Bipolar II Disorder: Symptoms, Treatment, and Clinical Management

Introduction to Bipolar II Disorder

In the United States alone, a staggering number of people suffer from some form of mental illness, and many more are at high risk of developing a mental condition. Worldwide, the number is even greater, especially in countries without the resources to provide needed care. Some mental conditions are more prevalent and easier to develop than others. Whereas serious diseases that manifest various forms of psychosis, like schizophrenia, are mostly prevalent in those who inherit them from family members, in those who have abused drugs long-term and consistently, or in those with brain injuries, milder conditions like bipolar disorder can be developed by virtually anyone.

In the United States, about 2.5% of the population has some form of bipolar disorder. This translates to approximately 6 million people. Because of this high number of sufferers, increasing research attention in the psychiatric and medical fields has been directed toward the study of the disease itself and toward ways to effect treatment. One important focus of such study has been the distinction between bipolar I and bipolar II. According to the Black Dog Institute, this distinction is important in terms of treatment. Whereas bipolar I disorder is typically treated with mood stabilizers as the standard of care, bipolar II presents a less clear-cut treatment approach. There has been considerable debate not only about such treatment but also about the way the distinction between the two types should be made, or indeed whether a distinction should exist at all. An increasing number of trials have focused on new antidepressant drugs and the beneficial role they might play in the treatment of bipolar II disorder.

When it comes to the distinction between the two, the greatest and clearest difference between bipolar I and bipolar II disorder is the frequency and intensity of the manic episodes. Although most diagnostic processes have focused on how the disorder manifests in terms of frequency and intensity, recent studies have also indicated a genetic element within the distinction between bipolar I and bipolar II. In bipolar II patients, for example, a sharing of alleles along the chromosome 18Q21 has been found among siblings with bipolar II, which suggests more consistency than would be accounted for by randomness.

There are also similarities between the two conditions. Both bipolar I and bipolar II patients exhibit a demographic pattern in which the first onset occurs in similar demographic groups. For both bipolar I and II, sufferers have a history of substance abuse that is greater over their lifetime than that of the general population.

The categorization of bipolar I and II is dependent upon the differences between the two conditions. Bipolar II tends to have a higher lifetime prevalence of anxiety disorders, which usually manifest as social and similar phobias. Bipolar II is also more chronic than its counterpart, whereas bipolar I has more severe episodes, especially at the initial stage. The Black Dog Institute also notes that bipolar II may easily develop into bipolar I.

Bipolar II is also known as "swinging bipolar." It includes at least one major depressive episode and one hypomanic episode lasting at least four days. The difference between the hypomanic stage of this disorder type and the hypermanic stage of bipolar I is that the former does not require hospitalization. It is a less severe manic stage than the one manifest in bipolar I patients. Although hypermania is observable in terms of mood disturbance, the implication is that it is far milder than the same stage for bipolar I patients.

When considered in realistic terms, the hypomanic stage manifests itself in both accomplishment and disaster. Individuals in the hypomanic stage, for example, may accomplish great feats and successes like becoming salesperson of the month or achieving best-selling authorship. They may be considered the "life of the party." However, there is also a dark side to this stage. Bad decision-making could result in social embarrassment, failed relationships, or even a lack of responsibility in the workplace. Whereas hypomania in bipolar II patients tends to be the highest level of mania, others may suffer from this condition as a prelude to the hypermanic stage.

The difficulty surrounding this condition, especially on the emotional level, is that the manic stage feels good. This, along with the potential for success and popularity, has resulted in the unwillingness of patients to seek treatment.

In short, the major difference between bipolar I and bipolar II disorder is that the former tends to be far more severe in the manic stages than the latter. The former also consistently responds to treatment with mood stabilizing drugs, while the latter does not necessarily respond to any single type of treatment. Furthermore, while anyone can develop either condition, the likelihood is higher in those with a family history of the condition and in those who have consistently suffered from substance abuse during their lifetime. Most sufferers develop the condition before their fiftieth birthday.

The study of bipolar II disorder is vital in terms of ensuring long-term mental health for people today. Mental health is one of the basic human needs in order to function effectively. Although the manic stage may result in some success and in a feeling of unmitigated energy and drive, it can also create social embarrassment and workplace problems for the sufferer. Hence, those who study the disorder will need to focus on specific areas of challenge and how these can be addressed.

Symptoms and Clinical Presentation

One interesting factor about the hypomanic episode in bipolar II sufferers is that this stage of the condition does not necessarily mean that the individual "feels good" or "high." It can also manifest as irritability. Some symptoms of this stage include rapid flights between ideas, rapid and loud speech, increased energy, and decreased sleep. In terms of their social situation, hypomanic people can be pleasant companions who make jokes, show interest in others, and display a highly positive mood. On the other hand, mania may result in unhealthy behavior, such as overspending, unsafe sex, and other impulsive and risky behaviors without any regard for the potential danger or consequences. A manic episode generally could last from a few days to a few months.

There are many specific symptoms of the hypomania stage. What separates this stage from ordinary happiness is a variety of factors, including high energy levels, positive mood, creativity, mystical experiences, and, on the more negative side, inappropriate behavior and irritability. Whereas ordinary happiness seldom results in a person engaging in dangerous behavior, the high experienced during a hypomanic episode may result in extreme behavior and extreme experiences. In addition, this stage of the condition could also include euphoria, an inflated self-esteem, aggressive behavior, agitation, an increased sex drive, easy distraction, substance abuse, and frequent absences from workplace or school responsibilities. Even psychosis may be one of the dangers associated with this stage.

In bipolar II disorder, however, the depressive symptoms are more prevalent than the hypomanic ones. The frequency and sequence of these moods vary widely among individuals. For some, a depressive episode would immediately follow a manic episode. Some experience the manic and depressive stages as a chronic cycle, while others have long periods in between the extremes, where they function normally. Depressive episodes occur similarly to clinical depression in the bipolar II sufferer, with symptoms like depressed mood, loss of pleasure, low energy and low activity, and thoughts of worthlessness and suicide. Other symptoms of this stage include anxiety, sleep problems, appetite disturbances, fatigue, loss of interest, lack of concentration, chronic pain, frequent absences from work or school responsibilities, and poor performance.

It is interesting to compare these symptom lists, especially in light of the fact that the two stages of the disorder result in many of the same symptoms, including irritability and a basic lack of responsibility in terms of work or school duties. The depressive symptoms could last for weeks, months, or even years in rare cases. The treatment of this stage is highly important in terms of preventing the danger of suicide.

These are all factors that need to be taken into account when it comes to the treatment of bipolar II disorder. With treatment, both the depressive and manic episodes are controlled and may cease earlier than when left untreated.

When it comes to the treatment of bipolar II disorder, various options are available. It is important to recognize that, due to the varied nature of the disorder, there cannot be a single standardized treatment in all cases.

Hypomania, for example, could masquerade as a sense of relentless optimism. There are many optimists in the world who do not suffer from any mental disorder other than perhaps a lack of grasp of reality. Hence, to effectively treat bipolar II disorder, an accurate diagnosis must be made. While hypermania is therefore somewhat easy to identify and treat, hypomania often remains untreated when not associated with risky or unacceptable behaviors.

Pharmacological and Medical Treatment

Generally, hypomania does not require hospitalization. To prevent the extremity of the depressive and hypomanic stages in bipolar II sufferers, mood stabilizers offer beneficial results, where the mood is leveled out in the long term. This is a preventive treatment and mitigates the negative consequences of both hypomania and depression.

Lithium is a mood stabilizer that is commonly used in this way. It is a metal presented in pill form and is particularly effective in controlling the manic stage of the disorder. This drug has been used to treat bipolar disorder I and II for more than 60 years. Since it takes time for the drug to take effect (up to weeks), it is an effective long-term treatment when hypomanic episodes are acute. Side effects are avoided by taking regular blood level and other laboratory tests, which include kidney and thyroid functioning.

Depakote is an antiseizure drug that also offers a stabilizing effect in terms of moods. It works more rapidly than lithium and has a good effect when it comes to prevention.

Lamictal, on the other hand, is particularly effective in preventing depressive lows, although it also functions to prevent hypomania and mixed episodes in those under standard therapy for the disorder.

Tegretol is another antiseizure drug that has been in use since the 1970s for the treatment of mania. Periodic liver functioning and white blood cell count tests are required to monitor the side effects of this drug. Its effectiveness for treating depression or preventing future episodes is not well established in research.

Antipsychotics are sometimes used to mitigate hypomania and depression in bipolar II individuals. Although psychosis is not one of the components of the condition, these drugs offer helpful prevention for future episodes. Particularly, antipsychotics like Abilify, Risperdal, Seroquel, and Latuda have been used in this way.

Benzodiazepines include Xanax, Ativan, and Valium. Commonly referred to as "minor tranquilizers," they can be used in the short term to control some of the acute symptoms of hypomania, including insomnia and agitation.

In terms of antidepressants, only Seroquel and Seroquel XR are FDA-approved for the treatment of depression in bipolar II individuals. Prozac, Zoloft, and Paxil are also sometimes used for this category of bipolar and are believed to be less likely to cause hypomania than in bipolar I individuals. Mood stabilizers such as lithium or Depakote are also used for bipolar II sufferers, while Lamictal is strong in terms of preventing relapses rather than treating acute episodes.

Many professionals have also begun to recognize the potential of psychotherapy and cognitive-behavioral therapy to help in the treatment and prevention of bipolar II disorder. This is particularly the case in terms of encouraging individuals to maintain a treatment regimen, despite the occasional enjoyment of high episodes.

Case Studies in Treatment-Resistant Depression

Because of the recurring nature of bipolar II disorder, it is typical to recommend ongoing treatment with medicines in addition to psychotherapy to prevent the risk of relapse. It must also be recognized, however, as mentioned above, that bipolar II disorder manifests in different ways for different individuals. This is in the nature of the disorder, which is far less easy to pin down than its bipolar I counterpart. Hence, not all conditions will be similarly responsive to all treatments. According to Cusin et al. (2012), for example, not all depressive episodes associated with bipolar II disorder respond to generally accepted medical treatments. In such cases, research needs to be responsive to individual situations, which could result in further benefits for other sufferers.

Cusin et al. (2012) mention two particular case studies regarding treatment-resistant bipolar II depression. The first is a 57-year-old woman with bipolar II disorder and attention deficit hyperactivity disorder (ADHD). She had depressive episodes that failed to respond to multiple medication trials, including ECT. To demonstrate the severity of her situation, her last depressive episode included 12 adequate antidepressant trials, none of which successfully relieved her symptoms. These symptoms included low mood, fatigue, anhedonia, and suicidal ideation.

Another example is a 48-year-old woman suffering from bipolar II disorder, ADHD, fibromyalgia, hypothyroidism, chronic depression, and suicidal ideation. Pharmaceutical interventions for her included mood stabilizers, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors. None of these provided any relief for her symptoms.

In both cases, some hope has been provided by the experimental use of intramuscular ketamine. For the first case, oral or intranasal ketamine provided no or little relief. However, after the first administration of intramuscular ketamine, there was complete remission of depression after a few days. When she had a partial relapse after five months, the dosage was increased and her symptoms remained dormant for four months.

Being more severe, the second case was somewhat more resistant to the ketamine treatment. The first trial of intramuscular ketamine was unsuccessful because she could not tolerate the dissociative symptoms that resulted. When the dosage was reduced, however, she experienced an improvement within one week. After a partial relapse after six months, bupropion was added to the dosage. The outcome is that, although she has not achieved full remission, the symptoms are sufficiently managed for her suicidal thoughts to have disappeared. She has also had success in her workplace, having been active in her work for six months.

In both cases, the individuals in question experienced some side effects, including irritability, nightmares, dissociative feelings, and headaches. Despite their preliminary nature, these cases offer some hope for those suffering from non-responsive depressive episodes. Intramuscular ketamine appears to be potentially effective for treatment-resistant conditions. The drug was well tolerated and remained effective after months of consistent use. Both individuals tolerated the drug relatively well. The authors therefore note that further study should be conducted in terms of determining the effectiveness of intramuscular ketamine for other sufferers, while also being investigated for its long-term efficacy, adverse effects, and potential risks of abuse. Possible adverse effects include cystitis, hepatotoxicity, and potential neurological effects. The positive results within the two individuals in question, however, should serve as a platform to encourage further study for the possible benefit of millions of others.