MT