Hypomania Part II: What It Means for Depression Treatment
Conventional wisdom states that hypomania (see my Feb 23 blog) is a psychopathology that needs to be avoided at all costs. Surprisingly, a literal reading of the DSM does not give that impression.
You could have knocked me over with a feather when, a few years back, I carefully read what the DSM had to say about hypomania. There was the usual laundry list of symptoms, but nowhere was it expressly stated that hypomania ALONE automatically justified admission to the bipolar club. Instead, says the DSM, hypomania needs to be tag-teamed with depression to qualify for the diagnosis of bipolar II. (For bipolar I, mania alone will do.)
This means if your psychiatrist first sees you when you feel like Shizuka Arakawa after winning a gold medal in figure skating, then he or she needs to probe for a history of depression. The catch is no one books emergency visits to psychiatrists when they are feeling on top of the world.
Typically, patients seek help when they are depressed. But it is impossibly difficult for individuals who feel depressed to accurately recall those times in their lives when they felt normal or better than normal. Not surprisingly, according to a 1994 DBSA survey and corroborated in subsequent studies, it takes a bipolar patient about 10 years from the time he or she first seeks help to the time his or her psychiatrist (typically the third or fourth one) arrives at a correct diagnosis.
Just to make matters slightly more confusing: There is a very strange DSM diagnosis called bipolar NOS (not otherwise specified) that does give psychiatrists discretionary leeway, but you only have to imagine NOS being applied to criminal law (murder NOS) or quantum physics (itty-bitty small particles NOS) to see the absurdity of this classification.
It was not until 1994 when the DSM-IV was published that the diagnosis of bipolar II was officially recognized. This is despite the pioneering diagnostician Emil Kraepelin first identifying hypomania in the early twentieth century. Kraepelin did not distinguish between what he called manic-depression (bipolar disorder) and unipolar clinical depression. The authors of the breakthrough DSM-III of 1980, however, drew a clear line, and ever since leading experts have been arguing where that line needs to be moved.
Even before the DSM-III, in a ground-breaking 1976 article, three of the top psychiatrists specializing in bipolar disorder - Dunner, Goodwin, and Gershon - proposed a bipolar II diagnosis. The basis for their proposal was that the DEPRESSIONS in patients with a history of hypomania seemed different than those with unipolar depression or in patients with a history of mania.
In other words (please forgive the triple-tonguing), find out what else is going on in a patient with depression besides the depression to better treat the depression.
Today, we are learning that individuals with bipolar depressions and unipolar depressions tend to respond differently to various medications. A standard antidepressant can pose a risk for many bipolar patients while certain mood stabilizing medications or antipsychotics (such as Lamictal, Zyprexa, Seroquel and to a lesser extent lithium) may work wonders for them. The clinician who gets it right in the early going – who is successful in finding a history of hypomania in a woefully depressed patient – is likely to spare that patient many long years of heartbreak and frustration.
So hypomania gives us a valuable insight into treating depression. But what about the hypomania, itself. Does hypomania truly justify treatment? And if so, how should it be treated? You would be amazed at what even the experts don’t know.
To be continued …
Part III: Can Too Much Hypomania Be Bad for You?
Published On: February 27, 2006
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