Bipolar II in Adults

During the hypomanic episode, at least three of the following symptoms occur (four symptoms if the mood is only irritable):

• Grandiosity or significantly inflated self-esteem
• Significantly decreased need for sleep (e.g., feels rested after only three hours of sleep)
• Pressured (fast, difficult-to-interrupt) speech or more talkative than usual
• Racing thoughts
• Distractibility
• Significant increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation
• Excessive involvement in activities that have a high potential for painful consequences (such as excessive spending, sexual indiscretions, or poor business investments)

Hypomanic episodes are distinguished from manic episodes primarily by severity; by definition, hypomanic episodes are not severe enough to cause marked impairment or necessitate hospitalization.  If impairment is severe or hospitalization is warranted, or if psychotic features are present, BPI is the more appropriate diagnosis.

BPII also requires a history of at least one major depressive episode.  Major depressive episodes are characterized primarily by depressed mood or loss of interest.  To meet diagnostic criteria, the individual must also experience at least four of the following symptoms, which must occur with the depressed mood or loss of interest nearly every day for two weeks or longer:

• Appetite disturbance or significant weight change (increased or decreased)
• Insomnia or hypersomnia (sleeping too much)
• Psychomotor agitation (being visibly restless or physically agitated) or retardation (being visibly slowed down)
• Fatigue or loss of energy
• Thoughts of worthlessness or excessive, inappropriate guilt
• Difficulty concentrating or making decisions
• Recurrent thoughts of death or suicide

Sometimes mixed episodes can occur, where the individual meets criteria for both a hypomanic episode and a major depressive episode concurrently.  Typically, the individual with BPII will also have periods of euthymia, where no significant mood symptoms are present.  However, euthymic periods occur less frequently and are often of a shorter duration in BPII compared to BPI.

BPII is characterized by abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to hypoactivation in several regions of the prefrontal cortex, which are involved in executive functioning and regulation of emotion.  Hyperactivation of limbic structures involved in emotion generation, including the amygdala, and reduced connectivity of the amygdala with frontal regions,have also been observed.  The disorder has a genetic component, although having a genetic predisposition to BPII does not necessarily mean that someone will develop BPII.

First Line Treatments

To manage severe mania symptoms or a mixed episode, combined pharmacological treatment with lithium plus an atypical antipsychotic such as olanzapine, risperdone, or quetiapine is the first-line treatment.  For a less severe hypomanic episode, monotherapy with lithium, valproate, or an atypical antipsychotic may be sufficient.  Short-term adjunctive treatment with a benzodiazepine may also be helpful.

In the case of a bipolar depressive episode, lithium or lamotrigine are considered first-line treatments.  Antidepressant monotherapy is not recommended, as this can trigger hypomanic symptoms.

Augmentation of first-line pharmacological interventions with psychotherapy is also indicated.  Psychological treatments with research support include:

• Psychoeducation about bipolar disorder.  (Strong research support for mania; modest research support for depression.)
• Cognitive therapy, in which the patient learns to challenge unhelpful and/or inaccurate thoughts and beliefs.  (Modest research support for both mania and depression.)
• Family-focused therapy, in which families are trained to notice the emergence of symptoms, assist with medication adherence, and engage in helpful coping responses. (Strong research support for depression.)
• Interpersonal and social rhythm therapy, in which the patient learns to effectively manage sleep and other schedules implicated in symptoms. Interpersonal components, such as managing interpersonal disputes, role transitions, and interpersonal isolation, are also included. (Modest research support for depression.)

Second Line Treatments

In cases of nonresponse to first-line treatment or "breakthrough" episodes despite continued pharmacological treatment, optimization of the medication dose should be the first intervention. 
During a depressive episode, augmentation with an antidepressant may be considered.  Antidepressant-induced manic symptoms are less likely in BPII compared to BPI.  Adjunctive medications to be considered may include:

• Selective serotonin reuptake inhibitor (SSRI)
• Venlafaxine
• Monoamine oxidase inhibitors (MAOIs)

Electroconvulsive therapy (ECT), in which small electrical currents are used to trigger a brief seizure, may also be provided as an augmentation strategy.  ECT may be indicated if the individual is pregnant or in the case of a mixed episode.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered to assist with depressive symptoms.  However, most of these treatments have not been evaluated in the context of BPII; therefore, the risk of triggering a manic episode should be carefully weighed against the potential benefits.

• A small pilot study found that augmentation of carbamazepine with Free and Easy Wanderer Plus (FEWP), which is reported to contain eleven herbal materials, was found to be more effective than carbamazepine alone in reducing depressive but not manic symptoms in BPI, but has not been tested in BPII.
• Omega-3 fatty acids have some support for management of bipolar depression and the risk of triggering mania appears minimal.
• Herbal therapies such as St. John's Wort may be considered, although the patient should be monitored for the emergence of mania symptoms.
• Acupuncture, S-adenosyl-L-methionine (SAMe), aromatherapy massage, therapeutic massage, and yoga have some modest support for reducing depressive symptoms, although these interventions have not been evaluated in BPII.