Letters to the Editor
Mnemonic for the Diagnosis of Hypomania Associated with Bipolar II Disorder
Dear Editor:
In the area of primary care psychiatry and general psychiatry, the 1990s could be termed “the decade of the anti- depressants.” This was a period of intense medical and public education focusing on depression as a legitimate, biologically based illness amenable to treatments with many newly available and different classes of antidepressants. This effort has helped alleviate the suffering of many patients and given clinicians—especially primary care physicians—new knowledge and tools to treat depressive illness. However, 15 years after the introduction of the first selective serotonin reuptake inhibitor (SSRI), fluoxetine, it is becoming apparent that antidepressants do not work for everyone: in controlled trials, the rate of symptom remission for anti- depressant therapy is at best 50% (1,2). Of more concern is the observation that antidepressants can make some patients worse by introducing or worsening anxious, agitated, or restless states and sometimes inducing insomnia intermingled with racing thought (3,4). Emerging evidence suggests that these antidepressant activations may be a result of unrecognized bipolar disorder (BD), usually BD II, which is being increasingly recognized as a common mood disorder both in outpatient psychiatry (5) and in primary care (6). Affected patients usually present in the depressed state, because their hypomanic episodes are typically elated and adaptive; patients suffering from depression lack specific recall of them (7). Because patients lack recall of hypomanic episodes, recognizing bipolar illness has been problematic, even in psychiatric settings (8,9). There is an average delay of 8 to 12 years before an accurate diagnosis is made. To help identify possible hypomanic episodes in a depression patient’s history, and thereby decrease the delay in accurate diagnosis, we have come up with a mnemonic incorporating the DSM-IV-R definition of hypomania. The mnemonic is HIGH-4, as follows:
H = |
Hyperactivity, or distractabilty, flight of ideas, pressured speech, and racing thoughts |
I = |
Insomnia and irritability |
G = |
Grandiosity, or inflated sense of self |
H = |
Hyperhedonia, or shopping sprees and high-risk sexual activity |
4 = |
4 days |
We believe that, by using this mnemonic to remind ourselves to look for the presence of hypomanic episodes in all depression patients in clinical settings, we can more accurately diagnose BD in a shorter time frame. This will allow us to use more appropriate therapies to treat BD patients and to avoid embarking on an antidepressant misadventure resulting in more suffering for our patients. In other words, when the patient is low, we should think HIGH-4!
References
1. Entsuah AR, Huang H, Thase ME. Response and remission rates in different subpopulations with major depressive disorder administered venlafaxine, selective serotonin reuptake inhibitors, or placebo. J Clin Psychiatry 2001;62:869–77.
2. Thase, ME, Entsuah AR, Rudolph RL. Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. Br J Psychiatry 2001;178:234–41.
3. Henry C, Sorbara F, Lacoste J, Gindre C, Leboyer M. Antidepressant induced mania in bipolar patients: identification of risk factors. J Clin Psychiatry 2001;62:249–55.
4. Akiskal HS, Maliya G. Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 1987;23:68–73.
5. Akiskal HS, Burgeois ML, Angst J, Post R, Moller HJ, Hirschfield R. Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord 2000;59(Suppl 1):S5–S30.
6. Manning JS, Haykal RF, Connor PD, Akiskal HS. On the nature of depressive and anxious states in a family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally. Compr Psychiatry 1997;38:102–8.
7. Dunner DL, Tay LK. Diagnostic reliability of the history of hypomania in bipolar II patients and patients with major depression. Compr Psychiatry 1993;34:303–7.
8. Hirschfield RM, Keller MB, Panico S, Arons BS, Barlow D, Davidoff F, and others. The National Depressive and Manic–Depressive Association consensus statement on the undertreatment of depression. JAMA 1997;277:333–40.
9. Living with bipolar disorder: how far have we really come? Constituency Survey of the National
Depressive and Manic–Depressive Association. Chicago (IL). National Depressive and Manic–Depressive Association; 2002.
John F Chiu, MD, CCFP
Pratap R Chokka, MD, FRCPC
Edmonton, Alberta
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