Soft bipolarity: How to recognize and treat bipolar II disorder

Daniel J. Smith, MD, MRCPsych
Clinical senior lecturer in psychiatry, Cardiff University School of Medicine, Cardiff, UK

At least 25% and possibly up to 50% of patients with recurrent major depressive disorder (MDD) have features of mild hypomania (the “soft end” of the bipolar spectrum) and might be better conceptualized as suffering from a broadly defined bipolar (BP) II disorder. The challenge is to differentiate MDD from BP II so that we make treatment decisions—such as antidepressants vs mood stabilizers—shown to improve the long-term course of patients’ depressive symptoms.

Diagnosis of BP II often is not straightforward and unfortunately may be delayed several years after patients first present for evaluation. To help clinicians make correct diagnostic decisions, this article:

• describes diagnostic criteria outside of DSM-IV-TR that can assist in identifying BP II disorder
• identifies subgroups of recurrently depressed patients whose primary disorder is more likely to be bipolar than unipolar
• provides a screening tool validated for identifying “soft” bipolarity
• offers a pragmatic clinical perspective on the treatment of BP II disorder.

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