Dr Wehr suggests that bipolar illness is a heterogeneous disorder; we agree. Use of the term apparent contradiction to explain the discrepancies in tricyclic induction of mania in different bipolar patients samples would have been better.Dr Wehr is correct in stating that 46% of the patients in the Prien et al study never reached the maintenance phase and, therefore, conclusions must be modified to indicate that they only apply to patients who could be maintained with the combination of lithium and imipramine. This limitation of the Prien et al study is not unique, and only a percentage of patients who enter the initial phases of any long-term maintenance study are actually randomized to study treatments.We concur that it would be helpful if the composition of patient groups in all studies is characterized as carefully as possible and that generalizations should be restricted to these subgroups.Dr
Shapiro DR, Quitkin FM, Fleiss JL. Unnecessary Confusion About Opposite Findings in Two Studies of Tricyclic Treatment of Bipolar Illness-Reply. Arch Gen Psychiatry. 1990;47(8):788. doi:10.1001/archpsyc.1990.01810200096017
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