Bipolar II Disorder: A Different Kind of Dangerous

For the past two weeks, Jada has driven past the same tree nearly every day. It’s several miles out of her way, and not particularly pretty. But it’s close to the road, on a quiet street without sidewalks or a bike lane, and its trunk is strong and broad. So Jada drives past, every day, wondering when she will get up the courage to step on the accelerator and slam her car straight into it.

Jada’s hopelessness, guilt and suicidal ideation aren’t new; she’s been struggling with these feelings since she was a teenager. Misdiagnosed with depression, it took years for Jada’s periods of extreme productivity, feelings of elation or anxiety, and mild insomnia to be diagnosed for what they were: hypomania. When she is finally correctly diagnosed with Bipolar II, she is told that she was lucky to have escaped diagnosis with the more severe version of the disorder, Bipolar I. But as her moods continue rocket back and forth, she wonders how her disease could get any worse  

Overview of Bipolar Disorder

Jada’s story is not unusual. Bipolar Disorder (BD) affects 5.7 million adults in the United States every year; about half of those have Bipolar II¹. A disease of two extremes, Bipolar Disorder is defined by the presence of manic or hypomanic symptoms on one pole, with depression on the other. Mania is an elevated mood state characterized by increased energy, talkativeness, grandiosity, distractibility, and impulsivity, usually combined with decreased need for sleep. The less severe version, hypomania lasts for less than a week and does not impair functionality or necessitate hospitalization. Depression is the opposite pole. Diagnosis requires a depressed mood state characterized by diminished interest, physical slowing, fatigue, changes in sleep and appetite, feelings of guilt and hopelessness, and thoughts of death or suicide.  The diagnosis of Bipolar I requires only a single episode of mania, though most peoples will also experience depressive episodes. But to be diagnosed with Bipolar II, you must have a history of both a Major Depressive and a hypomanic episode.

Mania vs. Hypomania

Because people with Bipolar II never experience full mania, it is sometimes considered a less severe disease. In fact, the diagnosis was not added to the Diagnostic and Statistical Manual of Mental Disorders – the psychiatrist’s primary diagnostic guide – until 1994. In some ways, this is understandable. Mania is, by definition, more severe than hypomania,. It often has severe and far-reaching consequences, including hospitalization, divorce, even financial ruin.

Yet hypomania is still a life-changing condition that needs to be taken seriously. It can be uncomfortable, leading to severe irritability, anxiety or akathisia; a feeling of painful restlessness. It can lead to high risk behaviors, such as substance abuse, dangerous driving and risky sexual practices. Even in its milder, euphoric form, the increased talkativeness, energy and impulsivity can strain relationships to the breaking point. Furthermore, since many people are happy and productive during a hypomanic episode, they are unlikely to bring it to the attention of their physician. This can lead to delayed and missed diagnoses.

Depression & Suicide  

Like Jada, nearly 40% of people with BD are initially diagnosed with Major Depressive Disorder³. While misdiagnosis is common for BD in general, diagnosis of Bipolar II is notoriously challenging. Because hypomania is milder and often does not impair daily life, people like Jada often do not report these symptoms. It can take years before their hypomania is discovered. During this time, they are often mistreated with antidepressants, which can in itself induce mania.

Patients with Bipolar II are also at higher risk of recurrence. They have a higher number of lifetime episodes than those with Bipolar I, and the interval between episodes gets shorter as the patient ages². As much as 20% of people transition directly from one episode to another, with no inter-episode recovery. There is also evidence that they have a higher incidence of mixed features, meaning they experience symptoms of both mania and depression simultaneously. Mixed features are associated with both increased severity and worse prognosis of the disease. It is also associate with a higher risk for suicide.

The lifetime suicide risk in people with BD is more than 20 times that of the general population². Over 1/3 of people with the disorder will attempt suicide at some point in their lives. With 20% lifetime risk of death by suicide, people with Bipolar live an average of 9.8 years less than the general population². In fact, it is believed that BD may account for as much as 25% of all completed suicides. While people with Bipolar I and II have similar rates of suicide attempts (36.2% and 32.4%, respectively), people with Bipolar II have a higher rate of completed suicides. While the exact reason for the increased lethality is unknown, increased time in the depressive state, increased severity of depression, and increased risk of mixed features are all likely contributors.

Long Term Effects

Even between mood episodes, people with Bipolar are affected by the disorder. Cognitive impairment, primarily in verbal memory and executive function, persists between episodes and often limits a patient’s ability to work. 15-30% of people demonstrate severe inter-episode impairment, and people with Bipolar Disorder have a lower average socioeconomic status than the general population, despite having equal levels of education. Although cognitive impairments are more severe in people with Bipolar I, a study found that Bipolar II disorder is linked to lower quality of life overall, even between episodes⁴.

People with Bipolar often have difficulty sticking to their treatment plan. Nearly half of people with BD stop taking their medications regularly at some point during treatment⁶. While there are many factors that contribute to this phenomenon, poor insight, lack of knowledge and denial of illness rank towards the top of the list⁶. Open and honest conversations about the disease, including its severity and time course, is a key component of helping people understand their disorder and stick with treatment. 

Conclusions

Bipolar Disorder is a chronic, severe, and episodic disease. While those with Bipolar II will never experience the full extent of mania, they spend more time in depressed episodes, commonly encounter misdiagnosis, have higher rates of dangerous mixed episodes, as well as increased lethality of suicide, and may even experience a lower quality of life overall. For those diagnosed with this disorder, it is important to understand that it is not simply a less severe form of Bipolar I. It’s a disease with real risks and should not be taken lightly.