Bi-Polar II: Hip-Hip Hooray for Hypomania

A side-effect of the proliferation of effective medications for depression is the possible over-reliance on depression as a diagnosis. We tend to find what we know we can treat.

The following case study highlights this issue. It points to the need for careful differential diagnosis. It invites us clinicians to be as aware of the lesser known diagnoses as we are of the more popular ones.

I began seeing her seven years ago. She had been in a near-fatal car crash and as a result had had major heart surgery. In the recuperation period she fell into a deep depression. She had a significant romance go sour during the same period.

She was bright, introspective, therapy-friendly and deeply depressed when I first saw her.

In a year of well-presented and well-received primarily cognitive behavioral therapy she got no better. I sent her to an outstanding psychopharmacologist. Her diagnosis came back: major depression with generalized anxiety.

In the ensuing six months, she went through Prozac, Zoloft, Pnfil, Tofranil, Effexor, Atavan, librium, and Xanax. Either she could not tolerate their side-effects, or they had no main effect.

Let me make a comment here. Our relatively new drug armamentarium can be almost miracle-like in its remarkable makeovers. But it can also require a good bit of trial and error, close monitoring, and some intuitive flair in the actual selection of a medication. It has its minuses as well as its pluses.

Finally, at the eighth month mark, a breakthrough. The client tended towards diarrhea and each antidepressant thus far had simply aggravated that condition. Enter a relatively old one: nortriptyline. Nortriptyline is constipating. Nortriptyline worked. She could tolerate a combination of nortriptyline and Klonopin.

After another six months the medicines were clearly working. In the absence of talk therapy (due to financial constraints) the medications were holding her. She was not getting more deeply depressed. She was not getting better, but at least she was not getting any worse.

Let me be specific about the gravity of the situation. I am talking about continual suicidal ideation and even a suicide plan. I am talking about a person unable to function until about 4 p.m. each afternoon. I am talking about relentless, ruminative self-talk (Why? Why me? Why now? What can be done? Can anything be done? Etc.) I am talking about one month in a psychiatric hospital when she could not sleep and needed further tinkering with her meds.

After five years, another major operation, and two more failed relationships, she was functioning adequately and not getting any worse. She was back in therapy with me. At times I thought what had been done for her was all that could be done for her. But she insisted that she was not "all better". And, in truth, she wasn't. She was living better with her depression and anxious symptoms, but these were not going away.

Breakthroughs came intermittently. She was convinced that the beta blocker she was taking was contributing to her depression. Several cardiologists told her this was not so. The cardiologist she eventually wound up with simply suggested she go off the beta blocker for three days and see what happens. In a day-and-a-half she was 30 percent better and so long as she stayed off the beta blocker she maintained this progress.

The seven year mark was characterized by a good therapeutic relationship, a good relationship with the psychopharmacologist, consistency with the meds that were working, staying off the beta blockers. She was no longer scraping herself out of the gutter. But she remained depressed in the morning, racked with guilt, self-doubt, and intermittent work (?) paralysis and her feelings that she was not yet where she wanted to be.

There is one important piece of data I have left out so far. The client had a place in the mountains, six hours from where she lived, to which she retreated every couple of months for a long weekend. She was never depressed there. In fact, she had boundless energy for working on her painting while there. It was her "working retreat house" and she enjoyed immensely, needed little sleep while there, and called her state while there, "high-level wellness."

This was an anomaly to other diagnosis of unipolar depression. Might she be manic-depressive? She read Kay Redfield Jamison's splendid memoir of mania -- An Unquiet Mind ( ) and she was given a trial of lithium. She did not resonate with the book and did not respond to the lithium.

I was close to giving up when she came in to one session all excited. She often read self-help books. That day she brought in Shadow Syndromes by John J. Ratey, M.D. and Catherine Johnson, Ph.D. ( ). The book describes the milder, less disastrous and sometimes harder to diagnose "shadow" forms of major mental maladies.

She read to me from what the text has to say about Bipolar II, which is also called "soft" bipolar! Like bipolar I (manic depression), it is characterized by major depression -- but not manias. Instead, there is only hypomania.

The words came tumbling out a bit too hurriedly as she reads to me that hypomanic people are "better than normal. They think more rapidly... are creative... their IQs are [ ] higher. They are more productive. They are more attractive in every sense: sexier, friendlier, more fun to know." (p. 106). In fact, many manic depressives would like to be able to take just enough lithium to make them hypomanic because "hypomanics are extraordinarily productive. They are people who can leap tall buildings in a single bound." (p. 109)

She says what I have been thinking as she read this: it describes her state in her mountain retreat. It suggests that what she calls "high-level wellness" is in fact "hypomania" -- a condition in which people are, remember, "better than normal."

She shares this insight with her psychopharmacologist. He wonders why he had not thought of it himself. Then he tells her that there is a medicine -- galopentin (Neurontin), that has just been approved for the treatment of bipolar II.

As of this writing, she has been in the neurontin for eight months. The illness is in remission. She has had not a depressed day and she has none (?) [of the?] side effects of the neurontin. She jokes that if this were the Sixties she would sell it on the street!

Her friends remark in her amazing comeback. Several had fairly given up on her. They are astounded by the effects of the neurontin.

It is evening. I am alone in my office. She is my last hour of the evening. A shooting star goes by. I tell her that I am thinking about writing about her therapy work with me and the psychopharmacologist. She asks me the name of what I am writing. I say that my working title is "Bipolar II: In Praise -- Perhaps -- of Hypomania." She holds her nose and shakes her head vigorously from side-to-side. "No, no, no. Call it "Hip-hip Hooray for Hypomania." We agree on a compromise title -- the title of this article.

Was it in fact a shooting star?

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