Swinging bipolar (II) presumes at least one major depressive episode, plus at least one hypomanic episode over at least four days. The same characteristics as mania are evident, with the disturbance of mood observable by others; but, the episode is not enough to disrupt normal functioning or necessitate hospitalization and there are no psychotic features.
Those in a state of hypomania are typically the life of the party, the salesperson of the month and more often than not the best-selling author or Fortune 500 mover and shaker, which is why so many refuse to seek treatment. But the same condition can also turn on its victim, resulting in bad decision-making, social embarrassments, wrecked relationships and projects left unfinished.
Hypomania can also occur in those with raging bipolar and may be the prelude to a full-blown manic episode.
While working on the American Psychiatric Association’s latest DSM version of bipolar (IV-TR), Trisha Suppes MD, PhD of the University of Texas Medical Center in Dallas carefully read its criteria for hypomania, and had an epiphany. “I said, wait,” she told a UCLA grand rounds lecture in April 2003 and webcast the same day, “where are all those patients of mine who are hypomanic and say they don’t feel good?”
Apparently, there is more to hypomania than mere mania lite. Dr. Suppes had in mind a different type of patient, say one who experiences road rage and can’t sleep. Why was there no mention of that in hypomania? she wondered. A subsequent literature search yielded virtually no data.
The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury. However, nowhere does it account for more subtle manifestations, often the type of states many bipolar patients may spend a good deal of their lives in. The treatment implications can be enormous. Dr. Suppes referred to a secondary analysis Swann of a Bowden et al study of patients with acute mania on lithium or Depakote which found that even two or three depressed symptoms in mania were a predictor of outcome.
Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably. Dr. Suppes defines the former as “an energized depression,” which she and her colleagues made the object of in a prospective study of 919 outpatients from the Stanley Bipolar Treatment Network. Of 17,648 patient visits, 6993 involved depressive symptoms, 1,294 hypomania, and 9,361 were euthymic (symptom-free). Of the hypomania visits, 60 percent (783) met her criteria for dysphoric hypomania. Females accounted for 58.3 percent of those with the condition.
Neither the pioneering TIMA Bipolar Algorithms nor the APA’s Revised Practice Guideline (with Dr. Suppes a major contributor to both) offer specific recommendations for treating dysphoric hypomania, such is our lack of knowledge. Clearly the day will come when psychiatrists will probe for depressive symptoms or mere suggestions of symptoms in mania or hypomania, knowing this will guide them in the prescriptions they write, thus adding an element of science to the largely hit or miss practice that governs much of medications treatment today. But that day isn’t here yet.