Treatment
Treating Hypomania
Are psychiatrists overshooting their targets?
Three years ago, I took a careful read of hypomania in the DSM-IV and had one of those knock-me-over-with-a-feather moments. Hypomania was listed as an episode rather than an illness, and not only that, "the episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization …"
Sure, the DSM refers to the type of behavior that could cause you to lose your job, your family, and your assets in a heartbeat, but apparently none of that qualifies as a "marked impairment."
If you took the DSM at face value, you would think that hypomania was little more than the good cholesterol of mood. For bipolar I, mania is clearly the bad cholesterol. Hypomania is even not a requirement for bipolar I and barely rates a mention. In bipolar II, the bad cholesterol is depression. If you’re lucky, you get to have hypomania.
The DSM does reserve the "Not Otherwise Specified (NOS)" category for apparently unipolar hypomanics and other diagnostic oddballs, but the understanding is that this designation is only applied on Feb 29 and other rare occasions.
So are psychiatrists simply not treating hypomania? Hardly. Are they treating hypomania exactly as they would be treating mania? That’s worth exploring.
Recognizing Hypomania
The pioneering diagnostician Emil Kraepelin identified hypomania in his classic 1921 work, but few have written about it since. An early May 2005 PubMed search revealed only 652 entries for hypomania vs 19,537 for mania and 176,667 for depression. A seminal 1976 article by Goodwin, Gershon, and Dunner proposed a new bipolar II diagnosis that would incorporate hypomania, but it took until 1994 for the DSM to get with the program.
In recent years, Akiskal, Hirschfeld, Angst, Cassano, and others have more closely examined the phenomenon of hypomania, as well as the populations in which they occur. Their findings suggest that instead of just two percent bipolars in the general population evenly divided among Is and IIs, we may have as many as six percent, nearly all of them bipolar IIs or people with depression who have some hypomanic features.
Said John Gartner PhD, an associate professor of clinical psychiatry at Johns Hopkins and author of "The Hypomanic Edge: The Link Between a Little Craziness and a Lot of Success in America," in an interview with this writer, "the most common form of this disorder is being treated as if it were a rare weird variation."
In his book Dr Gartner views hypomania as a genetically transmitted temperament whose adaptive advantages far outweighs the disadvantages. Thanks to the people brave enough (and crazy enough) to leave their settled existences to strike out for an uncertain life on a strange shore, argues Dr Gartner, America has been blessed with a generous supply of wild wacky creative geniuses and go-getters, plus an abundance of those egging them on. This is often a source of dismay to the Europeans, who are alarmed by our excesses, even as they embrace the many positive aspects of our culture. (See article.)
One of Dr Gartner’s case studies is the brilliant founding father Alexander Hamilton, who had a spot reserved on Mt Rushmore until he stupidly offered up his body for target practice. Which raises some interesting questions. Suppose lithium and other meds had been available to Hamilton. Would the treatment have dulled his brain and pushed him into depression? Would he have been too groggy and depressed to save the nation from certain bankruptcy?
Assuming the meds did successfully stabilize his mood, we still have the small matter of the extraordinary drive and imagination that earned him a place on the ten dollar bill. Suppose the treatment had amputated these very qualities out of his personality. Would his psychiatrist have viewed his complaining as yet another crazy patient addicted to hypomania?
Or would the meds have had a different effect? Would he have prudently skipped his appointment with Aaron Burr and gone on to become America’s greatest President?
So here’s a set of questions for my psychiatrist readers: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?
Treating Hypomania
There is only one book listed on Amazon with either hypomania or hypomanic in the title. Accordingly, it made sense for this writer to contact its author. It turns out Dr Gartner definitely has enough material for another book:
First Dr Gartner explained that one reason hypomania has been so under-recognized is due to faulty patient screening. A "no" response to the first question in the standard screening questionnaire meant skipping the following ones and moving to the next diagnosis. That first question was along these lines: Have you ever had a time when you were so high that you were out of control?
Said Dr Gartner: "Of course all the hypomanic people said no, because when they’re hypomanic they think they’re at their best. That’s when they’re most productive and happy and feel like themselves. They don’t consider that to be a period when they’re out of control."
Certainly, many of us feel hypomania is our true identity, not just a mood aberration to be medicated out of existence. "That’s very important," concurs Dr Gartner. "When you think about it, how many people have died just to preserve their sense of identity? Think of all the Jews who died because they wouldn't renounce their religion. All they had to say was, yes I’m a Christian. It’s hard for people who are not hypomanic to appreciate how integral this is to someone’s identity and how important it is to preserve that."
This led to the crux of our interview: "First of all, most psychiatrists don’t know when their patients are hypomanic because they haven’t been trained to look for it. Also, no one ever came to their offices saying, I’ve got hypomania, please cure me. When they do become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."
Some people can obviously benefit from meds, but Dr Gartner makes it clear we are talking of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge."
"I liken it to the pitcher in Bull Durham," he related, "the guy who has the 100 mile per hour fastball but keeps beaning the mascot. He needs a little bit more control. He’s got speed. You wouldn’t want to give him so much medicine that he threw a fifty mile per hour fastball. We want to slow it down just enough so that he can deliver the ball where it’s supposed to be."
Think of Hamilton, brilliant as ever, lightening up a tad on Aaron Burr.
This may involve clinicians rethinking their concept of therapeutic doses. Current dosing levels are based on trials involving bipolar I patients in the acute (initial) stage of mania. Even lithium, the most studied mood stabilizer, has not been tested for hypomania. The treatment guidelines are silent on the topic. In this so-called era of evidence-based medicine, we simply have no evidence.
Dr Gartner referred to a study that found that hypomanic bipolar IIs who had the best course of adjustment were people who were able to maintain a hyperthymic (mildly elevated) mood state. By playing it safe on the side of overmedicating their patients, Dr Gartner maintains, the meds may push their patients into depression. On top of this, patients often have to contend with weight gain, loss of libido, and cognitive dulling.
You know what’s coming next – patients go off their meds. They’ve had enough, they’re not themselves, and they’re not taking it anymore. Disastrous results often follow, reinforcing the stereotype that "you can’t trust these bipolars."
All because psychiatrists were afraid to take a calculated risk. Oh, the irony.
Lest We Create a Wrong Impression About Hypomania
While working on the American Psychiatric Association’s latest DSM version of bipolar (IV-TR), Trisha Suppes MD, PhD of the University of Texas Medical Center in Dallas carefully read its criteria for hypomania, and had an epiphany. "I said, wait," she told a UCLA grand rounds lecture in April 2003 and webcast the same day, "where are all those patients of mine who are hypomanic and say they don’t feel good?"
Apparently, there is more to hypomania than mere mania lite. Dr Suppes had in mind a different type of patient, say one who experiences road rage and can’t sleep. Why was there no mention of that in hypomania? she wondered. A subsequent literature search yielded virtually no data.
The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury, but nowhere does it account for more subtle manifestations, often the type of states many bipolar patients may spend a good deal of their lives in. The treatment implications can be enormous. Dr Suppes referred to a secondary analysis by Swann of a Bowden et al study of patients with acute mania on lithium or Depakote which found that even two or three depressed symptoms in mania were a predictor of outcome.
Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably. Dr Suppes defines the former as "an energized depression," which she and her colleagues made the object of in a prospective study of 919 outpatients from the Stanley Bipolar Treatment Network. Of 17,648 patient visits, 6993 involved depressive symptoms, 1,294 hypomania, and 9,361 were euthymic (symptom-free). Of the hypomania visits, 60 percent (783) met her criteria for dysphoric hypomania. Females accounted for 58.3 percent of those with the condition.
Think of the Bull Durham pitcher in Dr Gartner's analogy. This time we're taking about Tim Robbins deliberately beaning the mascot. For the time being, psychiatry has left him high and dry.
Yes, But What About Bipolar I?
It’s all well and good to apply a micro approach to hypomania in bipolar II, but what about bipolar I? As many of us who have been there can attest, hypomania is the fresh breeze that heralds the raging manic storm. Think of Hitler marching into the Rhineland. You don’t send in Chamberlain to do Churchill’s job.
But you don’t just bomb Berlin to rubble, either. As Dr Gartner explained, most psychiatrists received their training on the wards of psychiatric hospitals. The patients there are typically 911 cases requiring large doses to bring them down. The psychiatrists treating them are not looking to reduce the doses, because their main concern is to get them out of the hospital. In theory, the psychiatrists handling patients on an outpatient basis should be making the fine adjustments. In practice, they are often worried that lowering the doses will land them in professional hot water.
The treatment guidelines make a clear distinction between acute (initial phase) and maintenance (long term) treatment, recommending that the meds regime be simplified when the situation calls for it. So should the doses be gradually lowered, say below the recommended amounts? As in the case of treating hypomania, there is no evidence to go on.
There is also the element of risk vs reward. For many people, a full-blown manic episode is a rare event, say once or twice in a lifetime. Dr Gartner cited the case of a woman who was given lithium to treat a manic episode and kept on the same dose throughout her life. The lithium, however, contributed to a lifetime of depression.
"It’s really malpractice," Dr Gartner stated. Psychiatrists need to consider how many episodes the person had, how prone they are to episodes, how long ago the episode was, and so on. Whether for bipolar I or bipolar II, said Dr Gartner, the goal is still the same, "to make that person feel happier, healthier, more productive, and more like themselves."
Working With Your Psychiatrist
The era of "just take your meds and shut up" may be drawing to a close, thanks to greater numbers of informed patients willing to initiate a working partnership with their psychiatrists. No one – last of all Dr Gartner - is saying to ignore your psychiatrist and go off your meds. What Dr Gartner sees is a long-term relationship that involves both parties gradually inching toward that vital "sweet spot" that feels right to the patient. This may necessitate playing a game of "warm-warmer, cold-colder" for a number of years.
"So it’s not just a question of take this standard dose or achieve this blood level," Dr Gartner emphasizes. "It’s something that’s different for every patient."
Hypomania may be to this decade what depression was to the last, but more as a trait worth preserving – a legitimate baseline for many - than a pathology that needs eradicating. What requires our attention, says Dr Gartner, are those dangerous one or two seconds that cause us to do things we will later regret. Think of Hamilton posting his fateful letter to Burr.
Meditation and various self-awareness techniques can help in these situations, said Dr Gartner. So can smart psychiatry.
But the initiative needs to come from us. Hypomania is the true terra incognita of bipolar disorder. It may be the key to our personality or it may be a false high. It could represent our divine spark or the fire we shouldn’t be playing with. It may be our true yin-yang, the force and its dark side, Lord Shiva’s eternal dance of creation and destruction.
Ultimately, we are the only ones who can determine how the phenomenon applies to us and the type of outcome we should be seeking, but that kind of insight is likely to be the result of a long journey shared with the people who treat us. Now more than ever we need psychiatrists and therapists willing to listen.
May17, 2005, reviewed Feb 10, 2008
See Also
We're depressed way more than we are manic. Now if psychiatry only knew how to treat us.
Knowledge is Necessity
Copyright 2010 John McManamy Contact
