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Bipolar-II is a common type of depression which
affects 1 in 30 people.
Unfortunately there is little public awareness of this condition,
which borrows its name from the more well-known Bipolar-I Disorder. This similarity
in names is confusing, since the word bipolar brings to mind a more extreme
state called mania or
manic-depression.
People with Bipolar-II never have mania; instead,
they suffer from depressions that alternate with milder states of nervous
excitation called hypomania. Hypomania can make people feel anxious,
impulsive, hyperactive, irritable and, sometimes, happy and confident. Hypomania
may feel good or may feel uncomfortable, but unlike mania it never causes
people’s behavior to get significantly out of control.
Mood Swings and Depression
“I was silly and giddy one minute, bursting with rage the
next; running around excitedly in the afternoon but impossible to rouse out
of bed in the morning.” –Gogo Lidz
Bipolar-II affects
everyone differently, but a common theme is that it causes mood to shift up
and down throughout life. The first
symptoms usually appear during adolescence, and these early mood swings
often shift very rapidly as in the quote above. As people age, these shifts in mood usually
slow down. Over time, depressions
tend to occur more often and the ups (or hypomanias)
may fade away.
Depression is so common
in Bipolar-II that it is often misdiagnosed as “Major Depression.” In fact, 1 in 3
people diagnosed with Major Depression actually have Bipolar-II. Identifying the correct diagnosis is
crucial since Bipolar-II may worsen with antidepressant medication. The chart below details the differences
between Major Depression, Bipolar-I and Bipolar-II:
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Depression?
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Hypomania?
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Mania?
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Major Depressive Disorder
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Yes
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No
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No
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Bipolar-II Disorder
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Yes
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Yes
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No
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Bipolar-I Disorder
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Yes
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Yes
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Yes
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What is Depression?
Depression is a whole-body
illness which causes changes far beyond sadness. Many people with
depression do not even feel sad; instead they may feel emptiness or anger
or have no ability to experience pleasure (called anhedonia). Sometimes
depression expresses itself through fatigue or physical symptoms rather
than mental anguish.
Along with this change in
mood, depression causes important changes in the brain and body. These can
include poor sleep, fatigue, slowed thoughts, poor concentration, lack of
appetite or excessive eating, and lack of sex drive. The person’s
muscles may become lax and slowed, or tense and agitated. The immune
system, which protects the body from infection, may not work as well and
stress hormones may increase. If left untreated, depression can take a toll
on a person’s health, with consequences such as heart disease and
changes in the brain’s memory center.
There are many causes of
depression. The most common is Major Depressive Disorder, which is best
treated with antidepressants and psychotherapy. Depression can also be caused by a
medical illness or the effects of drugs or alcohol, and require different
treatment. In Bipolar II, depression
is one phase of an underlying problem with mood swings.
Because they may be rare or
mild, it can be difficult to identify the times of hypomania which
distinguish Bipolar-II from Major Depression. There are other clues which
can alert people with depression to look carefully for Bipolar-II. Most
importantly, if anyone in your family has bipolar or manic-depression it is
more likely that your depression is a Bipolar-II type. Depressions that
come on early in life, such as before age 20, are more likely to be
Bipolar-II, as are those which keep returning throughout life. Depressions
that come on after pregnancy (called post-partum depression) are also a
sign of Bipolar-II. Sometimes people
with Bipolar-II find that antidepressants work at first and then wear off,
leading to frequent medication changes.
Lastly, people with Bipolar-II
often have a highly reactive mood, and may experience mood swings even when
depressed. This mood reactivity is described as feeling easily hurt,
rejected or irritated by others, and overwhelmed by or sensitive to stress.
During depression, they may also have significant fatigue or
over-eating. Their mood may react to
seasonal changes, with depressions in the Winter and hypomania in the
Spring (read more about Light therapy for seasonal mood changes).
Other Symptoms of Bipolar-II
Mood impacts our thoughts as
much as our emotions. People with Bipolar-II are often misdiagnosed with
Attention Deficit Hyperactivity Disorder (ADHD) because of the difficulties
it causes in concentration. During hypomania, people are easily distracted
and their thoughts race quickly from topic to topic. They may wander in daydreams while
engaged in unrelated tasks, or their mind may be crowded with multiple
streams of thought.
These shifting thoughts make
it difficult to set priorities. They may hyperfocus
on an unimportant task at the expense of other obligations, or may shift
from task to task in a disorganized way.
Thoughts can be experienced very powerfully, which can be a source
of inspiration or frustration. Hypomania
can make people easily annoyed and quick to react. It becomes very hard not to “sweat
the small stuff”, and conflict with other people frequently erupts.
Energy is usually elevated
in hypomania. Sometimes this
heightens creativity and productivity.
Other times the surge in energy makes people feel edgy and restless,
and they may use alcohol or drugs to settle down. People in this state tend to sleep less. They may welcome this change or lie awake
in an anxious state of insomnia.
Anxiety is one of the most
common symptoms of hypomania. Usually this is experienced as an
uncomfortable feeling of dread, as if something bad may happen at any moment. Usually the person cannot identify what
they are afraid of. Often the
anxiety intensifies in social settings, and the intentions of other people
may be seen as hostile or mean-spirited.
Sometimes the person with
hypomania is not bothered by it at all and it is their relatives who are
concerned. Usually it is the
impulsive and hyperactive symptoms are what worry them. These symptoms can cause people to spend
too much money, jump into new relationships or start projects they can’t
finish.
Hypomania also has a
positive side, but I have emphasized the unpleasant aspects of it here
because those are what lead people to seek help. In its sunny-side,
hypomania can make people friendly, confident and outgoing. They can be
very happy, or euphoric, in a way that lifts the spirits of those around
them. Other people see them as inspiring, spontaneous, funny and generous. Indeed, hypomania is often a strength!
How is the diagnosis made?
Bipolar II can only be
diagnosed by an interview with a trained professional such as a
psychiatrist. There is no test for Bipolar-II, although research is
underway to develop genetic and brain-imaging tests to aid in the
diagnosis. You can help your doctor clarify the diagnosis by describing how
your mood has changed throughout your whole life.
There are also a several screening tests for bipolar available at: http://www.aikenmd.com/moodtest.htm.
While this test can’t
tell you if you have Bipolar, a score of 6 or above indicates that you
would benefit from further assessment with a psychiatrist. It is also
helpful to ask close relatives to complete one for you (a version for this
use is here), since certain symptoms are better observed or
remembered by family members.
How is Bipolar-II disorder treated?
Bipolar-II is usually treated with a combination of mood stabilizers and
antidepressants. Although antidepressants help in the short-term, there is
currently not enough research to know if they cause long term worsening of
mood swings in Bipolar-II. Antidepressants are much safer when used with
mood stabilizers, since these medicines help prevent mood swings for the
long term. Some mood stabilizers
actually enhance the growth of brain cells: protect brain cells from damage.
The squiggles and
lines above are brain cells. Treatment with a mood stabilizer (Valproic Acid, also called Depakote),
has helped the cells to the right to thrive and grow, while lack of
treatment (to the left) has caused cells to shrink away. Similar protective effects have also been
found for lithium and pramipexole.
Examples
of mood stabilizers include (click on the drug name to learn more):
Lamotrigine (lamictal)
Lithium (lithobid, eskalith)
Depakote (valproate)
Trileptal (oxcarbazepine)
Tegretol (carbamazepine)
Atypicals (aripiprazole,
abilify, zyprexa, olanzapine, risperdal, risperidone, seroquel, quetiapine, geodon, ziprasidone).
One of the most important
mood stabilizers for Bipolar-II is Lamictal.
This medicine has been used to treat seizures since the early 1990’s
and was approved by the FDA for Bipolar disorder in 2003. It is a major
advance because it is the only mood stabilizer which treats depression more
effectively than mania. Lamictal is particularly effective at preventing depression for the
long-term, an important benefit for Bipolar-II where the depressions can be
chronic and frequent if untreated.
Although its preventive
effects can change people’s lives, Lamictal
may not work right away because the dose has to be raised slowly over 1-2
months to prevent a rare but serious allergic skin reaction called Stevens-Johnson Syndrome.
Fortunately, once Lamictal is raised to an effective dose it is well
tolerated and does not cause weight gain or drowsiness.
It is important to
understand that very few medicines have been studied exclusively in
Bipolar-II, and most of what we know comes from studies of Bipolar-I. Lamictal
is one medicine that was studied in both groups, and yielded the good
results in people with Bipolar-II. Seroquel
(quetiapine) and Mirapex
(pramipexole) are two other medicines that have
been studied in bipolar-II.
A natural treatment which
helps bipolar depression is Fish Oil, or Omega-3 Fatty Acid. This nutrient
helps coat brain cells, and taking it regularly reduces mood swings and
increases the flexibility of brain cells in people with bipolar disorder. To work well, omega-3 needs to be dosed right,
and this is best done with the help of your doctor since most brands of
omega-3 recommend doses that are far below therapeutic levels.
The discovery of omega-3
came about when it was observed that cultures whose diets are high in fish
(eating around 1 pound a day) have low rates of depression. Dietary sources of this omega-3 include oily fish such as anchovies, mackerel and
salmon, as well as flaxseed, wheat germ, walnuts, canola oil and dark
greens such as spinach and kale. More information about food sources of
Omega-3 and its importance in the brain is at: http://efaeducation.nih.gov/.
Psychotherapy is also very
helpful for this condition, both to cope with the effects it has on your
life as well as to reduce the mood swings themselves.
How long should treatment last?
Having Bipolar-II means that
you are at risk for depression, particularly with stressful events. Actually, up to 30% of the general
population will get depression some time in their lives, so just being
human puts you at risk for depression.
Since medication works not just to treat but also to prevent
depression, how long you take it will be a personal decision that is best
made with an understanding of your own risk factors.
If you are thinking about
stopping a medication, talk to your doctor about what the risk would be for
your symptoms returning and what the safest way is to come off the medication. Lifestyle changes (see below) will be
especially important if you are not taking medicine.
What can else can I do to help Bipolar-II?
The most important thing you
can do is get regular sleep. A night without sleep is detrimental to
anyone’s health, but is particularly harmful in Bipolar-II. Too
little sleep can set off hypomania and further mood swings, while too much
sleep can cause depression.
Overall, a regular lifestyle
is very helpful to people with Bipolar-II. Everyone’s body is sensitive
to signals which help set our internal clock. This clock is kept by
hormones, and disruption of that system can lead to mood swings. Examples
of important signals include sleep, meals, exercise, intense or stimulating
social activity, sex, stressful events, travel, changes in sunlight or
season, menstrual cycles and childbirth. What helps in Bipolar-II is not
avoiding these signals but regulating them, at least the ones that are
within your control. This means trying to sleep, eat meals and exercise at
the same time each day as much as possible. Particularly at night, it is
important to develop rituals which ease you into sleep and avoid
over-stimulating activities which may keep you up. More advice on improving sleep is at www.aikenmd.com/sleep.htm.
Social Rhythm Therapy is
a form of therapy which helps people with bipolar achieve greater health through
life-style changes (click here
for more on this).
Another important role you
can play in your treatment is to develop a better awareness of your
symptoms. In particular, knowing the early signs of depression or mood
swings in you, and the stressors that trigger them, can help you prevent
problems before they get serious. One way to monitor your mood is by daily
recording in a mood chart; several are online:
mood chart (MS-Word file of Dr. Aiken’s
version)
www.psychiatry24x7.com (click “Tools &
Tests”, then “Mood Diary”)
www.manicdepressive.org/tools_all.html
www.zyprexa.com/pdf/MoodDiary.pdf
Mood charts can help
identify the type of mood swings you have and evaluate whether treatment is
working.
Avoiding recreational drugs
and moderating alcohol use is also very important. Most recreational drugs,
including marijuana, XTC, mushrooms, steroids, stimulants or speed, and
cocaine, will make Bipolar-II worse, particularly with long-term use. Drug
use can also cause mania, converting Bipolar-II into Bipolar-I.
Even legal drugs can cause
problems. Reducing caffeine can significantly improve sleep quality and
mood swings (you should lower your caffeine intake slowly to prevent
withdrawal headaches). Caffeine is
concentrated not just in coffee, sodas and tea but also in chocolate. While
people sometimes use alcohol to induce sleep or relieve mood swings,
continued use can fragment sleep and worsen bipolar. The same is true for
nicotine: the immediate effects of a cigarette may lift mood and improve
concentration, but long term use causes more depression.
A word of hope
I have described the illness
of Bipolar-II, and hope you’ll remember that you are not your
illness, and that even this illness can be a strength.
People who come out of depression often find renewed appreciation for life
and more compassion for the world around them. Research has found that,
despite its bleakness, depression gives people a more accurate view of
reality. Those with bipolar are among
the most creative, talented and industrious in our society. As you see to the right, they include
great leaders like Abraham Lincoln and Winston Churchill, artists and
writers such as Vincent Van Gogh, William Blake and Irving Berlin, and
actors Robin Williams, Carrie Fisher and Ben Stiller.
-Chris Aiken, M.D.
Updated 3/9/2007
Bipolar-II: A Young Woman’s Experience
In 2007, New York Magazine published an
accurate description of bipolar-II by Gogo Lidz. Her story
conveys vividly the problems that can arise when this condition is treated
with the wrong medications. Click here for Dr. Aiken’s commentary
and a link to her original article.
Related Books
Why
am I still depressed?, by Jim Phelps (2006). This author has gathered
an impressive amount of information on bipolar-II. It is one of few books
which focuses exclusively on bipolar-II and the bipolar spectrum (the other
books below are mostly about bipolar-I disorder). Dr. Phelps has also made his book freely available
online at http://www.psycheducation.org/
Self-help
workbooks: CBT, ACT and DBT
The
Bipolar Survival Guide, by David J. Miklowitz
(2002). The author developed a form of psychotherapy to help patients and
families with bipolar illness. His
book provides an up-to-date summary of ways to manage bipolar illness
through stress-reduction, self-monitoring and life-style modification.
The
Cyclothymia Workbook, by
Price Prestiss, Ph.D. (2005). This books is about cyclothymia, a
condition which often occurs in people with bipolar-II. Cyclothymia
simply means that your mood goes through frequent, short cycles of mild
depression, hypomania, irritability or hyperactivity.
Don't Let Your Emotions Run Your
Life: How Dialectical Behavior Therapy Can Put You in Control, by
Scott E. Spradlin. This is a guide to an updated version of
cognitive-behavioral therapy (CBT).
This therapy, called dialectical behavioral therapy (DBT) is
specifically tailored to people who have trouble with mood swings.
Educational
books
Surviving
Bipolar Illness by E. Fuller Torrey
(2005). Written by a physician who
has made important discoveries in bipolar illness, this guide is
particularly strong on the causes of and medication treatments for bipolar.
Bipolar
Disorder: A Guide for Patients and Families, by
Francis Mondimore (2006). A thorough and
compassionately written account of the treatments and causes of bipolar,
written by a psychiatrist at UNC-Chapel Hill. It gives equal focus to medications and
lifestyle management.
A
Mood Apart: The Thinker’s Guide to Emotion and It’s Disorders by Peter C. Whybrow (1999). This book is more
introspective than practical, but is an excellent guide to the science
behind mood and mood swings.
TOUCHED
WITH FIRE: Manic Depressive Illness and the Artistic Temperament, by K.
Jamison. A biographical exploration of the lives of writers and artists who
were presumed to have bipolar illness (see side-bar at right).
An
Unquiet Mind, by K. Jamison. The author is a prominent
scientist in the field of bipolar who also suffers from the condition. She
describes her experience with classic bipolar-I mania, but many people will
not identify with her description because classic mania is a rare
condition.
Online Resources
Bipolar
Disorder
PsychEducation: a very thorough and up-to-date web-site about
bipolar-II and related conditions.
Bipolar: A Guide
for Patients and Families (PDF, 2004)
Bipolar News a guide to the latest research on bipolar,
for clinicians, patients and families.
Harvard Bipolar Research Program
Depression and Bipolar Support
Alliance
Online Bipolar Support Group
Child and Adolescent Bipolar
Foundation
Visit the National Institute of
Mental Health; under “Select A Topic” choose “Bipolar
Disorder” to find useful brochures.
Depression
Light therapy for Seasonal
Affective Disorder
Depression and Bipolar Support
Alliance
National Foundation for Depressive
Illness
Depression in Older Adults (Large
Print or Small
Print )
Depression
and Pregnancy (PDF, 2001)
Depression
and Menopause (PDF, 2001)
Premenstrual
Depression (PDF, 2001)
Postpartum
Depression (PDF, 2001)
Postpartum
Depression Fact Sheet (PDF, 2001)
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