Bipolar II Disorder

Bipolar II Disorder is a mental disorder characterized by a clinical course of recurring mood episodes consisting of at least one major depressive episodes and at least one hypomanic episode. The depressive episode must last at least 2 weeks, and the hypomanic episode must last at least 4 days.

Epidemiology
  • Bipolar II has a similar prevalence as bipolar I disorder, with a prevalence of 0.8% in the United States, and 0.3% internationally.[1]
    • The combined prevalence rates of all forms of bipolar disorders (bipolar I, II, and unspecified) is 1.8%.[2]
  • The average age of onset is in the mid-20s, which is later than bipolar I disorder, but earlier than major depressive disorder.
  • Females are more diagnosed than males.
Prognosis
  • Although by definition hypomania is less severe than mania (bipolar I), the disability associated with bipolar II actually is similar to that of bipolar I. The economic burden of bipolar II is actually four times greater than that of bipolar I, because individuals spend as much time symptomatic (but predominantly with depressive symptoms) as those with bipolar I disorder.[3]
    • Typically, the hypomanic episodes in bipolar II do not themselves cause impairment.
    • Individuals with a rapid cycling pattern typically have a worse prognosis. Individuals who are married, have higher levels of education, and fewer years of illness have better recovery.[4]
    • The rates of completed suicide are also similar between bipolar II and bipolar I. 1 in 25 individuals will have completed suicide over the lifetime of the illness. Importantly, 1/3 of individuals with bipolar II disorder report a lifetime history of a suicide attempt (about similar as bipolar I). However, the lethality of attempts are actually higher in bipolar II.[5]
  • Many individuals may experience several episodes of depression before their first hypomanic episode.
  • Between 5 to 15% of individuals with bipolar II disorder will ultimately have a manic episode, which changes the diagnosis to bipolar I disorder.
Comorbidity
Risk Factors
  • The risk for developing bipolar II is highest among relatives of individuals with bipolar II disorder.
  • Genetic factors may also be involved.
Criterion A

Criteria have been met for at least 1 hypomanic episode and at least 1 major depressive episode.

Criterion B

There has never been a manic episode.

Criterion C

The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Criterion D

The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion A
  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood AND
  • Abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
Criterion B

During the period of mood disturbance and increased energy and activity, at least 3 of the following symptoms have persisted (4 symptoms if the mood is only irritable), represent a noticeable change from usual behaviour, and have been present to a significant degree:

  1. Distractibility (i.e. - attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  2. Indiscretion, characterized by excessive involvement in activities that have a high potential for painful consequences (e.g. - unrestrained buying sprees, sexual behaviours, or foolish business investments).
  3. Grandiosity or inflated self-esteem.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Activity (goal-directed) increasing (e.g. - either socially, at work or school, or sexually) or psychomotor agitation.
  6. Sleep decreased (e.g. - feels rested after only 3 hours of sleep).
  7. Talkative (more than usual or pressure to keep talking)

Mnemonic

The mnemonic DIGFAST can be used to remember the criteria for bipolar I and II disorder.[6]

  • D - Distractibility
  • I - Indiscretion
  • G - Grandiosity
  • F - Flight of ideas
  • A - Activity increased
  • S - Sleep decreased
  • T - Talkativeness
Criterion C

The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.

Criterion D

The disturbance in mood and the change in functioning are observable by others.

Criterion E
  • No marked social or occupational impairment
  • There is never hospitalization.
  • No psychotic features (If there are psychotic features, the episode is, by definition, manic)
Criterion F

The episode is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication or other treatment) or another medical condition.

What If There is an Antidepressant-induced Hypomania?

A full hypomanic episode that emerges during antidepressant treatment (e.g. - medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that 1 or 2 symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a true bipolar disorder.

Episode Specifier

Specify current or most recent episode:

  • Hypomanic
  • Depressed

Severity Specifier

  • Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
  • Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
  • Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.

Remission Specifier

  • In partial remission: Symptoms of the immediately previous manic, hypomanic, or depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanic, or major depressive episode following the end of such an episode.
  • In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.

With anxious distress

  • At least 2 of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression:
    • (1) Feeling keyed up or tense
    • (2) Feeling unusually restless
    • (3) Difficulty concentrating because of worry
    • (4) Fear that something awful may happen
    • (5) Feeling that the individual might lose control of himself or herself
  • Severity:
    • Mild: 2 symptoms
    • Moderate: 3 symptoms
    • Moderate-severe: 4 or 5 symptoms
    • Severe: 4 or 5 symptoms and with motor agitation
Note: Anxious distress has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings. High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately the presence and severity levels of anxious distress for treatment planning and monitoring of response to treatment.

With mixed features

The mixed features specifier can apply to the current manic, hypomanic, or depressive episode in bipolar I or bipolar II disorder:

Manic or hypomanic episode, with mixed features:

  • A. Full criteria are met for a manic episode or hypomanic episode, and at least 3 of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania:
    • (1) Prominent dysphoria or depressed mood as indicated by either subjective report (e.g. - feels sad or empty) or observation made by others (e.g. - appears tearful)
    • (2) Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation made by others)
    • (3) Psychomotor retardation nearly every day (observable by others and not merely subjective feelings of being slowed down)
    • (4) Fatigue or loss of energy
    • (5) Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick)
    • (6) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior
  • C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania
  • D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication, other treatment)

Depressive episode, with mixed features:

  • A. Full criteria are met for a major depressive episode, and at least 3 of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression:
    • (1) Elevated, expansive mood
    • (2) Inflated self-esteem or grandiosity
    • (3) More talkative than usual or pressure to keep talking
    • (4) Flight of ideas or subjective experience that thoughts are racing.
    • (5) Increase in energy or goal-directed activity (either socially, at work or school, or sexually)
    • (6) Increased or excessive involvement in activities that have a high potential for painful consequences (e.g. - engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
      • (7) Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia)
  • B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior
  • C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features
  • D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication, or other treatment)
Note: Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.

With rapid cycling

This specifier (can be applied to bipolar I or bipolar II disorder). There is presence of at least 4 mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode.

Note: The essential feature of a rapid-cycling bipolar disorder is the occurrence of at least 4 mood episodes during the previous 12 months. These episodes can occur in any combination and order. The episodes must meet both the duration and symptom number criteria for a major depressive, manic, or hypomanic episode and must be demarcated by either a period of full remission or a switch to an episode of the opposite polarity. Manic and hypomanic episodes are counted as being on the same pole. Episodes are demarcated by either partial or full remissions of at least 2 months or a switch to an episode of the opposite polarity (e.g. - major depressive episode to manic episode). Except for the fact that they occur more frequently, the episodes that occur in a rapid-cycling pattern are no different from those that occur in a non-rapid cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern exclude those episodes directly caused by a substance (e.g. - cocaine, corticosteroids) or another medical condition.
Hypothyroidism, antidepressant use, and substance use is associated with rapid cycling. So assessing thyroid function, stopping any offending antidepressants, stimulants, and other psychotropics that might contribute to cycling is critical!

With melancholic features

  • A. 1 of the following is present during the most severe period of the current episode:
    • (1) Loss of pleasure in all, or almost all, activities
    • (2) Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)
  • B. 3 or more of the following:
    • (1) A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood,
    • (2) Depression that is regularly worse in the morning
    • (3) Early-morning awakening (i.e. - at least 2 hours before usual awakening)
    • (4) Marked psychomotor agitation or retardation
    • (5) Significant anorexia or weight loss
    • (6) Excessive or inappropriate guilt

With atypical features

This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode.

  • A. Mood reactivity (i.e. - mood brightens in response to actual or potential positive events)
  • B. 2 or more of the following:
    • (1) Significant weight gain or increase in appetite
    • (2) Hypersomnia
    • (3) Leaden paralysis (i.e. - heavy, leaden feelings in arms or legs)
    • (4) A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
  • C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode

With psychotic features

Delusions or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood-incongruent:

  • With mood-congruent psychotic features:
    • The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment
  • With mood-incongruent psychotic features:
    • The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes

With catatonia

This specifier can apply to an episode of mania or depression if catatonic features are present during most of the episode.

With peripartum onset

This specifier can be applied to the current or, if the full criteria are not currently met for a mood episode, most recent episode of mania, hypomania, or major depression in bipolar I or bipolar II disorder if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

With seasonal pattern

This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least 1 type of episode (i.e. - mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year.

  • A. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year (e.g. - in the fall or winter) in bipolar I or bipolar II disorder. Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g. - regularly being unemployed every winter).
  • B. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year (e.g. - depression disappears in the spring)
  • C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no non-seasonal episodes of that polarity have occurred during that 2-year period.
  • D. Seasonal manias, hypomanias, or depressions (as described above) substantially outnumber any nonseasonal manias, hypomanias, or depressions that may have occurred over the individual’s lifetime.

Psychometric Scales for Bipolar Disorder

Name Rater Description Download
Young Mania Rating Scale (YMRS) Clinician Most frequently utilized to assess manic symptoms. 11 items on the patient’s subjective report over the last 48 hours plus clinical observations.[7] Takes 15–30 minutes to complete. YMRS Download
Mood Disorder Questionnaire (MDQ) Patient The MDQ screens for Bipolar Spectrum Disorder, (which includes Bipolar I, Bipolar II and unspecified bipolar disorder). There are 13 self-rated questions. It has a 90% specificity and 70% sensitivity for eventual diagnosis of bipolar disorder.[8] MDQ Download
    • Perhaps the most challenging differential diagnosis to consider is major depressive disorder, which may be accompanied by hypomanic or manic symptoms that do not meet full criteria (i.e. - either fewer symptoms or a shorter duration than required for a hypomanic episode). This is especially true in evaluating individuals with symptoms of irritability, which may be associated with either major depressive disorder or bipolar II disorder. A hypomanic episode should not be confused with the several days of euthymia and restored energy or activity that may follow remission of a major depressive episode. Conversely, once a hypomanic episode has been confirmed, the diagnosis becomes by bipolar II disorder, and never returns back to major depressive disorder.
    • In cyclothymic disorder, there are numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode or a true hypomanic episode. Bipolar II disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a major depressive episode occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder is given.
    • Bipolar II disorder must be distinguished from psychotic disorders (e.g. - schizoaffective disorder, schizophrenia, and delusional disorder). These disorders are all characterized by periods of psychotic symptoms that occur in the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms, previous course, and family history.
    • Anxiety disorders need to be considered in the differential diagnosis and may frequently be present as co-occurring disorders.
    • Substance use disorders and substance/medication-induced mood episodes should also be ruled out prior to the diagnosis of bipolar II disorder.
    • Attention-deficit/hyperactivity disorder (ADHD) may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for sleep, overlap with the symptoms of hypomania. The “double counting” of both ADHD and bipolar II symptoms can be avoided if the clinician clarifies whether the symptoms represent a distinct episode and if the noticeable increase over baseline required for the diagnosis of bipolar II disorder is present.
    • The same convention as applies for ADHD also applies when evaluating an individual for a personality disorder such as borderline personality disorder, since mood lability and impulsivity are common in both personality disorders and bipolar II disorder. Symptoms must represent a distinct episode, and the noticeable increase over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a personality disorder should not be made during an untreated mood episode unless the lifetime history supports the presence of a personality disorder.
  • Other bipolar disorders
    • Diagnosis of bipolar II disorder should be differentiated from bipolar I disorder by carefully considering whether there have been any past episodes of mania and from other specified and unspecified bipolar and related disorders by confirm ing the presence of fully syndromal hypomania and depression.

There are key differences in the diagnostic criteria between bipolar I and bipolar II disorder. The table below outlines these differences.

Comparison of Bipolar I vs. Bipolar II

Bipolar I Bipolar II
Diagnostic Criteria manic episode only hypomanic episode + depressive episode
Length > 7 days > 4 days
Impairment Severe Minor to none
Hospitalization Possible No
Psychosis Possible No

Mixed Features: Mania and Hypomania Symptoms Can Also Occur During Depressive Episodes!

Patients with bipolar I and bipolar II disorder experiencing active depressive episodes can also have concomitant manic/hypomanic symptoms at the same time – most commonly distractibility, flight of ideas, racing thoughts, and psychomotor agitation (least common).[9]

Bipolar II and borderline personality can often present in very similar ways. Affective instability, with repeated, rapid, and abrupt shifts in mood, are considered the core symptoms in borderline personality disorder. Thus, affective instability can be misdiagnosed as hypomania, or vice versa. A good longitudinal history and interview can often help differentiate between the two.

  • Compared to bipolar I disorder, bipolar II disorder outcomes and treatments remain understudied. Thus, many of the treatment recommendations are made from expert clinical opinion, with limited evidence.[10]

For Women of Childbearing Age...

Contraceptive counselling and medication risks must be included as part of the comprehensive treatment plan for bipolar disorder. This is for two reasons:
  • Contraception efficacy: many of the treatments used in bipolar disorder, especially anticonvulsants (such as carbamazepine, topiramate, and lamotrigine) can significantly reduce the effectiveness of oral contraceptives (OCPs), and increase the risk for unintended pregnancy. On the flipside, OCPs can also reduce the efficacy of medications like lamotrigine.
  • Teratogenicity: valproate products (valproic acid, divalproex) have high teratogenic potential and also increase the risk for developmental disorders in infants exposed to valproate in utero. Thus, women on valproate products should be on contraception, and informed about the risks of using valproate during pregnancy. Additionally, individuals wishing to become pregnant should work with their clinician to switch off from valproate.
Hypomania
  • Since hypomania by definition means an individual is not hospitalized, it causes no to minimal functional impairment and may even be associated with “better-than-normal” function.
Maintenance

Pharmacological Treatments for Maintenance Therapy in Bipolar II (Not Bipolar I!) Disorder

Adapted from: Yatham, L. et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97–170.
1st line Monotherapy: quetiapine, lithium, lamotrigine
2nd line Monotherapy: venlafaxine
3rd line Monotherapy: carbamazepine, divalproex, escitalopram, fluoxetine, other antidepressants, risperidone*
Depression

Pharmacological Treatments for Bipolar II (Not Bipolar I!) Depression

Adapted from: Yatham, L. et al. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97–170.
1st line Monotherapy: quetiapine
2nd line Monotherapy: lithium, lamotrigine, sertraline, venlafaxine, ECT
Adjunctive therapy: bupropion
3rd line Monotherapy: divalproex, fluoxetinea, tranylcypromine, ziprasidoneb
Adjunctive therapy: agomelatine, bupropion, eicosapentaenoic acid (EPA), ketamine (IV or sublingual), N-acetylcysteine, pramipexole, T3/T4 thyroid hormones
Not recommended Paroxetine

Should Antidepressants Be Used in Bipolar II Depression?

Similar to the concerns about the use of antidepressants in Bipolar I depression, there is also controversy about the use of antidepressants in Bipolar II depression. The most recent recommendations from the Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines suggest that antidepressant only be used for Bipolar II patients that present with a pure depressive syndrome, and be avoided in those who present with mixed symptoms, or have a history of antidepressant-induced hypomania. Additionally, the patient should be warned to monitor for early warning signs of hypomania.
  • No evidence exists for specific psychosocial interventions in acute mania. However, after treatment of mania, adding psychosocial interventions in addition to medication treatment is very important.
    • In fact, on average, adjunctive psychosocial interventions reduce recurrence rates by about 15%.[11]
  • Psychosocial interventions can decrease relapse rates, mood fluctuations, need for medications, hospitalizations, and increase functioning and medication adherence.
  • Psychoeducation is a first-line treatment in maintenance therapy, and includes providing information about the course of illness, treatments, and coping strategies for both the patient and the family. Psychoeducation can also be delivered in individual or group settings.[12]

Adjunctive Psychological Treatments in Bipolar Disorder

Adapted from: Yatham, L. et al (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97-170.
Mania Maintenance Bipolar Depression
1st line None • Psychoeducation (PE) None
2nd line None Cognitive behavioural therapy (CBT)
• Family-focused therapy (FFT)
• Cognitive behavioural therapy (CBT)
• Family-focused therapy (FFT)
3rd line None • Interpersonal and social rhythm therapy (IPSRT)
• Peer support
• Interpersonal and social rhythm therapy (IPSRT)
Insufficient evidence None Cognitive and functional remediation, dialectical behavioural therapy (DBT), family/caregiver interventions, mindfulness‐based cognitive therapy (MBCT), online interventions Psychoeducation, cognitive and functional remediation, dialectical behavioural therapy (DBT), family/caregiver interventions, mindfulness‐based cognitive therapy (MBCT), online interventions

Bipolar Disorder Guidelines

Guideline Location Year PDF Website
Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) Canada, International 2018 PDF Link
American Psychiatric Association (APA) USA 2002 PDF Guideline (2002)
Guideline Watch (2005)
Quick Reference
National Institute for Health and Care Excellence (NICE) UK 2014 PDF Link
British Association for Psychopharmacology (BAP) UK 2016 PDF Link
Royal Australian and New Zealand College of Psychiatrists (RANZCP) AUS, NZ 2015 PDF Link
1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.