Bipolar II: A Frequently Missed Diagnosis in the Treatment of People with Depression

Depression & Anxiety 1,976 views
Written by Timothy Pfaff

Awareness is growing that the mere absence of extreme manic episodes may not rule out that someone dealing with severe bouts of depression may in fact be bipolar II—an important distinction in treatment.

Bipolar II: A Frequently Missed Diagnosis in the Treatment of People with Depression

Few people are satisfied with the word “depression.” It’s too vague to encompass all the phenomena that make it up, and it’s just clinical enough to be off-putting—both to people living with depression and those around them.

But as words go, it’s got legs. Regardless of how or why, feeling bad is such a basic component of the experience of being human that it, and its offspring, anxiety, make their appearances in mankind’s earliest surviving literature. It’s certainly been a place-holder in the DSM, the Diagnostic and Statistical Manual of Mental Disorders, first published in 1952 and now in its fifth edition.

It’s a commonplace in mental-health thinking that, as a bona fide mental illness, depression—thought to affect at least ten percent of the world’s population—is significantly under-diagnosed. Now imposing questions are being asked about the degree to which it may be mis-diagnosed.

That there are degrees of depression, often varying widely from individual to individual, is self-evident enough to have established itself as “settled science.” The thinking is now that it exists—and is experienced by people with it—along a broad continuum.

At or near one end of that continuum is a condition now called Bipolar II. It is distinguished from Bipolar I—the “old” bipolar—primarily by the absence of the unmistakable manic episodes at the “high” end of the elation-depression cycle. But the specialists now taking Bipolar II seriously—and the people with chronic depression willing and often avid to reassess their idanoses and conditions—are clear about one thing. Bipolar II is not “bipolar lite.”

The evidence is that it’s chronic, that it can be severe—particularly on the depressive side of the “mood” swing—and that treating it as if it were the same as “ordinary” clinical depression is at best wrong and at worst dangerous.


Because the inclination toward depression, across the whole spectrum, does tend to run in families, manic episodes are phenomena not only people with technical skills observe. That said, manic episodes, particularly repeated ones, often do, of necessity, result in periods of institutionalization.

Too, the “excitement” associated with them is such that they have become rich fodder for media and the arts. Manic behavior is of its nature florid, and if not always attention-seeking, reliably attention-getting. Even the most avid car-salesman is unlikely not to notice that his exuberant, fast-talking customer has already gotten credit approval on three luxury sports cars that same day.  

Whether or not you care to bring in the word “psychotic” to describe it, manic behavior is too conspicuous—too divorced from the reality that prevails around it—to go unnoticed. At its most extreme, a full-blown manic episode convinces the person who is having it of some kind of personal supremacy. The range is, roughly, from “I can do anything” to “I’m above the law,” with occasional stops at “I’m God.”

More often than not, it looks as desperate as the person having it feels, despite claims of “never having felt better in my life.” Its most combustible, and socially communicable, component looks like, because it is, extreme anxiety.


Sticking with lay language, hypomanic experiences involve prolonged feelings of elation, personal power, and a kind of feverish interest in all kinds of things. But usually such experiences happen at a pitch that scares, if anyone, most likely the person having those feelings, or at the high point in the “mood swing.” The associated depression, whether consequent or a precursor, can be crushing, sometimes to the point of disabling.

The three defining characteristics of a hypomanic episode are prolonged high spirits and/or energy, pressured speech (going as far as what is termed a “flight of ideas"), and a reduced need for/interest in sleep and, sometimes, eating. Accompanying behaviors may be greater than usual sexual or psycho-motor activity, irritability, or increased risk-taking behavior, including financial risks.

Critically, hypomanic episodes do not often lead to dysfunction or anything like obvious psychosis. They are often unrecognized by others, particularly in the cases of people who are normally “high energy.” And they rarely interfere with successful functioning in the world or require intervention or institutionalization.

Diagnosis of Bipolar II

The latest edition of the DSM, the DSM-5, gives the criteria for a diagnosis of Bipolar II as:

  • One or more major depressive episodes
  • At least one episode of hypomania lasting at least most of the day and for at least four days,
  • and, according to the American Psychiatric Association in 2013, as noted in “Bipolar II Disorder DSM-5 296.89 (F31.81),” three or more of the following symptoms will be present (American Psychiatric Association, 2013):
  1. Inflated self-esteem or grandiosity
  2. Decreased need for sleep
  3. More talkative
  4. Subject experience of thoughts/ideas racing
  5. Distractibility
  6. Increase in goal-directed activity or psychomotor agitation, or
  7. Excessive involvement in pleasurable activities with a high potential of painful consequences
  8. The individual will not have experienced a manic episode or mixed episode.”

A serious problem for people living with depression is the inclination to self-diagnose on the basis of the above.

An accurate diagnosis of Bipolar II is made through testing, both psychological and clinical. Of late there are even indications that evidence of Bipolar II can be found in electrocardiograms.

Firm, meaningful diagnosis of Bipolar II must come from psychiatrists and other specialists trained to recognize and identify it.

What difference does the diagnosis make?

The prevailing opinion is that the principle—some would say critical—difference in treatment is in the area of medication. That said, professional opinions about appropriate medications vary considerably, the more so when individual variables are taken into account.

In brief, some professionals think the SSRIs in common use to treat clinical depression are actually contra-indicated, if not actually harmful, to people with Bipolar II. In some cases, specialists recomend combining SSRIs with medications from new groups of drugs alternately called “mood stabilizers” and atypical anti-psychotics (AAPs).

In other cases, medical professionals insist on discontinuing SSRIs (for a variety of reasons involving both their effects and the side effects associated with them). On the other hand, some psychiatrists recommend, at least initially or transitionally, increasing the dosage of an SSRI has that has proved effective over time.

Any decisions about medications or change of medications should be made by a qualified physician and monitored closely at the time of change and for a meaningful period afterwards.

It would be an oversight not to note that some people newly diagnosed with Bipolar II make decisions not to take or alter their medications. Some cases are less debilitating than others, and there are people who find the hypomanic phases conducive to their productivity or creativity without dire results. As with taking medications, any decision not to take, or change, medications should be made in close consultation with a qualified physician.

Paying attention and self-care

The professionals—and the people living with depression who have recognized and benefitted from diagnosis or re-diagnosis with Bipolar II—agree that it is under-diagnosed. That is, too often, it is mistaken for, and treated as, more basic a simpler form of clinical depression.

One of the phenomena now associated with Bipolar II is a heightened sensitivity to sensory inputs, particularly noise and light. In the case of Bipolar II, a characteristic response to excessive sensory input is agitation, anxiety, and irritability leading to rage and outbursts. It’s not diagnostic of Bipolar II but not uncharacteristic of it, either.

If any of the above catches your attention—in the sense of any level of identification or a sense that “that explains [X]"—it is worth noting and reporting to any of your treating professionals. To the extent that a case of Bipolar II is—as it is frequently misleadingly called—“soft,” the individual dealing with it may be most important of all in the process of recognizing its possibility.

Properly diagnosed, there are effective treatments available. At the practical level, a great deal of it may lie in the area of behavior modification, much of which can be self-identified and –implemented—precisely because when you’re not in a hypomanic phase, “you know best.” Knowing when to stop, rest, eat, sleep, nap—even shop, i.e., not when stores are busiest and crowds and noise the greatest—can have a highly salutary effect on someone living with Bipolar II.