Pearls

When to treat subthreshold hypomanic episodes

Current Psychiatry. 2012 August;11(8):55-55

References

1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

2. Pigott HE, Leventhal AM, Alter GS, et al. Efficacy and effectiveness of antidepressants: current status of research. Psychother Psychosom. 2010;79(5):267-279.

3. Nelson JC, Pikalov A, Berman RM. Augmentation treatment in major depressive disorder: focus on aripiprazole. Neuropsychiatr Dis Treat. 2008;4(5):937-948.

4. Daly EJ, Trivedi MH. A review of quetiapine in combination with antidepressant therapy in patients with depression. Neuropsychiatr Dis Treat. 2007;3(6):855-867.

5. Price LH, Carpenter LL, Tyrka AR. Lithium augmentation for refractory depression: a critical reappraisal. Prim Psychiatry. 2008;15(11):35-42.

6. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-1875.

7. The Mood Disorder Questionnaire. http://www.drpaddison.com/mood.pdf. Accessed June 20 2012.

8. Angst J, Azorin JM, Bowden CL, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry. 2011;68(8):791-798.

According to DSM-IV-TR, the minimal duration of a hypomanic episode is 4 days.¹ Should we treat patients for hypomanic symptoms that last <4 days? Could antidepressants’ high failure rate² be because many depressed patients have untreated “subthreshold hypomanic episodes”? Aripiprazole, quetiapine, and lithium all have been shown to alleviate depression when added to an antidepressant.^3-5 Is it possible that these medications are treating subthreshold hypomanic episodes rather than depression?

The literature does not answer these questions. To further confuse matters, a subthreshold hypomanic episode may not be a discrete episode. In such episodes, hypomanic symptoms may overlap at some point and the duration of each symptom may vary.

When I administer the Mood Disorder Questionnaire,^6,7 I ask patients about 13 hypomanic symptoms. Patient responses to questions about 7 of these symptoms—increased energy, irritability, talking, and activity, feeling “hyper,” racing thoughts, and decreased need for sleep—can help demonstrate the variability of symptom duration. For example, a patient may complain of increased energy and irritability for 3 days, increased activity and feeling “hyper” for 2 days, increased talking and a decreased need to sleep for 1 day, and racing thoughts every day.

Alternative criteria

Considering this variation, I often use the following criteria when considering whether to treat subthreshold hypomanic symptoms:

≥4 symptoms must last ≥2 consecutive days
≥3 symptoms must overlap at some point, and
≥2 of the symptoms must be increased energy, increased activity, or racing thoughts.

However, some patients have hypomanic symptoms that do not meet these relaxed criteria but require treatment.⁸ I also need to know when these episodes started, how frequently they occur, and how much of a problem they cause in the patient’s life. I often treat subthreshold hypomanic episodes with an antipsychotic or a mood stabilizer. As with all patients I see, I consider the patient’s reliability, substance abuse history, and mental status during the interview.

When to treat subthreshold hypomanic episodes

References

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