Three Depressions, Two Antidepressants and One Question Nobody Asked: Screening for Bipolar II Disorder in a 34-Year-Old With Recurrent Depression Before a Third Antidepressant
[Student Name]
University of Phoenix
PMH/501: Neuropsychiatric Disorders
Week 3 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Mr. H., a 34-year-old sales manager, is referred by his primary care clinician after his third episode of major depression. Sertraline helped partly during his first episode; escitalopram, during his second, seemed to make him "wired and irritable" for a few weeks before the depression returned. He now asks for "something stronger." His PHQ-9 score is 18. Before choosing a third antidepressant, I ask a question that his records do not show anyone asking: has he ever had periods of unusually high energy?
Why the Question Matters
Bipolar disorder often presents first and most often with depression, and hypomanic episodes may not be seen as illness by the patient, who may remember them as productive or happy times. Merikangas et al. (2007), in a nationally representative U.S. sample, estimated lifetime prevalence of 1.0% for bipolar I, 1.1% for bipolar II and 2.4% for subthreshold bipolar disorder, with most people having comorbid conditions, particularly anxiety disorders. Depressive episodes in bipolar II were more severe and impairing than in bipolar I, and the authors noted that inappropriate treatment of bipolar spectrum disorder was a serious problem.
Screening With the Mood Disorder Questionnaire
Hirschfeld et al. (2000) developed the Mood Disorder Questionnaire, a self-report screen for bipolar spectrum disorder, and reported that when 7 or more items were endorsed, clustered in one period and caused at least moderate problems, the screen correctly flagged about three in four people with bipolar spectrum illness and correctly cleared about nine in ten without it, in psychiatric outpatients. Mr. H. endorses 9 items, reports that several occurred during the same period and rates the resulting problems as moderate. The screen is positive.
The screen does not diagnose; it tells me which history to take next.
The Structured History
I ask about specific periods. Mr. H. describes two episodes, at 26 and 31, each lasting about a week, when he slept four hours a night without tiredness, talked rapidly, started several projects, spent heavily on sports equipment and felt "better than ever." Coworkers commented that he seemed different. Neither episode led to hospitalization or severe impairment. His wife, who joins with his permission, confirms the second episode and says he was irritable and hard to be around. His father had "mood swings" and drank heavily.
Applying DSM Criteria
DSM describes hypomania as four or more consecutive days of a noticeably high, expansive or irritable mood together with raised energy, with three or more symptoms such as decreased need for sleep, pressured speech, racing thoughts, distractibility, increased goal-directed activity or risky behavior, observable by others, and it stops short of the severe impairment or hospital admission that would define mania. Mr. H.'s episodes meet these criteria. With at least one hypomanic episode and recurrent major depressive episodes, he meets criteria for bipolar II disorder.
The Escitalopram Reaction
His "wired and irritable" weeks on escitalopram may have been antidepressant-associated activation or a mixed or hypomanic state. Ghaemi et al. (2004) compared antidepressant response in bipolar and unipolar depression and found that patients with bipolar disorder were more likely to develop new or worsened rapid cycling and antidepressant-induced mania and to lose response over time. His history fits this pattern.
Why Hypomania Is Missed
Hypomania is often experienced as a welcome time of energy and confidence, so patients rarely report it as a symptom, and clinicians rarely ask. Patients seek care when depressed, and a cross-sectional depression screen captures only the current episode. Collateral history from a partner or family member, as Mr. H.'s wife provided, often reveals episodes the patient minimizes.
Family History as a Clue
His father's mood swings and heavy drinking may reflect undiagnosed bipolar disorder, which is highly heritable. A family history of bipolar disorder in a person with depression raises the probability of a bipolar course and is one of several clinical features, along with early onset, recurrent episodes and antidepressant-associated activation, that should prompt careful screening.
Mood Charting
Asking Mr. H. to keep a daily mood and sleep chart for several weeks will provide prospective information and help both of us recognize early signs of new episodes. Sleep loss is a common early warning sign of hypomania.
Explaining the Diagnosis
I explain to Mr. H. that his depressions and his energetic periods are two sides of one condition, and that this understanding explains why antidepressants alone have not worked well. He is relieved that there is a reason, though worried about the label. I emphasize that bipolar II disorder is common, treatable and compatible with a full career.
Safety
People with bipolar II disorder face a substantial suicide risk, highest when depression or mixed features are present. I complete a structured suicide risk assessment; he has passive thoughts without plan or intent and agrees to a safety plan with crisis contacts.
Why Not Diagnose From the Screen Alone
The Mood Disorder Questionnaire misses about a quarter of people with bipolar spectrum disorder and flags some without it (Hirschfeld et al., 2000). A positive screen in a patient with anxiety or personality traits could reflect mood instability of another kind. That is why the structured history of distinct episodes, confirmed by his wife, carries the diagnosis rather than the score.
Communicating With His Primary Care Clinician
I send a summary explaining the revised diagnosis, the evidence for it and the recommendation to avoid antidepressant monotherapy, so that future prescribers do not repeat the cycle.
Sleep Regularity
Irregular sleep and shift changes can trigger episodes in bipolar disorder. His job involves frequent travel across time zones; I note this as a target for later management.
Alcohol and Mood
Even modest alcohol use can destabilize mood, disturb sleep and interfere with treatment, so I discuss limiting it.
Next Visit
We will meet in one week with his completed mood chart to begin treatment planning together.
Excluding Other Explanations
Substance-induced mood episodes must be considered; Mr. H. denies stimulant use and drinks two beers on weekends. Thyroid function is normal. Borderline personality traits can cause mood instability, but his episodes are distinct and lasting days, not hours of reactivity.
What Changes
The diagnosis changes the plan. Rather than a third antidepressant alone, treatment of bipolar II depression involves medications with evidence in bipolar depression, such as quetiapine or lamotrigine, with psychoeducation, mood charting and attention to sleep regularity. The management course will address these choices; for now, I communicate the revised diagnosis to his primary care clinician and recommend against a new antidepressant without a mood stabilizer.
Conclusion
Mr. H.'s recurrent depression and activation on an antidepressant prompted screening with the Mood Disorder Questionnaire, whose positive result led to a structured history revealing two hypomanic episodes. He meets criteria for bipolar II disorder, a common and impairing condition often treated as unipolar depression. Asking about hypomania before a third antidepressant changed the diagnosis and the direction of his treatment.
References
Ghaemi, S. N., Rosenquist, K. J., Ko, J. Y., Baldassano, C. F., Kontos, N. J., & Baldessarini, R. J. (2004). Antidepressant treatment in bipolar versus unipolar depression. American Journal of Psychiatry, 161(1), 163-165. https://doi.org/10.1176/appi.ajp.161.1.163
Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873
Merikangas, K. R., Akiskal, H. S., Angst, J., Greenberg, P. E., Hirschfeld, R. M. A., Petukhova, M., & Kessler, R. C. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 64(5), 543-552. https://doi.org/10.1001/archpsyc.64.5.543
How this PMH 501 Week 3 example is structured
The PMH/501 Week 3 work usually examines depressive and bipolar disorders and their differential diagnosis. This paper shows the step that most often changes the diagnosis, a structured history of hypomania, and connects it to evidence on prevalence, detection and treatment response. Students search this week as PMH 501 Week 3, PMH501 Wk 3 or PMH/501 Wk 3; all three are the same assignment.
PMH/501 Week 3 questions, answered
What does PMH/501 Week 3 usually ask for?
Many sections ask students to assess and differentiate depressive and bipolar disorders, often through a case of depression with features suggesting bipolarity.
What is bipolar II disorder?
A mood disorder with at least one major depressive episode and at least one hypomanic episode, a milder, shorter period of elevated or irritable mood and increased energy, without full mania.
Why does bipolar II disorder matter for treatment?
Treating it as unipolar depression with antidepressants alone may be less effective and can be associated with mood switching or cycling, so the diagnosis changes medication choice.
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