Key definitions

• Depressive episode: A period of low mood, diminished interest, fatigue, sleep/appetite changes, worthlessness, and functional impairment.
• Hypomania: A distinct period of abnormally elevated, expansive or irritable mood with increased activity or energy, lasting at least 4 days by DSM-5 — clinically, shorter-duration hypomanic symptoms (e.g., 1–3 days) may still be relevant and suggest bipolar spectrum features.
• Short-duration hypomania: Hypomanic-like episodes that are briefer than formal criteria but recurrent, subthreshold or clinically meaningful (also called brief hypomania or subsyndromal hypomania).

Why this matters

• Presence of hypomanic symptoms—even short—changes diagnostic formulation (bipolar II spectrum, other specified bipolar disorder) and treatment (caution with antidepressants alone).
• Increased risk of mood instability, cycling, and treatment-emergent mania/hypomania if antidepressants are used without mood stabilisers.
• Impact on psychosocial functioning, occupational stability and risk management (impulsivity, substance use).

Assessment: practical steps

1. Detailed timeline: Map mood episodes, duration, frequency, triggers, and sequence (depression → hypomania or vice versa).
2. Collateral history: Obtain family and informant history (family bipolar disorder increases pre-test probability).
3. Screening tools: Mood Disorder Questionnaire (MDQ), Hypomania Checklist (HCL-32) — interpret cautiously for short-duration symptoms.
4. Substance & medication review: Stimulants, corticosteroids, thyroid meds, or substances can mimic hypomanic symptoms.
5. Risk assessment: Suicidal ideation, impulsivity, risky behaviours during hypomanic periods — assess and document.
6. Differential diagnosis: ADHD, personality disorder, situational stress, thyroid disease, Cushing’s, neurological causes — rule out medical contributors.

Differential diagnosis — quick table

Treatment principles

Treatments should be individualised. Presence of hypomanic symptoms shifts practice toward mood-stabilising strategies and cautious use of antidepressants.

• Prioritise mood stabilization: Consider mood stabilisers (lithium, valproate, lamotrigine) or certain atypical antipsychotics depending on clinical profile.
• Antidepressants with caution: Antidepressants can precipitate hypomania/mania or rapid cycling; if used, combine with a mood stabiliser and monitor closely.
• Psychoeducation & shared decision-making: Explain bipolar spectrum concept, medication risks/benefits, and early warning signs of mood switches.
• Address comorbidities: Substance use, anxiety, sleep disorders and medical issues must be treated concurrently.
• Safety planning: For suicidal ideation during depressive phases and for impulsive risk during hypomanic periods.
• Regular monitoring: Mood charts, sleep/eating logs, medication side effects, and functionality tracking.

Pharmacological options (overview)

• Lithium: Gold-standard mood stabiliser with anti-suicidal benefits; useful for maintenance and reducing recurrence.
• Valproate / Divalproex: Effective for mood stabilization (use caution in women of childbearing potential).
• Lamotrigine: Particularly helpful for bipolar depression and preventing depressive relapse; slower onset for acute depression.
• Atypical antipsychotics: Quetiapine, lurasidone, olanzapine-fluoxetine combo (OFC) have evidence in bipolar depression; choice guided by side-effect profile.
• Antidepressants: SSRIs/SNRIs may be used cautiously if combined with a mood stabiliser; avoid monotherapy in suspected bipolar-spectrum cases.
• Adjunctive options: Benzodiazepines short-term for insomnia/anxiety (short courses), careful with dependence risk.

Medication must be prescribed by a psychiatrist with informed consent and monitoring (lithium levels, liver function, pregnancy planning where relevant).

Psychological & psychosocial interventions

• Cognitive Behavioural Therapy (CBT): Structured approach for depressive symptoms, relapse prevention and behavioural activation.
• Interpersonal and Social Rhythm Therapy (IPSRT): Targets social rhythm stability — useful in bipolar spectrum to stabilise sleep/wake and routines.
• Family-focused therapy: Psychoeducation and communication skills to reduce relapse and improve support.
• Mindfulness-based and relapse prevention interventions: Improve emotion regulation and early recognition of switches.
• Substance use interventions: Motivational interviewing and integrated treatment if comorbid substance use present.

Monitoring & early warning systems

1. Mood charting: Daily ratings of mood, sleep, energy, and medication adherence (paper or apps).
2. Early warning signs: Reduced need for sleep, increased talkativeness, risky spending, decreased concentration, sudden optimism—document and act early.
3. Relapse-prevention plan: Pre-agreed steps for patient/family when warning signs appear (contact clinician, adjust meds, increase support, safety measures).

Safety & risk management

• Assess suicidality during depressive phases and impulsive risk during hypomanic periods.
• Create a safety plan: emergency contacts, remove/secure means, crisis numbers, when to seek ED or call a psychiatrist.
• Consider brief admissions for severe mood instability or if outpatient safety cannot be assured.

Practical tips for clinicians

• When in doubt about bipolarity, err on the side of caution: favour mood stabilisers and specialist referral before long-term antidepressant monotherapy.
• Always obtain collateral information — patients often minimise hypomanic symptoms.
• Use structured screening tools but interpret in clinical context.
• Document reasoning for medication choices clearly and discuss risks/benefits with patients and families.

Self-help & supportive tips for patients

• Keep a simple daily mood and sleep log.
• Maintain consistent sleep-wake times and regular routines.
• Limit alcohol and recreational drugs which can destabilise mood.
• Build a small support team (family/friend/clinician) who know early warning signs.
• Practice stress-reduction: paced breathing, grounding, brief walks, structured activity.

When to refer urgently

• Frequent mood switches with functional impairment despite outpatient care.
• Active suicidality or serious impulsive behaviour (spending, sexual risk, driving dangerously).
• Diagnostic uncertainty requiring specialist assessment (complex comorbidity, pregnancy, medical interactions).

Key takeaways

• Brief hypomanic episodes alongside depressive episodes suggest bipolar-spectrum illness and change management priorities.
• Prioritise mood stabilisation, psychoeducation, and careful use (or avoidance) of antidepressant monotherapy.
• Use structured assessment, collateral history and monitoring to guide treatment choices.
• Combine pharmacological approaches with psychosocial interventions (IPSRT, CBT, family therapy) for best outcomes.