PSYCH 650 Week 3 Depressive and Bipolar Disorders Example

Twenty Years of Depression, Then Three Sleepless Weeks: When a Depression Diagnosis Turns Out to Be Bipolar II

[Student Name]

University of Phoenix

PSYCH/650: Psychopathology

Week 3 Assignment

[Instructor Name]

[Date]

The crisis unit, its staff and the client are composites written for a model paper; diagnostic criteria and research findings come from the sources listed.

Mood disorders are among the most common causes of disability worldwide, and distinguishing depressive from bipolar illness shapes treatment. Mrs. L., who arrived at our unit after three sleepless weeks, shows why the distinction is so easy to miss.

The Case

Mrs. L., forty-five, teaches high school chemistry in Mesa, Arizona. Since her twenties she has had recurrent episodes of depression, roughly every two to three years, each lasting several months, with low mood, loss of interest, exhaustion, guilt and, twice, thoughts of suicide. She has been treated by her primary care physician with several antidepressants. Six weeks ago, during a depressive episode, her physician switched her to a new antidepressant. About three weeks later, her husband noticed that she was sleeping only three hours a night yet felt energetic, talked rapidly, interrupted others, started several home renovation projects and spent eleven thousand dollars online on lab equipment and art supplies. She was irritable when he questioned her. After she shouted at a parent during a meeting, her principal sent her home, and her husband brought her to our unit.

In the intake interview, her husband recalled two earlier periods, years ago, when she was "unusually upbeat" for about a week, slept little, took on extra projects and seemed like "the best version of herself." She had never mentioned these to her doctor.

Defining Episodes

The DSM-5-TR (American Psychiatric Association, 2022) builds mood disorders from episodes. A depressive episode needs a fortnight or more of low mood or lost pleasure, with enough companion symptoms to hurt or impair. Mania means a week or more of mood running unusually high or irritable, energy surging, little sleep, rapid talk and reckless choices, severe enough to wreck functioning, require a hospital or bring psychotic features. Hypomania is the milder cousin: the same kind of lift, kept up for four days or more, without the collapse in functioning, the hospital stay or the loss of contact with reality.

Bipolar I disorder requires at least one manic episode. Bipolar II disorder requires at least one hypomanic episode and at least one major depressive episode, without any manic episode.

Applying the Criteria

Mrs. L. has now gone three weeks sleeping little without tiring, talking fast, launching one project after another, snapping at people and spending freely. The key question is severity. Being sent home from work and the scale of spending suggest marked impairment, which would point toward a manic episode. However, the DSM specifies that a full manic episode emerging during antidepressant treatment and persisting beyond the drug's physiological effect counts toward bipolar I; when symptoms are less severe, clinicians must judge carefully. The team's psychiatrist judged the current episode as hypomanic with significant impairment developing, and the two earlier unreported periods appeared to be hypomanic episodes that occurred without antidepressants. Her history of recurrent major depression combined with past hypomania pointed to bipolar II disorder, with close monitoring for progression to mania.

Why Bipolar II Hides

Judd et al. (2003) followed eighty-six patients with bipolar II disorder prospectively for an average of more than thirteen years, recording their weekly symptom status. Patients were symptomatic about half of all weeks, and depressive symptoms dominated: they spent roughly thirty-nine times as many weeks with depressive symptoms as with hypomanic symptoms. Much of the depressive time involved subthreshold or minor depression rather than full episodes.

These findings explain how Mrs. L.'s illness could look like recurrent depression for twenty years. Her hypomanic periods were brief, felt good and were not reported, while her depressions brought her to treatment.

For two decades, the only part of her illness anyone asked about was the part that hurt.

How Common Is the Bipolar Spectrum?

Merikangas et al. (2011) analyzed surveys of over sixty thousand adults in eleven countries in the World Mental Health Survey Initiative. Lifetime prevalence was about 0.6 percent for bipolar I, 0.4 percent for bipolar II and 1.4 percent for subthreshold bipolar disorder, totaling about 2.4 percent for the bipolar spectrum, with higher rates in the United States. Most people with bipolar disorder also had other disorders, especially anxiety, and many had not received treatment, particularly in low-income countries.

Screening for Past Hypomania

Hirschfeld et al. (2000) built a one-page checklist, the Mood Disorder Questionnaire, that asks people whether they have ever had stretches of unusual energy and related changes, whether those changes came together and how much trouble they caused. In a sample of psychiatric outpatients, the questionnaire identified most patients with bipolar spectrum disorders and correctly screened out most without them. Screening tools are not diagnostic, but they prompt clinicians to ask about histories patients do not volunteer.

Had Mrs. L. been screened years ago, and had her husband been asked, the earlier hypomanic periods might have been identified.

Other Explanations to Rule Out

Before settling on bipolar II, the team considered other explanations. Stimulant use or high-dose steroids can produce manic-like symptoms; her toxicology screen was negative, and she takes no steroids. Thyroid overactivity can cause insomnia, agitation and racing thoughts; her thyroid tests were normal. Some neurological conditions emerging in midlife can change behavior; her neurological examination was unremarkable. Borderline personality disorder can involve impulsivity and mood shifts, but its mood changes are usually brief and reactive, lasting hours rather than days, and Mrs. L. had no history of the unstable relationships and identity disturbance typical of that disorder. Ruling out alternatives is part of diagnosis, not a formality.

The Value of Collateral History

The diagnosis turned on information Mrs. L. had never offered: her husband's memory of two earlier upbeat weeks. People rarely seek help for periods when they feel energetic and productive, and many do not recognize them as symptoms. Asking family members about past changes in sleep, energy and spending is one of the most useful steps in mood disorder assessment.

Why the Diagnosis Matters

Treating bipolar depression with antidepressants alone may be ineffective for some people and is associated with risk of switching into hypomania or mania or with mood cycling in vulnerable individuals. Bipolar disorder is usually treated with mood stabilizers or certain antipsychotic medications, along with psychotherapy and attention to sleep and routine.

Safety

Mrs. L.'s history includes suicidal thoughts during depression, and the period after a hypomanic or manic episode can bring a crash into depression. Staff assessed suicide risk at intake and planned to reassess daily.

The Plan

The psychiatrist discontinued the antidepressant, started a mood stabilizer and arranged outpatient follow-up with a psychiatrist rather than primary care. The team educated Mrs. L. and her husband about early warning signs, the role of sleep regularity and how to track moods. Her husband agreed to share observations with her psychiatrist.

Conclusion

Mrs. L.'s twenty-year history of depression, combined with previously unreported hypomanic periods and a current episode during antidepressant treatment, points to bipolar II disorder. Research on the long-term course of bipolar II, its prevalence and screening explains why such cases are often missed and why careful history matters for treatment.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

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

Judd, L. L., Akiskal, H. S., Schettler, P. J., Coryell, W., Endicott, J., Maser, J. D., Solomon, D. A., Leon, A. C., & Keller, M. B. (2003). A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Archives of General Psychiatry, 60(3), 261-269. https://doi.org/10.1001/archpsyc.60.3.261

Merikangas, K. R., Jin, R., He, J.-P., Kessler, R. C., Lee, S., Sampson, N. A., Viana, M. C., Andrade, L. H., Hu, C., Karam, E. G., Ladea, M., Medina-Mora, M. E., Ono, Y., Posada-Villa, J., Sagar, R., Wells, J. E., & Zarkov, Z. (2011). Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Archives of General Psychiatry, 68(3), 241-251. https://doi.org/10.1001/archgenpsychiatry.2011.12