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Bipolar and hypomania


What Is It, Comparison vs Mania, Symptoms & Treatment

Overview

What is hypomania?

Hypomania is a condition in which you have a period of abnormally elevated, extreme changes in your mood or emotions, energy level or activity level. This energized level of energy, mood and behavior must be a change from your usual self and be noticeable by others.

Hypomania is a symptom of bipolar disorder, but can also be a symptom of other mental health conditions.

What’s the difference between hypomania and mania?

Hypomania is a less severe form of mania. The criteria that healthcare professionals use to make the diagnosis of either hypomania or mania is what sets them apart. These differences are as follows:

Hypomania Mania
How long the episode lastsAt least four consecutive daysAt least one week
Severity of episodeNot severe enough to significantly affect social or work/school functioningCauses severe impact on social or work/school functioning
Need for hospitalizationNoPossibly
Need for hospitalizationCan’t be present for a diagnosis of hypomaniaIs among possible symptoms

What triggers a hypomanic episode?

Each person’s triggers may be different. Some common triggers include:

  • A highly stimulating situation or environment (e.g., lots of noise, bright lights, large crowds).
  • A major life change (e.g., divorce, marriage, job loss).
  • Lack of sleep.
  • Substance use, such as recreational drugs or alcohol.

It’s smart to develop a list of your triggers to know when a hypomanic episode may be starting. Since hypomania doesn’t cause severe changes in your activity level, mood or behavior, it may be helpful to ask family and close friends who you trust and have close contact with to help identify your triggers. They may notice changes from your usual self more easily than you do. Share your trigger list with your close, trusted friends so they can tell when you might need help.

How long does a hypomanic episode last?

According to the criteria for hypomania, hypomania must last at least four days. But it can last up to several months.

What happens after a hypomanic episode?

After a hypomanic episode you may:

  • Feel happy or embarrassed about your behavior.
  • Feel overwhelmed by all the activities you’ve agreed to take on.
  • Have only a few or unclear memories of what happened during your manic episode.
  • Feel very tired and need sleep.
  • Feel depressed (if your hypomania is part of bipolar disorder).

Symptoms and Causes

What are the symptoms of hypomania?

Symptoms of a hypomanic episode are the same but less intense than mania. Hypomanic symptoms, which vary from person to person, include:

  • Having an abnormally high level of activity or energy.
  • Feeling extremely happy, excited.
  • Not sleeping or only getting a few hours of sleep but still feel rested.
  • Having an inflated self-esteem, thinking you’re invincible.
  • Being more talkative than usual. Talking so much and so fast that others can’t interrupt.
  • Having racing thoughts — having lots of thoughts on lots of topics at the same time (called a “flight of ideas”).
  • Being easily distracted by unimportant or unrelated things.
  • Being obsessed with and completely absorbed in an activity you’re focus on.
  • Displaying purposeless movements, such as pacing around your home or office or fidgeting when you’re sitting.
  • Showing impulsive behavior that can lead to poor choices, such as buying sprees, reckless sex or foolish business investments.

What’s the difference between feeling good vs hypomania?

It takes time to know the difference. Everyone enjoys being happy and feeling good. But feeling good doesn’t always mean you are good. Over time, you’ll start to understand yourself and learn the warning signs that you may be starting to have an elevated mood that is different than just feeling good.

Ask family and close friends who you trust, and have frequent contact with, to give you feedback. Ask them to tell you when they see beyond normal changes in your mood or behaviors.

What does hypomania feel and look like?

What hypomania feels like and looks like will be different for each person. Some examples of things you might feel and/or do include:

  • Get into an intense cleaning frenzy and clean all surfaces of every room in your house.
  • Stay up until 3 a.m. or don’t go to bed at all and not feel tired the next morning.
  • Start a project, or more than one project, and work non-stop on these projects for 20 hours straight.
  • Feel that you can’t fail at anything you want to do, even if you have no training or experience.
  • Call and text all your friends all day and night and post a large number of pictures and comments on social media.
  • Quickly jump from subject to subject when talking, and talking very fast.

What causes hypomania?

Scientists aren’t completely sure what causes hypomania. However, there are several factors that are thought to contribute. Causes differ from person to person.

Causes may include:

  • Family history. If you have a family member with bipolar illness, you have an increased chance of developing mania. This is not definite though. You may never develop mania even if other family members have.
  • Chemical imbalance in your brain.
  • Side effect of a medication (such as some antidepressants), alcohol or recreational drugs.
  • A significant change in your life, such as a divorce, house move or death of a loved one.
  • Difficult life situations, such as trauma or abuse, or problems with housing, money or loneliness.
  • High stress level and inability to manage it.
  • Lack of sleep or changes in sleep pattern.
  • As a symptom of mental health problems including cyclothymia, seasonal affective disorder, postpartum psychosis, schizoaffective disorder or other physical or neurologic condition such as brain injury, brain tumors, stroke, dementia, lupus or encephalitis.

Diagnosis and Tests

How is hypomania diagnosed?

Your healthcare provider will ask about your medical history, family medical history, current prescriptions and non-prescription medications and any herbal products or supplements you take. Your provider may order blood tests and body scans to rule out other conditions that may mimic mania. One such condition is hyperthyroidism. If other diseases and conditions are ruled out, your provider may refer you to a mental health specialist

To be diagnosed with hypomania, your mental health specialist may follow the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, DSM-5. Their criteria for manic episode is:

  • You have an abnormal, long-lasting elevated expression of emotion along with a high degree of energy and activity that lasts for at least four consecutive days and is present most of the day, nearly every day.
  • You have three or more symptoms to a degree that they’re a noticeable change from your usual behavior (four symptoms if mood is only irritable). (See the symptoms section of this article for a list of the symptoms used as criteria.)
  • The hypomanic episode is not severe enough to significantly interfere with your social, work or school functioning and there’s no need for hospitalization.
  • The hypomanic episode can’t be caused by the effects of a substance (medications or drug abuse) or another medical condition.

If you have hypomania, you don’t have thoughts that are out of step with reality — you don’t have false beliefs (delusions) or false perceptions (hallucinations). If you do have these symptoms of psychosis, your diagnosis is mania.

What is bipolar II disorder?

Bipolar II disorder is a type of bipolar disorder in which people experience depressive episodes as well as hypomanic episodes (shifting back and forth), but never mania. People with bipolar II disorder tend to have longer and more frequent depressed episodes than people with bipolar I disorder.

If the severity of your symptoms never rises to the level of mania, you have bipolar II disorder. If you have even a single episode of what is considered mania or one psychotic event (delusions or hallucinations) during a hypomanic episode, your diagnosis would change to bipolar I disorder.

Management and Treatment

How is hypomania treated?

Hypomania is treated with psychotherapy, antipsychotic medications and mood stabilizers.

Psychotherapy

Psychotherapy involves a variety of techniques. During psychotherapy, you’ll talk with a mental health professional who will help you identify hypomania symptoms and triggers and learn ways to cope with or lessen the effects of hypomanic episodes.

Medications

Antipsychotic medication choices include:

  • Ariprazole (Abilify®).
  • Lurasidone (Latuda®).
  • Lanzapine (Zyprexa®).
  • Quetiapine (Seroquel®).
  • Risperridone (Risperdal®).

Mood stabilizers include:

  • Lithium.
  • Valproate (Depakote®).
  • Carbamazepine (Tegretol®).

(If you’re pregnant or plan to become pregnant, let your provider know. Valproate can increase the chance of birth defects and learning disabilities and shouldn’t be prescribed to individuals who are able to become pregnant. )

Sometimes antidepressants are also prescribed.

Managing hypomania without medications

If your hypomania is mild, you may be able to cope without medications. Your healthcare provider may suggest having a greater focus on self-care to stay as healthy as possible.

Suggested actions may include:

  • Go to bed at the same time each night and get plenty of sleep (six to nine hours).
  • Avoid stimulating triggers such as coffee, tea, colas, sugar, noisy and crowded environments.
  • Eat a healthy diet, such as the Mediterranean or Dash diet.
  • Get 30 minutes of exercise on most days of the week. Even two short walks a day is beneficial.
  • Don’t use illegal or recreational drugs or alcohol.
  • Learn ways to relax. Yoga, meditation, listening to calming music, aromatherapy are a few examples.
  • Take all medications as prescribed or instructed on package labeling. If you think you’re having side effects or new side effects to a medication, call your provider. Never stop taking — or change the dose — of a prescription medication without talking to your provider first. Make sure they know all supplements, herbal products and vitamins you take.
  • Join a support group. Ask your provider for contact information for local support groups. You might find it helpful to talk with other people who have similar medical experiences and share problems, ideas for coping and strategies for living and caring for yourself.

Prevention

Can hypomania be prevented?

Episodes of hypomania can’t always be prevented. However, you can learn ways to better manage your symptoms and prevent them from getting worse.

Suggestions on your “to-do list” might include:

  • Keeping a “mood diary” to become more self-aware of events that trigger an oncoming episode of hypomania. These events are unique to you. Sometimes you can’t recognize your own triggers. Ask your trusted, close family and friends to help identify when they see changes in your mood, behavior and energy level that is different from your usual self.
  • Following other coping strategies. (See the bulleted list under, “Managing hypomania without drugs,” just above in this article.)

Outlook / Prognosis

What outcome can I expect if I’ve been diagnosed with hypomania?

If you’ve been diagnosed with hypomania, you can have a favorable outcome if you learn about your condition, learn to recognize when you’re having a hypomanic episode and engage in coping strategies to lessen the severity or prevent events. Always take any prescribed medications as directed by your healthcare provider.

A note from Cleveland Clinic

Being amped up about your life and being in a good mood is usually thought to be a good thing. It can be if that’s how you normally are most of the time. This is what makes hypomania a little tricky to diagnose. Key to a diagnosis of hypomania is that your elevated mood, behavior or activity level must last at least four days (all day or most of the day) and must rise to the level that’s beyond normal and is noticeable by others. Know that a team of healthcare professionals — your primary care provider, psychologists and/or psychiatrist — is ready to help you figure this out.

Frequently Asked Questions

Can my diagnosis change between bipolar II disorder and bipolar I disorder?

Yes. If you have been diagnosed with the less severe condition of hypomania and have even a single episode of mania (as defined by the criteria), your diagnosis will change to bipolar I disorder. Once you have a diagnosis of bipolar I disorder – even if you never have another manic episode – your diagnosis can never be changed back to bipolar II disorder. You’ll always have a bipolar I disorder diagnosis.

Bipolar disorder - Symptoms and causes

Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will experience some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy).

Bipolar disorder care at Mayo Clinic

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Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.

  • Bipolar I disorder. You've had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).
  • Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode.
  • Cyclothymic disorder. You've had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).
  • Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early 20s. Symptoms can vary from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

  • Abnormally upbeat, jumpy or wired
  • Increased activity, energy or agitation
  • Exaggerated sense of well-being and self-confidence (euphoria)
  • Decreased need for sleep
  • Unusual talkativeness
  • Racing thoughts
  • Distractibility
  • Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments

Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships. An episode includes five or more of these symptoms:

  • Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
  • Marked loss of interest or feeling no pleasure in all — or almost all — activities
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)
  • Either insomnia or sleeping too much
  • Either restlessness or slowed behavior
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Decreased ability to think or concentrate, or indecisiveness
  • Thinking about, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

When to see a doctor

Despite the mood extremes, people with bipolar disorder often don't recognize how much their emotional instability disrupts their lives and the lives of their loved ones and don't get the treatment they need.

And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.

If you have any symptoms of depression or mania, see your doctor or mental health professional. Bipolar disorder doesn't get better on its own. Getting treatment from a mental health professional with experience in bipolar disorder can help you get your symptoms under control.

When to get emergency help

Suicidal thoughts and behavior are common among people with bipolar disorder. If you have thoughts of hurting yourself, call 911 or your local emergency number immediately, go to an emergency room, or confide in a trusted relative or friend. Or contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

If you have a loved one who is in danger of suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

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Causes

The exact cause of bipolar disorder is unknown, but several factors may be involved, such as:

  • Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
  • Genetics. Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.

Risk factors

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:

  • Having a first-degree relative, such as a parent or sibling, with bipolar disorder
  • Periods of high stress, such as the death of a loved one or other traumatic event
  • Drug or alcohol abuse

Complications

Left untreated, bipolar disorder can result in serious problems that affect every area of your life, such as:

  • Problems related to drug and alcohol use
  • Suicide or suicide attempts
  • Legal or financial problems
  • Damaged relationships
  • Poor work or school performance

Co-occurring conditions

If you have bipolar disorder, you may also have another health condition that needs to be treated along with bipolar disorder. Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

  • Anxiety disorders
  • Eating disorders
  • Attention-deficit/hyperactivity disorder (ADHD)
  • Alcohol or drug problems
  • Physical health problems, such as heart disease, thyroid problems, headaches or obesity

More Information

  • Bipolar disorder care at Mayo Clinic
  • Bipolar disorder and alcoholism: Are they related?

Prevention

There's no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you've been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:

  • Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you're falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.
  • Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen your symptoms and make them more likely to come back.
  • Take your medications exactly as directed. You may be tempted to stop treatment — but don't. Stopping your medication or reducing your dose on your own may cause withdrawal effects or your symptoms may worsen or return.

By Mayo Clinic Staff

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Bipolar Disorder | Symptoms, complications, diagnosis and treatment

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Episodes of mood swings may occur infrequently or several times a year.

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When the mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, alertness, judgment, behavior, and the ability to think clearly.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medication and psychological counseling (psychotherapy).

Symptoms

There are several types of bipolar and related disorders. They may include mania, hypomania, and depression. The symptoms can lead to unpredictable changes in mood and behavior, leading to significant stress and difficulty in life.

  • Bipolar disorder I. You have had at least one manic episode, which may be preceded or accompanied by hypomanic or major depressive episodes. In some cases, mania can cause a break with reality (psychosis).
  • Bipolar disorder II. You have had at least one major depressive episode and at least one hypomanic episode, but never had a manic episode.
  • Cyclothymic disorder. You have had at least two years - or one year in children and adolescents - many periods of hypomanic symptoms and periods of depressive symptoms (though less severe than major depression).
  • Other types. These include, for example, bipolar and related disorders caused by certain drugs or alcohol, or due to health conditions such as Cushing's disease, multiple sclerosis, or stroke.

Bipolar II is not a milder form of Bipolar I but is a separate diagnosis. Although bipolar I manic episodes can be severe and dangerous, people with bipolar II can be depressed for longer periods of time, which can cause significant impairment.

Although bipolar disorder can occur at any age, it is usually diagnosed in adolescence or early twenties. Symptoms can vary from person to person, and symptoms can change over time.

Mania and hypomania

Mania and hypomania are two different types of episodes, but they share the same symptoms. Mania is more pronounced than hypomania and causes more noticeable problems at work, school, and social activities, as well as relationship difficulties. Mania can also cause a break with reality (psychosis) and require hospitalization.

Both a manic episode and a hypomanic episode include three or more of these symptoms:

  • Abnormally optimistic or nervous
  • Increased activity, energy or excitement
  • Exaggerated sense of well-being and self-confidence (euphoria)
  • Reduced need for sleep
  • Unusual talkativeness
  • Distractibility
  • Poor decision-making - for example, in speculation, in sexual encounters or in irrational investments

Major depressive episode

Major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in daily activities such as work, school, social activities, or relationships. Episode includes five or more of these symptoms:

  • Depressed mood, such as feeling sad, empty, hopeless, or tearful (in children and adolescents, depressed mood may manifest as irritability)
  • Marked loss of interest or feeling of displeasure in all (or nearly all) activities
  • Significant weight loss with no diet, weight gain, or decreased or increased appetite (in children, failure to gain weight as expected may be a sign of depression)
  • Either insomnia or sleeping too much
  • Either anxiety or slow behavior
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Decreased ability to think or concentrate, or indecisiveness
  • Thinking, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorder may include other signs such as anxiety disorder, melancholia, psychosis, or others. The timing of symptoms may include diagnostic markers such as mixed or fast cycling. In addition, bipolar symptoms may occur during pregnancy or with the change of seasons.

When to see a doctor

Despite extreme moods, people with bipolar disorder often do not realize how much their emotional instability disrupts their lives and the lives of their loved ones and do not receive the necessary treatment.

And if you are like people with bipolar disorder, you can enjoy feelings of euphoria and be more productive. However, this euphoria is always accompanied by an emotional disaster that can leave you depressed and possibly in financial, legal, or other bad relationships.

If you have symptoms of depression or mania, see your doctor or mental health professional. Bipolar disorder does not improve on its own. Getting mental health treatment with a history of bipolar disorder can help control your symptoms.

gender characteristics of the course and therapy

For the first time about circular psychosis, or "insanity in two forms", two French psychiatrists J. Falret and J. Baillarger reported in the middle of the 19th century. E. Kraepelin at 1896, proposed a group of affective psychoses with polar clinical manifestations (depressive and manic) to be combined into a single manic-depressive psychosis based on the phase course of the disease with alternating exacerbations and remissions and a favorable prognosis, in contrast to dementia praecox. At the same time, he pointed out the difficulty of drawing clear boundaries between these polar affective disorders, since they can quickly replace each other and mix. For example, one may encounter depression with agitation or mania with lethargy [1]. Later, E. Bleuler noted that “the more it is possible to trace the patient's life, the less often it is possible to make the correct series of one homogeneous attacks” [2]. This was confirmed in later studies, which showed that during the life of the patient the polarity of attacks, their frequency, duration and severity may change. Approximately 40% of patients who were initially diagnosed with recurrent depression were subsequently diagnosed with bipolar affective disorder (BAD). In other words, a "drift" from a pseudo-monopolar flow to a BAR is possible [3].

In 1957, K. Leonhard [4] proposed the division of affective psychoses into monopolar and bipolar ones, which was confirmed in a number of subsequent studies [5, 6].

In 1976, the American psychiatrist D. Dunner proposed to divide bipolar disorder into two types, depending on the manifestations of manic syndrome [7]. In DSM-5, in addition to BAD type I, which occurs with mania, and BAD type II, which occurs with hypomania, which, as a rule, does not require hospitalization [8], cyclothymia is distinguished, which is considered by a number of authors as BAD type III. The position of the latter remained controversial for a long time. E. Kraepelin considered it as a "cyclothymic temperament" - a predictor of manic-depressive psychosis [6]. Yu.V. Kannabich considered cyclothymia to be a non-psychotic form of phasic diseases, and P.B. Gannushkin attributed cyclothymia to a number of psychopathy [9]. A subsequent study showed that in 1/3 of the personalities of the cyclothymic circle, affective symptoms worsen over time - the appearance of more pronounced hypomania, accompanied by the abuse of psychoactive substances and alcohol, violations of the law, and more severe and prolonged depressions [10, 11]. J. Klerman (1987) included cyclothymia in the bipolar spectrum of disorders, and also proposed his own variants of the bipolar disorder classification, including 6 types of the course of the disease. The classification has been expanded to include antidepressant-induced manias; unipolar, or recurrent, mania without depression; depressions associated with hyperthymic temperament; recurrent depression in patients whose relatives suffer from bipolar disorder; late depression with mixed features progressing to a syndrome similar to dementia. The latter are more often diagnosed in the elderly due to the burden of somatic and neurological diseases [12].

The ICD-10 does not distinguish between individual types of bipolar disorder, using a predominantly syndromic approach to diagnosis, which allows the most accurate characterization of the patient's status and the stage of his disease at the present time, taking into account the severity and accompanying symptoms [13].

Difficulties in diagnosing BAD

If at present the definition of BAD as an independent nosology has been resolved, then the issues of differential diagnosis of recurrent affective disorder (RDD) and BAD, as well as the establishment of differences in the depressive syndrome within these disorders, constitute a certain diagnostic difficulty and many studies are devoted to them [14].

The key differential criterion for the diagnosis of bipolar disorder, as mentioned above, is the presence of hypomanic or manic phases in the anamnesis of the disease. However, the frequent misdiagnosis of recurrent depressive disorder in patients with bipolar disorder is due to the fact that patients do not assess the hypomanic or manic state as painful, therefore they do not go to the doctor and do not report the past "mood lift" when collecting anamnestic information. In the French study EPIDEP [15], using a specially designed questionnaire to objectify the history data obtained from patients, the prevalence of bipolar disorder among depressed patients increased almost 2-fold, from 22 to 40%.

Factors complicating the process of diagnosis include frequent comorbidity of bipolar disorder with other disorders, especially with anxiety and addictive disorders [16, 17], as well as delayed onset of manic or hypomanic symptoms in patients with recurrent depressive phases [18].

Epidemiology and medical and social significance of bipolar disorder

Due to the difficulty of correctly and timely diagnosing bipolar disorder, information on the prevalence of this disorder in the population varies widely. Incidence rates in the general population range from 1.5-6.5%. The ratio of incidence among men and women is 1:1. At the same time, there is evidence of a higher incidence of women with BAD type II [19]. According to the results of a number of studies, the frequency of BAD I is from 0.4 to 1.6%, and BAD II is from 0.5 to 1.9% [20]. In Russia, there is no separate record of cases of BAD I and BAD II due to the absence of separate codes for them in the ICD-10 [19].

Despite the fact that the specific contribution of bipolar disorder to the total number of depressive states is not so large, the disorder itself is associated with a high risk of social maladaptation. R. Joffe et al. [21] showed that 50% of the time per year, patients with bipolar disorder are in a euthymic state, 41% are in a state of depression, and only 9% - in a state of mania. However, the quality of their life, social and family functioning, the possibility of self-realization are violated even in the euthymic period, which a number of authors [16, 22] associate with “strange”, defiant and impulsive behavior both during affective upsurges and in the period between attacks. Among patients with bipolar disorder, the unemployment rate is 2 times higher than in the general population. Also, the frequency of divorces in families in which the husband or wife suffers from bipolar disorder is 3 times higher than in the control group of mentally healthy people.

The risk of developing alcoholism in bipolar disorder is 6-7 times higher than in the general population [17], while in men it is 3 times higher, and in women it is 7 times higher [23]. The views of individual researchers on the relationship between BAD and alcoholism are different: some believe that BAD can be a risk factor for the formation of dependence on psychoactive substances (alcohol and drugs), others allow the provoking effect of the latter on the development of affective disorders, and others believe that there are common links in the pathogenesis these diseases.

A decrease in the quality of life of patients with bipolar disorder is associated not only with a mental health problem, but also with concomitant somatic diseases, such as overweight and obesity, hyperlipidemia, arterial hypertension, diabetes mellitus, pathology of the osteoarticular system, chronic obstructive pulmonary disease [24] . These data can presumably be explained by a decrease in adherence to treatment due to a decrease in motivation in such patients [25], especially considering that patients diagnosed with bipolar disorder are much more likely to have comorbid addictive disorders [26].

BAD is also associated with a high suicidal risk - more than ¼ of patients make a suicide attempt during their lifetime [27]. According to the WHO (2001), BAD ranks 6th among the causes of disability [28]. A number of studies have found that, on average, patients with bipolar disorder lose about 9 years of life expectancy, 14 years of working capacity, and 12 years of normal health [29–31].

BAR course and forecast

BAD is a disease with a complex psychopathological structure, in which there are affective phases of different polarity and severity. The intermission following the completion of the phase is characterized by an euthymic mood and the formation of criticality towards the painful episode. In some cases, the hypomanic state is assessed by patients not as painful, but, on the contrary, as a period of increased efficiency and productivity. Depending on the combination of phases and the presence of intermissions between them, several types of BAR flow are distinguished.

The relapsing "classic" type of flow, described by E. Kraepelin, is characterized by phase alternation with euthymic intervals between them. At the same time, the duration of interictal intervals shortens with age, and residual affective symptoms often persist in the interictal period [32, 33]. Intermission after the first affective attack is usually the longest and averages 4.5 years, subsequently reduced to 1 year [34].

Dual phases of different polarity with the subsequent onset of intermission constitute an alternating type of flow. As with the relapsing course, there is a tendency to lengthen the phases and shorten the euthymic intervals up to the transition to a continual course, characterized by the absence of remissions between episodes.

A special type of continual flow is the fast cyclic type. In accordance with the DSM-IV criteria, it is determined by the development of at least four affective phases within 1 year, which can be separated by short-term remissions up to 2 months. Each depressive episode should last at least 2 weeks, each manic or mixed episode should last at least 1 week, and each hypomanic episode should last at least 4 days [35]. This type of course is more common in women with type II bipolar disorder who suffer from hypothyroidism and are constantly taking antidepressants. Such patients have an early onset of the disease and a more severe course of depressive phases associated with a high suicidal risk [36, 37]. The fast cyclic flow tends to transition to ultrafast forms with phase change over the course of a month or even a day and are actually represented by mixed states [38].

Mixed states are longer compared to manic and depressive phases, characterized by a more severe course, resistance to therapy, and unexpected suicidal attempts [39].

The disease has very pronounced gender characteristics. In men, bipolar disorder begins earlier than in women [40], while the first phase is more often manic in men, and depressive in women [41, 42]. During the course of the disease, this dependence persists: the proportion of manic episodes in men is greater than in women. In women, the manifestation of the disease is often associated with menstrual-generative function and periods of hormonal changes (pubertal, postpartum, menopausal) [43]. In 20–30% of women with bipolar disorder, within 1 month after delivery, another attack of the disease develops, more often depressive [44, 45]. A postpartum episode of bipolar disorder (mania or depression in general) occurs in 40–67% of cases [46]. Although manic (hypomanic) phases are a key phenomenon in the diagnosis of bipolar disorder, patients spend most of their time depressed [47, 48]. This may be related to the fact that BAD type II is diagnosed more often in women, and BAD type I is equally common in women and men [49]. Consequently, the longer clinically expressed mania does not fall into the field of vision of a psychiatrist, the longer patients (more often women) will receive inadequate treatment.

Features of depressive syndrome in bipolar disorder

Determining the nosological status of depression, i.e., within the framework of which disease an affective disorder arose, is still a debatable issue in psychiatry. This is due to the fact that until now the etiology of depression is not completely clear. A depressive state is considered as multifactorial, i.e. dependent on biological, psychological and social causes.

Despite the development of biological research (neurochemistry, genetics, neuroendocrinology), most specialists, when diagnosing RDR or BAD and prescribing therapy in practice, still focus on the clinical features of depressive states and the course of the disease.

Bipolar spectrum disorders are characterized by an earlier age of onset (19.5 ± 0.7 years) compared to RDR (37.9 ± 1.6 years), a higher frequency of exacerbations, with a shorter duration of episodes, deterioration in the autumn winter time versus classic spring-autumn exacerbations in RDR, more pronounced diurnal fluctuations with deterioration in the morning hours. Hyperthymic premorbid predominates in the group of patients with bipolar disorder, while anxiety premorbid predominates in patients with RDR, and affective disorders, schizophrenia, and alcoholism are less common in immediate relatives than in patients with phase change [50]. A weak response to antidepressant monotherapy may also be indicative of a bipolar course [51].

Despite the importance of identifying hypomania or mania for inclusion in section F31 "Bipolar affective disorder" of the ICD-10 [13], depressive episodes are of much greater clinical and socioeconomic importance in the structure of the disease.

There are significant differences in the ratio of the total duration of depressive and manic phases and between different types of bipolar disorder. One study by the US National Institute of Mental Health [43] found that patients with BAD type I and BAD type II spend a total of 30% and 52% of the observation time in the depressive phase, respectively.

Along with the differences in the duration of the depressive phase, according to many domestic and foreign authors, there are also clinical features of depression in BAD type I and BAD type II. In patients with type II bipolar disorder, anxiety affect predominates, while in patients with type I bipolar disorder, complaints of apathy are more common. Despite a higher level of psychomotor retardation, the risk of suicidal activity is significantly higher in the type I bipolar group. Patients with BAD type II are more likely to have somatic complaints and the development of panic attacks [10].

Depression in the structure of bipolar disorder does not always meet the criteria for a typical depressive episode (F32) according to ICD-10. In recent decades, special attention has been paid to the study of atypical depressions, the symptoms of which do not fit into the classical triad. With psychopathological differentiation of the disorders dominant in the clinical picture, A.S. Avedisova and M.P. Marachev [52] identified three variants of atypical depression with a predominance of 1) mood reactivity, 2) inversion of autonomic symptoms (hyperphagia, hypersomnia, "lead paralysis"), 3) sensitivity to rejection. According to these authors, in patients with bipolar disorder more often (33.3%) than in patients with RDR (5.5%), atypical depression occurs with a predominance of inverted autonomic symptoms. The psychopathological picture of this variant suggests the presence of hypersomnia (up to 16 hours/day, including daytime sleep), hyperphagia with an increase in body weight and sensations of heaviness in the limbs ("lead paralysis").

Patients with bipolar disorder are characterized by comorbid somatic, mental disorders and addiction diseases. Moreover, certain differences were found in women and men. In a large-scale retrospective study conducted in 45 US states from 2010 to 2014 [53], it was found that the most common comorbid somatic diseases in patients with bipolar disorder were hypertension (20.5%), asthma (12.5%) and hypothyroidism. (8.1%). At the same time, they were 3 times more common in women. Also, women with bipolar disorder had a higher risk of developing cardiometabolic disorders (obesity, diabetes mellitus).

Of the comorbid psychiatric disorders, men diagnosed with bipolar disorder are more prone to addiction disorders, while anxiety and personality disorders are more common in women. There is a clear relationship between anxiety symptoms and depression in bipolar disorder [54, 55].

The rarest comorbid mental disorder in patients with bipolar disorder is eating disorder (0.1% of men and 0.6% of women), but women are 11 times more likely to develop it [53].

Domestic and foreign authors agree that gender features exist not only within disorders in general, but are also determined when considering individual syndromes.

It has been found that depressive syndrome in women is more characteristic of diurnal mood swings, anxiety, suicidal thoughts, fatigue and lack of sleep, increased appetite and weight gain; in men, sad affect, motor retardation, somatic symptoms, concomitant diseases of the cardiovascular, respiratory and genitourinary systems, alcohol and psychoactive substance abuse are more often detected [51, 56]. Some researchers single out the concept of "male depressive syndrome", which is characterized by sudden and recurrent bouts of anger, irritability, aggression, which can be explained by the reluctance to share experiences and seek help [57].

There are a number of gender differences in depression in terms of socio-psychological functioning. In women, depression often leads to a pronounced decrease in volitional self-regulation, which is expressed in a decrease in performance at work, an untidy appearance, and problems in the sexual sphere [58].

It should be noted that the results obtained reflect the gender characteristics of predominantly unipolar depression, but do not give an idea of ​​the features of the depressive syndrome within the framework of bipolar disorder, which may be important for prognosis and treatment.

Treatment of depression in bipolar disorder

The presence of two polar phases in the structure of one disease is important for determining the tactics of treating patients with bipolar disorder. Approaches to the treatment of bipolar depression differ significantly from the treatment of depressive syndrome in other diseases. If in the case of recurrent depression the need for the use of antidepressants is not in doubt, then the use of antidepressants in patients with bipolar disorder is one of the most discussed issues.

There are several typical approaches to the treatment of bipolar depression. Thus, experts of the American Psychiatric Association consider lithium and lamotrigine to be the first-line drugs for the treatment of non-psychotic bipolar depression. Additional prescription of antidepressants is recommended only for very severe depression [59, 60]. The recommendations of the British Association of Psychopharmacologists state the need for a combination of drugs from the group of selective serotonin reuptake inhibitors (SSRIs) and antimanic drugs (lithium, valproates, atypical antipsychotics) for depression of any severity from the very beginning of therapy [61]. The Canadian guidelines for the treatment of bipolar depression in BAD type I follow similar approaches. Quetiapine is considered the first-line treatment for depression in type II bipolar disorder and has been shown to be effective in many studies. If it is ineffective, combined therapy with mood stabilizers and antidepressants is recommended [62, 63].

Most researchers agree that the appointment of antidepressants "bipolar" patients significantly increases the risk of phase inversion and the development of unfavorable forms of the course of BAD (continuous, fast-cyclic). According to some authors, tricyclic antidepressants (TCAs) provoke phase inversion in bipolar disorder in more than 30% of cases [64]. The frequency of inversion is directly proportional to the dosages of antidepressants used.

Modern studies have shown that the inclusion of an antidepressant in the regimen of relief therapy accelerates the process of recovery from an attack and significantly increases the effectiveness of treatment without provoking the development of an inversion of the depressive phase in patients with bipolar disorder [65].

One of the first studies was conducted to study the effectiveness of paroxetine in the treatment of bipolar depression. The frequency of antidepressant-induced manias was 2–3%, which is several tens of times less than with TCAs [66].

Factors associated with a high risk of phase reversal include young age, type I bipolar disorder, rapid phase change bipolar disorder, substance abuse, mixed state, and a history of similar response to antidepressant therapy.

When using antidepressant monotherapy, a full remission is observed only in 15-20% of patients, and 20-25% of patients relapse within a few months, regardless of whether the antidepressant was continued or discontinued [67].

In accordance with the clinical guidelines for the treatment of depression in bipolar disorder, it is recommended to limit the prescription of antidepressants to a minimum period and, already at the first stage of treatment, use them in combination with an antipsychotic and / or mood stabilizer in order to prevent phase inversion.

Monotherapy with mood stabilizers seems appropriate for mild or moderate symptoms in patients who do not have a suicidal risk [68]. A number of studies have shown good efficacy of lithium carbonate, carbamazepine and lamotrigine in the treatment of depressive conditions in the context of bipolar disorder, however, the development of a thymoanaleptic effect usually takes more than 6 weeks. One double-blind, placebo-controlled study [69] of 195 patients with type I bipolar disorder showed a positive antidepressant effect after 7 weeks of lamotrigine therapy. In another study [70], the addition of the anticonvulsant topiramate or the antidepressant bupropion to normothymic therapy with valproate or lithium in 36 outpatients with bipolar depression found a reduction in depressive symptoms after 2 weeks of treatment. There is also a work [71], in which it was found that the combination of the mood stabilizer and the antidepressant paroxetine leads to an earlier manifestation of the antidepressant effect without phase inversion.

J. Doree et al. [72] found that in cases of failure of antidepressant monotherapy, the combination of an antidepressant with quetiapine is statistically significantly more effective than the combination of an antidepressant with lithium, both in terms of the number of responders (88 and 50%, respectively) and the number of patients who achieved remission (88 and 50%, respectively). 38% respectively).

In the proposed treatment algorithms for bipolar depression, quetiapine at a dose of 600 mg/day or more is the first-line drug for type I bipolar disorder, while it is recommended to start with lamotrigine 50-200 mg/day for type II bipolar depression, and quetiapine is an alternative option in lower doses [73].

Therapy of bipolar depression with atypical antipsychotics is usually recommended for bipolar depression type 1, anxiety, suicidal thoughts, delusions of self-blame, self-deprecation. Thus, olanzapine monotherapy proved to be effective for patients with bipolar depression and comorbid anxiety [27].

Some modern authors [74] insist on the abolition of antidepressant therapy on the 2nd week after the establishment of clinical remission with a gradual dose reduction, but allow the return of thymoanaleptic therapy in case of deterioration of the patient's condition.

Since the end of the last century, scientists and physicians have been increasingly interested in the study of gender specifics in the treatment of depression.

The lower rate of renal filtration and hepatic metabolism in women, the higher percentage of adipose tissue compared to men and, at the same time, lower body weight lead to a higher level of concentration and a longer half-life of therapeutic drugs. These pharmacokinetic features may explain the better efficacy of antidepressant therapy in women and the possibility of using lower dosages [75].

However, a number of studies have found differences in therapeutic response to different groups of antidepressants. A slower response in women compared to men was obtained with TCAs, while women achieved faster clinical improvement with SSRIs [76].

In a study by J. Davidson et al. [77] showed that monoamine oxidase inhibitors (MAOIs) were more effective than TCAs in women, while men improved more quickly when treated with the latter.

The researchers explain the observed differences by a number of factors. S. Kornstein et al. [76] noted a difference in therapeutic response to sertraline (SSRI) and imipramine (TCA) only in premenopausal women; no differences were found in postmenopausal women. Separate studies have also shown that estrogens can increase serotonergic activity [78]. An assumption was made about the effect of female sex hormones on the pharmacodynamics of antidepressants in terms of stimulating the action of SSRIs and inhibiting the activity of TCAs [76]. It is necessary to take into account the clinical features of depression. In women, depression more often includes atypical symptoms, which may explain the better response to SSRIs and MAO inhibitors [76, 77].

In one of the comparative placebo-controlled studies of venlafaxine (selective serotonin and norepinephrine reuptake inhibitor SNRI) and drugs from the SSRI group (fluoxetine, paroxetine, fluvoxamine) in groups of men and women, it was found that in men there were no clinically significant differences in response to drugs, while women treated with venlafaxine had a faster response (at week 2) compared to SSRIs (at week 4) and achieved sustained clinical improvement [79].

A number of studies have noted gender differences not only in the efficacy but also in the tolerability of antidepressants: when using TCAs, men are more likely to experience side effects such as difficulty urinating, sexual dysfunctions, and nausea in women. Adverse events with the use of SSRIs: in men - dyspepsia, sexual dysfunction, frequent urination; in women - nausea, dizziness.

In recent years, the antidepressant Valdoxan (Agomelatine), an agonist of melatonin MT1- and MT2- and an antagonist of serotonin 5-HT2C receptors, has positively proven itself in the treatment of depression, which, due to its unique mechanism of action, has high antidepressant efficacy in depression of various genesis and varying severity, including severe endogenous depressive states [80]. Disorders of circadian rhythms in endogenous depression, manifested by sleep disturbances, diurnal fluctuations in the state with the corresponding dynamics of therapy, are an additional indication for the appointment of agomelatine. The results of one of the meta-analyzes [81] showed that the efficacy of agomelatine is comparable to other antidepressants (SSRIs, SNRIs), and also has a better tolerability profile, leading to a lower risk of discontinuing treatment due to the development of adverse events. Another meta-analysis [82], which summarized the results of 76 clinical trials (16,389patients) in a study of the efficacy and tolerability of the 10 most common antidepressants in the treatment of major depressive disorder, it was shown that agomelatine was in first place in the number of patients in remission, and also differed in the maximum indicators of good tolerance.

The efficacy of agomelatine was equally high compared with placebo in both women and men [83]. A comparative evaluation of the effectiveness of agomelatine in recurrent depression and bipolar affective disorder showed that responders in both groups appeared already at the 2nd week of therapy, especially in the group of patients with bipolar disorder (34. 8% vs. 9,1%). The initial response was faster in men with bipolar depression, especially in patients with bipolar I type who received an additional anticonvulsant (depakin or lamotrigine). By the end of therapy (week 8), the response rate was 90.9% in the RDR group and 91.3% in the BAD group. According to the corresponding study of agomelatine conducted by domestic authors, 65.2% of patients with bipolar disorder and 54.5% with RDR achieved complete remission [3].

The absence of side effects such as weight gain, excessive daytime sedation, and sexual dysfunction make agomelatine an attractive treatment for depression in women, especially during menopause and postmenopause [78].

The results of studies of the efficacy and tolerability of agomelatine allow it to be considered as a first-line drug in the treatment of depression [80].

The literature data presented in this review indicate that there are still a number of issues that require clarification related to the diagnosis and determination of the boundaries of bipolar disorder, the study of gender characteristics of the course of the disease, its clinical manifestations, in particular depression, pharmacokinetics and pharmacodynamics of psychotropic drugs, efficacy and tolerability.

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