Mania and Hypomania: Latest Thinking on Diagnosis and Duration of Episodes

BIPOLAR UPDATE

The diagnosis of bipolar disorder is challenging. On this, the evidence is clear: The condition is frequently both underdiagnosed and overdiagnosed—though missing the diagnosis is more common.¹ Patients having (hypo)manic episodes may function fairly well (or, as they see it, very well indeed) and may not recognize or want to acknowledge their abnormal mood state. They usually do not seek care at those times. Indeed, if they have appointments, they may forget them, cancel, or just choose not to appear. When asked whether they have had hypomanic or manic episodes (in the usual few words that clinicians frequently employ), they may firmly deny it. Erroneous diagnoses and incorrect treatment can then continue for many years. Additionally, the rate of suicide in bipolar disorder is quite high.²

The most important initial advice we can give readers of this column is to please pull out the DSM-5-TR and review the criteria for mania, hypomania, and the mixed specifier. (They are exactly the same as in DSM-5.) Then, take the time to carefully assess patients with depression and ask about these criteria, looking particularly for a history of discrete episodes of (hypo)mania lasting at least a few days. It can help to have a significant other or family member who knows the patient well give input as to whether these discrete episodes have been occurring and how long they last. They may, in particular, recognize the earliest signs of an episode before the patient does.

On the other hand, avoid making a positive diagnosis of bipolar disorder after hearing about or observing just a couple of manic symptoms (eg, racing thoughts, rapid speech, tangential speech, irritable mood). Quick mania diagnosis on a hunch is also an error-prone process with bipolar disorder. We have seen many patients who get diagnosed as bipolar and then are tried on our full spectrum of mood stabilizers over years, enduring all their adverse effects, and still struggle with mood instability until the correct diagnosis is finally made. Patients with rapid or overly productive speech and thoughts could have posttraumatic stress disorder, attention-deficit/hyperactivity disorder, substance use disorders, or other problems—or all of them, contributing to these symptoms at different times. If so, each needs to be treated separately, prioritized in order of importance.

Having said that clinicians should follow the DSM-5-TR criteria, it may be that the criteria need improvement. I was privileged to be a member of an international task force of experts in the diagnosis of bipolar disorder that was convened to address possible changes in the DSM-5 criteria, particularly in the definitions of (hypo)manic episodes. This initiative was funded by the National Health and Medical Research Council of Australia. Investigators sent a questionnaire to 64 individuals from 14 countries spanning 5 continents, probing different aspects of the criteria.³

Perhaps the most important issue addressed was the DSM’s episode duration criteria. Currently, it is 7 days for mania (and a bipolar I diagnosis) and 4 days for hypomania (and a bipolar II diagnosis). Patients with briefer episodes that otherwise meet phenotypic criteria would not be diagnosed with bipolar I or II disorder (though they could meet criteria for one of the related bipolar spectrum disorders). Task force members were asked what they thought of the current duration requirement. Some felt that any duration of the syndromal criteria should be sufficient for diagnosis. However, most responders (75%) thought that ultrashort episodes have many possible explanations and some limit should be imposed. Of those nominating a finite period, the modal recommendation was 2 days for both mania and hypomania.³

Thus, for patients who have a sufficient number of symptoms to meet criteria, it may be that (hypo)mania durations of as little as 2 days could be a reasonable basis for concluding that the diagnosis is probably bipolar disorder and such patients should receive the normally indicated, evidence-based treatments. In many cases, this would mean stopping or avoiding antidepressants.

In differentiating bipolar I from bipolar II, the majority voted that the DSM should continue to include marked disturbance in functioning at work or socially during manias to diagnose bipolar I disorder. However, the criterion that hospitalization for the mania would automatically qualify the patient for bipolar I was strongly opposed. This requirement was considered arbitrary and too dependent on local health services practices, insurance, or other external factors. However, if the patient was hospitalized, that certainly could be an indicator of severity and likely mania. The task force agreed that psychosis during mania should be retained as a criterion for bipolar I mania.

The task force has studies underway to evaluate how well these proposed changes in the criteria apply in a series of patients derived from the clinical practices of task force members. They are also looking at 78 possible symptoms of (hypo)mania to see whether any are better than the 7 currently used in DSM-5-TR.⁴

Dr Osser is an associate professor of psychiatry at Harvard Medical School; a psychiatrist at the Veterans Affairs (VA) Boston Healthcare System, Brockton Division; and codirector of the VA National Bipolar Disorders TeleHealth Program. He is also a Psychiatric Times editorial board member. Dr Osser reports no conflicts of interest.

References

1. McIntyre RS, Zimmerman M, Goldberg JF, First MB. Differential diagnosis of major depressive disorder versus bipolar disorder: current status and best clinical practices. J Clin Psychiatry. 2019;80(3):ot18043ah2.

2. Trott M, Suitani S, Arnautovska U, et al. Suicide methods and severe mental illness: a systematic review and meta-analysis. Acta Psychiatr Scand. Published online October 1, 2024.

3. Parker G, Tavella G, Macqueen G, et al. Revising Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for the bipolar disorders: phase I of the AREDOC project. Aust N Z J Psychiatry. 2018;52(12):1173-1182.

4. Parker G, ed. Bipolar II Disorder: Modelling, Measuring and Managing. 3rd ed. Cambridge University Press; 2019.