Evidence-Based Reviews

Soft bipolarity: How to recognize and treat bipolar II disorder

Current Psychiatry. 2009 July;8(7):41-48

References

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2. Angst J. The bipolar spectrum. Br J Psychiatry. 2007;190(3):189-191.

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4. Angst J, Gamma A, Bennazzi F, et al. Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord. 2003;73:133-146.

5. Judd LJ, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord. 2003;73:123-131.

6. Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry. 2001;58:1265-1270.

7. Smith DJ, Harrison N, Muir W, et al. The high prevalence of bipolar spectrum disorders in young adults with recurrent depression: toward an innovative diagnostic framework. J Affect Disord. 2005;84(2-3):167-178.

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9. Akiskal HS, Benazzi F, Perugi G. Agitated “unipolar” depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. J Affect Disord. 2005;85(3):245-258.

10. Ghaemi SN, Wingo AP, Filkowski MA, et al. Long-term antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks. Acta Psychiatr Scand. 2008;118(5):347-356.

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⁶ Other reports have indicated that at least 40% of young adults with recurrent MDD satisfy broad diagnostic criteria for bipolar disorder.⁷

Higher rates of unrecognized bipolar disorder have been identified in patients with treatment-resistant depression. In a prospective study of 61 consecutive MDD patients referred to a mood disorders clinic, 59% satisfied DSM-IV-TR criteria for bipolar disorder.⁸

Consequences. Undiagnosed BP II disorder is an important clinical issue because bipolar features in patients presumed to have recurrent MDD can adversely affect long-term outcomes. Many of these patients will be treated exclusively with antidepressants despite evidence that antidepressant monotherapy for bipolar depression—at least for some patients—can cause more frequent mood episodes, mood destabilization, and possibly an increase in suicidal behaviors.^9,10

This point is highlighted in the United Kingdom’s National Institute of Health and Clinical Excellence (NICE) guidelines for bipolar disorder, which recommended that antidepressants be prescribed for bipolar depression only in combination with mood stabilizer treatment and withdrawn within 2 to 3 months of recovery.¹¹

The American Psychiatric Association’s (APA) practice guideline for treating bipolar disorder, published in 2002, advises against antidepressants as monotherapy for bipolar depression, recommending instead that lithium or lamotrigine be used first-line. A revised APA guideline is scheduled for publication this year.¹²

Why is BP II underdiagnosed?

Notwithstanding the limitations of DSMIV-TR criteria for hypomania, additional factors contribute to under-recognition of BP II in clinical practice.

Clinical Point

Because patient insight regarding hypomania is poor, I find it enormously helpful to obtain a corroborative history from a relative

Patient insight regarding hypomania is generally poor. Not surprisingly, individuals with severe and disabling depressive episodes often fail to recognize the pathological aspects of brief (and comparatively infrequent) periods of elevated mood and overactivity. For this reason, I always obtain a corroborative history from a relative when assessing a patient for possible bipolar disorder. I find this enormously helpful for confirming or excluding a BP II diagnosis.

Dominant depressive symptoms. The clinical course of bipolar disorders is dominated by low-grade depressive symptoms and recurrent depressive episodes rather than mania or hypomania. This is especially true for BP II disorder, where the ratio of time spent with depressive symptoms relative to time with hypomanic symptoms is approximately 30:1.¹³ The fact that BP II patients in general seek help only during depressive periods means that consultations inevitably focus on the diagnosis and treatment of depression, rather than long-term prophylaxis of both depressive and hypomanic episodes.

Indistinguishable symptoms? Bipolar depressions are generally thought to be clinically indistinguishable from unipolar depressions, but this might not be clear-cut. Although differentiating symptoms of unipolar and bipolar depression can be difficult in clinical practice, evidence suggests that certain symptoms may be more common in bipolar than unipolar depression:

atypical depressive features such as mood reactivity, overeating, oversleeping, and excessive fatigue¹⁴
depressive psychotic symptoms, especially in younger patients¹⁵
“mixed” depressive episodes (depressive episodes with concurrent manic symptoms).¹⁶

Other variables are associated with bipolar outcome in apparently unipolar depression (Table 2). These include shorter but more frequent depressive episodes and a strong family history for mood disorders, such as a first-degree relative with bipolar disorder or multiple family members with MDD. BP II also tends to be highly comorbid with anxiety disorders, alcohol and drug abuse, and personality disorders (especially borderline personality disorder).

How to recognize BP II disorder

To detect and diagnose BP II disorder, systematically assess hypomanic features in all patients who present with recurrent MDD, especially those who have an early age of onset or don’t seem to be responding well to antidepressant monotherapy. As noted, a corroborative history from a close relative is essential. Within a full clinical assessment, use the features listed in Table 2 to help differentiate bipolar depression from unipolar depression.

Screening instruments for hypomania are no substitute for a careful psychiatric history but can be very helpful in everyday clinical practice. The most well-known is the Mood Disorder Questionnaire (MDQ);¹⁷ other options include the Hypomania Checklist (HCL-32)¹⁸ and the Bipolar Spectrum Diagnostic Scale (BSDS).¹⁹ In general, the MDQ performs better at detecting BP I in psychiatric practice settings, whereas the HCL-32 and BSDS may be more useful in primary care and general population settings.²⁰

The BSDS has a particular focus on the softer end of the bipolar spectrum,¹⁹ and in my experience patients like its narrative structure. It can help prompt discussions about previous hypomania symptoms and mood instability. In this sense, the BSDS is a useful adjunct to the routine clinical assessment of patients with recurrent depressive disorders. Click here to view the BSDS.