I agree with most of the points in Dr. Shivakumar and Dr. Suppes’ article on the Texas Medical Algorithm Project (TMAP) and with the algorithms they mentioned (Current Psychiatry, February 2004).
However, the article does not address the difference between bipolar type I and bipolar type II disorder. While this may at first seem trivial, recognizing the difference is crucial to planning treatment. Since rapid cycling and depression are more prevalent than hypomania in bipolar type II, patients with this form of the disorder often require different medication(s) than do those with bipolar type I.
Also, some psychotropics are appropriate for outpatient treatment but not for inpatients and vice-versa. For example, lamotrigine takes time to work up to an effective dosage without significantly increasing the risk for rash; this would be reasonable treatment for an outpatient with bipolar type II but is not practical for an inpatient, especially with bipolar type I.
Michael S. Wilson, II, MD
Louisiana State University Health Sciences Center
New Orleans
Dr. Suppes responds
Dr. Wilson raises the issue of treatment recommendations for bipolar I versus bipolar II disorder.
All treatment guidelines—including the American Psychiatric Association Guidelines, Texas Algorithms, and others—are based on evidence gathered from studies of bipolar I patients. The full article from the TMAP consensus conference discusses this issue as well as the paucity of data available to make treatment recommendations for patients with bipolar II disorder.1
Unfortunately, this has not changed dramatically over the last 4 years. The good news is that numerous ongoing studies will reveal how best to treat bipolar II patients.
Dr. Wilson also notes that time to response makes a medication appropriate for use in one setting but not in another. Given today’s brief inpatient stays, any antidepressant or maintenance medication started during hospitalization will not begin to work until after discharge. Following titration guidelines with lamotrigine is critical, but as with antidepressants the time to response is a few weeks. Thus, these medications will require outpatient monitoring to assess efficacy and tolerability.
Delineating treatment for patients with bipolar II disorder is important. No matter how the prevalence is evaluated, bipolar II disorder affects many individuals. We recently reviewed the evidence in this area2 and were struck by how little attention this patient group has received to date.
Trisha Suppes, MD, PhD
Associate professor, department of psychiatry
Director, Bipolar Disorder Research Program
University of Texas Southwestern Medical Center
Dallas
- Suppes T, Dennehy EB, Swann AC, et al. Report of the Texas consensus conference panel on medication treatment of bipolar disorder 2000. J Clin Psychiatry 2002;63:288–99.
- Suppes T, Dennehy EB. Evidence-based long term treatment of bipolar II disorder. J Clin Psychiatry 2002;63(suppl 10):29–33.