Should DSM-V include a diagnostic category for people with major depressive disorder with subthreshold hypomania? This isthe question that is at the center of the paper I just read. My initial answer to this question was a resounding “No”,because of some of the challenges the authors discuss. However, having read the paper, I have come to the conclusion that there may be some use for subsyndromal hypomania as a separae diagnosis.
The authors start by evaluating the prevalence and possible misdiagnosis of unipolar depression vs. bipolar disorder. Previous research found that aproximately 40-50% of people with major depressive disorder have a lifetime history ofsubsyndromal hypomania, depending on the precise criteria used. Furthermore, individuals with such a history are much more likely than individuals without subthreshold hypomania to eventually be diagnosed with bipolar disorder, usually even bipolar I.
In addition, those with major depression and a history of sunthreshold hypomania generally have a worse outcome, more mood episodes, and more work impairment than depressed individuals without a history of subsyndromal hypomania. With regards to family history, people with major depression and subthreshold hypomania are more likely to have family members with mania or other bipolar disorders than those with only depressive symptoms. An early onset (before age 21) of depression and a presentation with atypical features are also characteristic of people with subthreshold hypomania.
For the above reasons, the authors recommend that subthreshold hypomania be included in DSM-V. There is some debate as to which criteria should be used, but they advise an emphasis on overactivy rather than just mood elevation and a duration of at least two days with at least three of seven hypomania symptoms met. The authors also recommend that subthreshold hypomania should be seen as in the middle between pure depression and bipolar II. They argue against the diagnosis of individuals with major depression and subthreshold hypomania as bipolar, because of the stigma this can create.
This stigma was one of my initial reasons to oppose the widening of the bipolar spectrum to include subsyndromalhypomania. The other reason, which the authors also address, is the potential overprescription of antipsychotics and moodstabilizers. There is no evidence that antidepressants would be bad for individuals with major depression who might havesubthreshold hypomania, and neither is there evidence that mood stabilizers or antipsychotics prevent a worsening fromsubsyndromal hypomania to full-blown (hypo)mania. Given the fact that antipsychotics and mood stabilizers have significantside effects, it is not recommended that they be used without merit.
However, the authros do argue for better psychosocial treatmetn of individuals with depression and subthresholdhypomania. They state that cognitive-behavioral therapy, psychoeducation and some other psychosocial interventions may betailored more effectively towards those with subthreshold hypomania if this is idenftified in people with major depression.This is also in light of the worse outcome usually seen in individuals wiht subtreshold hypomania. Psychotherapy,apparrently, might help people manage their hypomanic symptoms.
So, contrary to what I expected, the authors of this study are not Big Pharma puppets who advocate the widespread use ofthe newest and most expensive medications. They also, interestingly, do not seem to suggest that mood disorders as a wholeare underdiagnosed, or that in general more people should be seen as mentally ill. They rather try to pinpoint the symptomsof a subgroup of depressed individuals more precisely than could previously be done. This does not directly change myopinion on subthreshold bipolar yet, but it does give me some thought.
Reference
Nusslock R, Frank E (2011), Subthreshold Bipolarity: Diagnostic Issues and Challenges. Bipolar Disorders, 13:587-603. DOI: 10.1111/j.1399-5618.2011.00957.x.
I’m not one to advocate widening the criteria of any disorder. Normally, I would shout, “No!”, at the top of my lungs. But, I’ve noticed a lot of buzz about “treatment resistant depression” lately. This “treatment resistant depression” is being combatted with mood stabilizers. These drugs are typically reserved for BP patients. Why do you suppose there is a sharp increase in treatment resistant depression?
I have a few conclusions. First, it could be the distinct possibility that there are a certain percentage of doctors that are trying to cover themselves from malpractice for misdiagnosis. Second, it could be patients that are not receptive to a BP diagnosis. Or third, it really is classified as MDD, because it doesn’t meet the current criteria for BP.
Clarify for me. What do professionals consider “sub-threshold hypomania”, because I know that my own hypomania doesn’t usually hold a candle to the full-blown thing. And I know that my hypomania was difficult to detect and was the whole reason for my original misdiagnosis. Mild hypomania… Hmmm. It seems like more of an actual mood than a diagnosis.
But, I cannot discredit the research entirely. Other research indicates that bipolar disorder worsens without treatment over a period of time. So, it would make perfect sense that if BP were being treated as MDD, then the symptoms aren’t being completely addressed. Naturally, it would worsen.
Now, if there is no evidence that medications don’t make much of a difference, then I don’t know why we’re addressing this. Dx’s are not labels, they’re for treatment purposes.
If they want in the BP spectrum so badly, then why don’t they adjust BP-NOS. That’s what it’s for, right? Add subthreshold hypomania into that Dx as criteria, and poof! We have our bases covered! Or are they looking for a special classification to put in MDD? Because once we start throwing around any word that contains “mania”, it becomes BP territory.
Expand away, but I think it should be considered only in cases of “treatment resistant depression” that has a “subthreshold hypomania” component. That would give more license to open up discussion for mood stabilizers and hopefully get those people properly diagnosed and medicated before it gets worse.
@LunaSunshine: the definition of subthreshold hypomania was rather vague adn varied across studies (this paper was a review of other reseearch), but the most useful definition according to the authors used as a criterion overactivity plus three hypomania symptoms with a duration of two days.
As for medication, I didn’t know that treatment-resistant depression could be helped with mood stabilizers. This paper said there is no evidence that mood stabilizers/antipsychotics prevent a sliding down from subthreshold bipolar into bipolar II or I. It said nothing about treatment-resistant depression. Of course, the fact that there is no current pharmacotherapy, doesn’t mean there won’t come one. Besides, the authors of this paper did say that psychosocial interventions are different for bipolar (and subthreshold hypomania) vs. depression.
I am not sure what I think of the BP-NOS thingy. As currently proposed for DSM-V, “other specified bipolar disorder” will have several subtypes including several forms of subthreshold hypomania (“unspecified bipolar” is not yet defined as far as I know). The problem with this is that people with a current DSM-IV diagnosis of depression will carry the additional stigma of a bipolar diagnosis in DSM-V and will potentially be treated with mood stabilizers/antipsychotics which may not work. That’s why the authors of this paper propose a mood spectrum that runs from depression to bipolar I, but they are rather inconsistent since they do still call it bipolar all the while.
Drug companies are actually marking new generation mood stabilizers for “treatment resistant depression”. I have seen this especially in the instance of Abilify.
Originally, they told my sister and I that we had “treatment resistant depression”. I ended up getting more SSRI’s added to the mix, and she ended up getting a mood stabilizer. Guess which one of us faired better? Really neither. Because they were more interested in treating the depressive symptoms while ignoring the hypo/manic symptoms.
Here we are, over a decade later. I was diagnosed with BP II and my sister ended up with BP II. Understandable. She’s had full blown psychotic episodes, whereas I have only experienced paranoia to the threshold of psychosis. I often wonder if we had BP in the first place. But, now that this study has come out, I am starting to wonder if we only exhibited “subthreshold hypomania” at the time. I’ll tell you this. It’s difficult to tell what’s what in that developmental stage. Depression, hypomania, any of that. Hormones? Or dysfunction?
Here’s the thing with hypomania. Hardly anyone would report it, even if they recognized it. Hypomania doesn’t always seem like a dysfunction. In fact, I considered myself to be extremely high functioning, up until this year. That’s when I discovered dysphoric hypomania, and realized how damaging I have / could have been while experiencing it. Hypomania is hardly detectable and usually only is when it shows a level of dysfunction. The only way I recognized it was seeing hyperactive, uncharacteristic behaviors from myself. Excessive risk taking, outwardly seeking stimulation, overtalkativeness, extreme extroversion, promiscuity and hypersexuality (as compared to other women of the same age group), and various other watered down symptoms of mania. I am a different person while experiencing hypomania.
So what exactly are they seeking here? BP III? The biggest question of all is, how does this subthreshold hypomania create dysfunction for a person? I know dysphoric hypomania can cause all kind of disturbances for me. Without the sleep, my cognitive function begins to suffer. It’s not like I can’t think, it’s that my thoughts are so scattered that the force of the racing thoughts it’s enough to greatly overwhelm me. It’s like trying to catch bits of paper in the wind. You know those pieces of paper have something very important on them, but you’re only catching little pieces here and there.
If the subthreshold hypomania is not creating a disruption in everyday life, then I’m not sure it can be considered to be a component of disorder. If it does, then there’s something to think about.