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    Dr. Goldberg: Prognosis in I vs. II
    RogueFemale2 posted:
    Dear Dr. Goldberg:

    This is probably one of those posts that will make you say, "Sigh. There's absolutely no way to answer this pointless question because there are far too many diffuse factors to consider." But obviously that won't prevent me from asking anyway.

    Generally speaking and all other things being equal, is the prognosis for a patient with Bipolar I disorder worse than the prognosis for a patient with Bipolar II disorder? By prognosis I mean, what is the general outlook within each of these categories for the diagnosed person to have stability and success in life, and not to commit suicide or destroy life in some other way. Does the person with Bipolar I face significantly greater obstacles than the person with Bipolar II? Or is it completely dependent on how well each individual takes care of himself or herself, in terms treatment adherence, coping skills, etc.?

    As a corollary question, I've sometimes heard people say, "It's only Bipolar II," with the suggestion that Bipolar II is not a particularly significant illness in comparison with Bipolar I, or that Bipolar II is just "bipolar lite." I'm trying to think of an analogy here . . . it would be like saying that Bipolar I is the equivalent of double pneumonia while Bipolar II is only a common upper respiratory infection. One is quite serious while the other one really is not. Is that true? Or not?

    Joseph F Goldberg, MD responded:
    Dear Karen,
    No sighs or groans, but let's say, conditional factors; because there is so much variability in outcomes in both BP I and BP II, a more accurate question would be, what factors lead to a better or poorer prognosis in bipolar disorder per se? In BP II disorder, the "only [BP II>" refers to the highs, which, by definition, do not interfere with functioning. (If they did, the diagnosis would become BP I.) Psychosis, by definition, also doesn't occur in hypomanias (psychosis equals mania, not hypomania). So from the "high" side, the prognosis is far better in BP II than BP I disorder. But, the depressions tend to be more pervasive and last longer and have greater severity in BP II than BP I disorder. To the extent that disability in bipolar disorder tends to derive more from depressions than manias, BP II is often more disabling. However, formal comparative studies of work and social functioning between BP I and BP II disorder have shown more similarities than differences -- a recent study by a renowned bipolar research program in Barcelona found no differences in functional outcome between BP I and BP II patients. Suicide attempt and completion rates are higher in BP II than BP I disorder (or in unipolar depression). Attentional and related cognitive deficits are more pervasive in BP I disorder (about a half a standard deviation below the normal population) than BP II disorder (about a half an SD beloe the norm). Some authorities think that more frequent episodes per year (ie, rapid cycling) is more common in BP II than BP I disorder.
    So, mainly, prognosis in BP II depends on the responsiveness of to depression. As a general rule, the longer someone is well the longer they remain well (tautological as that is), meaning the best predictor of good outcome is doing well for as long as possible.

    Dr. G.
    RogueFemale2 replied to Joseph F Goldberg, MD's response:
    Dr. Goldberg:

    Thank you for this concise and clear response--and without any sighs or groans, to boot!

    So, if it is true that "the longer someone is well the longer they remain well," if one does in fact remain well (i.e., without any significant relapses of either severe depression or disabling mixed-ish episodes, in the case of Bipolar II), is it, at some point, conceivably possible to say that the disease is in some sense no longer a problem or even that a full recovery has occurred, and thus the patient no longer requires treatment with medicine? Or is that laughably wishful thinking, given that "the best predictor of good outcome is doing well for as long as possible" could simply indicate that the patient has done well precisely because he or she has been med compliant?

    I do honestly apologize for my tendency toward theoretical questions. I had a doctor scold me once (really!) for "over intellectualizing," but I need to ask these kinds of questions in order to understand and to accept. It helps me, immeasurably.

    Joseph F Goldberg, MD replied to RogueFemale2's response:
    Dear Karen, There is some small % of people with bipolar disorder who seem to have only 1 or a few episodes with complete remissions, need few medicines to stabilize, and then may have many years go by with no symptoms such that a taper-off to no medicines may be feasible...but such instances are few and far between. I've seen it maybe a few times in 20 years. I've also seen people appear stable for several years off of medicines and then eventually relapse. More often, prolonged wellness while on medication is a sign that something's working, rather than a prompt to uproot the foundation and see if the building still stands. Dr G
    RogueFemale2 replied to Joseph F Goldberg, MD's response:
    Ah. Point taken.

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