What Is Bipolar II Disorder?
Bipolar II disorder (pronounced "bipolar two") is a form of mental illness. Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time.
However, in bipolar II disorder, the "up" moods never reach full-blown mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.
A person affected by bipolar II disorder has had at least one hypomanic episode in their life. Most people with bipolar II disorder have episodes of depression more often. This is where the term "manic depression" comes from.
A Visual Guide to Understanding Bipolar Disorder
Bipolar II Risk Factors
Virtually anyone can have bipolar II disorder. About 2.5% of the U.S. population has some form of bipolar disorder – nearly 6 million people.
Most people are in their teens or early 20s when symptoms of bipolar disorder first start. Nearly everyone with bipolar II disorder gets it before age 50. People with an immediate family member who has bipolar are at higher risk.
Bipolar II Symptoms
During a hypomanic episode, a higher mood can show up as either euphoria (feeling "high") or as crankiness.
Symptoms during hypomanic episodes include:
- Flying suddenly from one idea to the next
- Having exaggerated self-confidence
- Rapid, "pressured" (uninterruptible) and loud speech
- Increased energy, with hyperactivity and less need for sleep
People in a hypomanic episodes are often quite pleasant to be around. They can often seem like the "life of the party" – making jokes, taking an intense interest in other people and activities, and infecting others with their positive mood.
What's so bad about that, you might ask? Hypomania can also lead to erratic and unhealthy behavior. Hypomanic episodes can sometimes progress onward to full manias that affect a person's ability to function (bipolar I disorder). In mania, people might spend money they don't have, seek out sex with people they normally wouldn't, and engage in other impulsive or risky behaviors with the potential for dangerous consequences.
The vast majority of people with bipolar II disorder spend more time with depressive symptoms than hypomanic ones. Depression can occur soon after hypomania subsides, or much later. Some people cycle back and forth between hypomania and depression, while others have long periods of normal mood in between episodes.
Untreated, an episode of hypomania can last anywhere from a few days to several months. Most commonly, symptoms continue for a few weeks to a few months.
Depressive episodes in bipolar II disorder are similar to "regular" clinical depression, with depressed mood, loss of pleasure, low energy and activity, feelings of guilt or worthlessness, and thoughts of suicide. Depressive symptoms of bipolar disorder can last weeks, months, or, rarely, years.
Bipolar II Treatment
Hypomania often seems to be happiness and relentless optimism. When hypomania is not causing unhealthy behavior, it often may go unnoticed and therefore remain untreated. This is in contrast to full mania, which by definition causes problems in functioning and requires treatment with medications and possibly hospitalizations.
People with bipolar II disorder can benefit from preventive drugs that level out moods over the long term. These prevent the negative consequences of hypomania, and also help to prevent episodes of depression.
Lithium (Eskalith, Lithobid): This simple metal in pill form is highly effective at controlling mood swings (particularly highs) in bipolar disorder. Lithium has been used for more than 60 years to treat bipolar disorder. Lithium can take weeks to work fully, making it better for long-term treatment than for acute hypomanic episodes. Blood levels of lithium and other levels (such as kidney and thyroid functioning) must be monitored periodically to avoid side effects.
Carbamazepine (Tegretol): This anti-seizure drug has been used to treat mania since the 1970s. Its possible value in treating bipolar depression, or preventing future highs and lows, is less well-established. Blood tests to monitor liver functioning and white blood cell counts also are needed from time to time.
Lamotrigine (Lamictal): This drug is approved by the FDA for the maintenance treatment of adults with bipolar disorder. It has been found to help delay bouts of mood episodes of depression, mania, hypomania (a milder form of mania), and mixed episodes in people being treated with standard therapy. It is especially helpful in preventing lows.
Valproate (Depakote): This antiseizure drug also works to level out moods. It has a more rapid onset of action than lithium, and it can also be used "off label" to prevent highs and lows.
Some other anti-seizure medications, such as oxcarbazepine (Trileptal), are also sometimes prescribed as "experimental" (less-proven) treatments for mood symptoms or associated features in people with bipolar disorder.
By definition, hypomanic episodes do not involve psychosis and do not interfere with functioning. But antipsychotic drugs, such as aripiprazole (Abilify), asenapine (Saphris), cariprazine (Vraylar), lumateperone (Caplyta), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), and others, are sometimes used in hypomania and some (notably, Caplyta and Seroquel) are used for depression in bipolar II disorder.
This class of drugs includes alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan) and is commonly referred to as minor tranquilizers. They are used for short-term control of acute symptoms that come with hypomania, such as insomnia or agitation.
Seroquel and Seroquel XR are the only medications FDA-approved specifically for bipolar II depression. Common antidepressants such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are also sometimes used in bipolar II depression, and are thought to be less likely to cause or worsen hypomania than is the case in bipolar I disorder. Psychotherapy, such as cognitive behavioral therapy, may also help.
Because bipolar II disorder typically involves recurrent episodes, continuous and ongoing treatment with medicines is often recommended for relapse prevention.
Bipolar II medications
Doctors use many types of drugs to treat bipolar disorder. Some fight the extreme highs of mania, and others treat the lows of depression. You might take one drug at a time or a few at the same time.
The best bipolar medicine is the one that works best for you. Work with your doctor to decide on the medication plan that helps you the most.
You may keep taking these medications for years or decades, even if it’s been a long time since your last manic or depressive episode. This is called maintenance therapy and helps stop the symptoms from coming back.
Keep in mind that the term "mood stabilizer" can be misleading. If you take one, your mood can still change during the day. These medicines treat full episodes of mania or depression that last for several days or weeks at a time.
For some people, traditional antidepressants may trigger a manic episode. Because of this risk, your doctor should keep track of you closely if you take one.
Your doctor can’t predict how well a particular bipolar medication will work for you. You may need to try several kinds and different doses to figure out the right approach. And that can take time.
It can be frustrating, but don't give up. Eventually, you and your doctor should be able to find a prescription that works for you.
Side effects of bipolar drugs
Like any drug, bipolar medicines can cause some side effects. They vary depending on which medications you use. These side effects can include:
- Hair loss
- Sexual problems
- Weight gain
- Liver damage
- Kidney damage
- Belly pain
- Skin reactions
Some medications can affect how well your liver works or the amount of white blood cells or platelets you have. You may need regular tests to make sure that you're staying healthy. The antipsychotic drug ziprasidone (Geodon) is linked to a rare but serious skin reaction called DRESS syndrome (drug reaction with eosinophilia and systemic symptoms).
Many side effects will go away after a few weeks of treatment. If you still feel bad after that, see your doctor. Don't assume you have to just live with the side effects. Your doctor may be able to change your dose, give you another medicine to control the side effects, or try a different medication altogether.
If you have bipolar disorder, taking your medication should be part of your routine. Take it at the same time every day. It's easier to remember if you do it along with another daily activity, like brushing your teeth, eating breakfast, or getting into bed. A weekly pillbox can help you see if you've missed a dose.
Be sure to talk to your pharmacist or doctor about the best time of day to take your bipolar medications. Some are best if you take them in the morning or at bedtime, and others with meals or after meals.
Make sure you know what to do if you accidentally miss a dose. Ask your doctor. Don't assume that doubling up is a good idea.
Stick to your treatment
Medications for bipolar disorder are powerful drugs, and you must take them exactly as your doctor recommends. Don't stop taking a medicine without your doctor's approval. It can be dangerous.
When you're feeling good, you might decide that you want to stop taking your medication. But that's a bad idea unless your doctor agrees. Treatment only during mood episodes may not be enough to prevent symptoms from coming back. In most people, maintenance treatment between mood episodes makes mania and depression happen less often and makes them less severe. If you're feeling good now, that's likely because your medication is working. So stick with it.
Other bipolar II treatments
Is electroconvulsive therapy (ECT) a viable treatment for bipolar depression?
Guidelines from the American Psychiatric Association suggest that ECT is an appropriate and sometimes preferred treatment for depressed bipolar patients who have psychotic symptoms or a very high risk for suicidal behavior. In addition, ECT may benefit women who are pregnant and have severe bipolar depression or mania.
What about psychotherapy for help with bipolar depression?
Along with medications for bipolar depression, patients may benefit from ongoing psychotherapy. This one-on-one therapy combines interpersonal psychotherapy with behavioral techniques to help patients learn how to more effectively manage interpersonal problems, stay on their medications, and normalize their lifestyle habits. A very large study sponsored by the National Institute of Mental Health called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) found that in addition to medications, adding a structured psychotherapy – such as cognitive behavioral therapy, interpersonal/social rhythm therapy, or family-focused therapy – can speed up treatment response in bipolar depression by as much as 150%.
Bipolar II Prevention
The causes of bipolar disorder are not well understood. It's not known if bipolar II disorder can be prevented entirely.
It is possible to reduce the risk of future episodes of hypomania or depression once bipolar disorder has developed. Regular therapy sessions with a psychologist or social worker, along with medication, can help efforts to stabilize mood, leading to fewer hospitalizations and better feelings overall. Psychotherapy can help people better recognize the warning signs of a relapse before it takes hold, and can also help to ensure that prescribed medicines are being taken properly.
How Is Bipolar II Disorder Different From Other Types of Bipolar Disorder?
People with bipolar I disorder have full mania – a severe, abnormally elevated mood with erratic behavior. Manic symptoms lead to serious disruptions in life, causing legal or major personal problems.
In bipolar II disorder, the symptoms of elevated mood never reach full-blown mania. Hypomania in bipolar II is a milder form of mood elevation. But the depressive episodes of bipolar II disorder are often longer-lasting and may be even more severe than in bipolar I disorder. Therefore, bipolar II disorder is not simply a "milder" overall form of bipolar disorder.