Pharmacologic management of bipolar-II disorder

Byline: David. Bond, Lakshmi. Yatham According to the Diagnostic and Statistical Manual of Mental Disorders, 4[sup] th Edition, Text Revision (DSM-IV-TR)[sup] [1], bipolar II disorder (BDII) consists of recurrent episodes of depression and hypomania. Although the lifetime prevalence of BDII remains a matter of debate, with some studies reporting rates as high as 5% [sup] [2], most epidemiological surveys suggest a prevalence of 1%-2% [sup] [3],[4] .[sup] This makes BDII at least as common as bipolar I disorder (BDI), which has a lifetime prevalence of 1% [sup] [4] .[sup] BDII is sometimes viewed as a form of bipolar illness, but this is a misconception, as it is associated with rates of disability that are comparable to BDI [sup] [5] .[sup] As well, BDII may have the highest frequency of suicidal behaviour of any mood disorder[sup] [6] . Although BDII is defined by the occurrence of hypomania, for many patients it appears to be a predominantly depressive illness. Studies in treated samples demonstrate that BDII patients spend approximately half of their lives with depressive symptoms [sup] [7],[8] ,[sup] In fact, BDII is likely the most common cause of depression after major depressive disorder, with studies suggesting that 18.5% of family practice patients with depression and 40% of depressed patients in psychiatric specialty settings suffer from BDII [sup] [9],[10] . This[sup] is indicative of both the frequency of depressive symptoms, and the possibility that depressions do not respond as well to treatment as hypomanias. Hypomanias, in contrast to depressions, are often brief and are not uncommonly associated with minimal to mild disability[sup] [2],[5] . The frequency and severity of depression in BDII, coupled with the difficulties inherent in retrospectively ascertaining a history of hypomania, commonly lead to the misdiagnosis of BDII as major depressive disorder (MDD). To avoid this pitfall, clinicians should be finely attuned to the possibility of BDII as a cause of depression, and must be rigorous in screening all depressed patients for a history of hypomania. Furthermore, it is important to be aware of a number of barriers to the diagnosis of hypomania. First, patients and their families often do not recognize hypomania as a pathological state, and they frequently do not volunteer a history of hypomanic symptoms. Second, although the DSM-IV-TR requires a 4-day duration of symptoms to diagnose hypomania, hypomania is frequently briefer, with some studies suggesting a median duration of 1-3 days[sup] [2] .[sup] Thus, in addition to thoroughly screening patients for hypomanic symptoms, we have found a number of clinical tools useful in making the diagnosis. These include obtaining collateral history from family members; having patients keep daily mood diaries; and also having them complete the Mood Disorders Questionnaire (MDQ), a 13-item self reported questionnaire with queries about common hypomanic symptoms [sup] [11] .[sup] Although the MDQ has not been as rigorously studied as a screening instrument in BDII as it has in BDI, our clinical experience suggests that it can be a helpful diagnostic aid. Finally, the value of long-term follow-up cannot be overstated, as hypomanic symptoms often become obvious during long-term follow-up. Partly as a result of difficulties in making the correct diagnosis, the prevalence of hypomania has until recently been underestimated, and its treatment consequently understudied. Lacking an adequate evidence base, physicians are sometimes left with no alternative but to make treatment decisions for BDII patients based on the results of BDI studies. However, genetic [sup] [12] ,[sup] family history [sup] [13] ,[sup] and long-term follow-up studies [sup] [14] clearly indicate that BDI and BDII are distinct illnesses. More importantly, a number of clinical trials suggest that BDII patients may respond quite differently to mood stabilizing medications [sup] [15],[16],[17] and antidepressants [sup] [18] compared to patients with BDI. …

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