It is therefore critical to inquire as to the presence of past hypomania in every person presenting with depression, otherwise the possibility of a bipolar diathesis is easily missed.

It is therefore critical to inquire as to the presence of past hypomania in every person presenting with depression, otherwise the possibility of a bipolar diathesis is easily missed.



What are mania and hypomania? Mania is defined on the basis of symptoms and signs that are out of character for the individual and usually occur in discrete episodes (table 1). In the DSM-IV the diagnosis of mania requires the persistence of euphoric mood for a period of at least seven days, during which a minimum of three additional symptoms (four if mood is mainly that of irritability) are present. Technically, the predomi-nant mood is either that of excessive happiness, described as euphoria, or, alternatively, feelings of irri-tability. In practice, individ-uals will often describe feel-ing “pumped up” and “energised” or “wired”, with a notable increase in drive and goal-directed activ-ity that often results in increased pleasure-seeking behaviour. Other features include a decreased need for sleep, racing thoughts and dis-tractibility. Not surprisingly, many of these symptoms, and risk-taking behaviour in particular, can result in sig-nificant social or occupa-tional impairment, with potentially painful conse-quences such as risk to health, livelihood or reputa-tion. The symptoms and signs of mania can be conve-niently remembered using the mnemonic FIDGETS. (table 2). Hypomania is defined along the same lines as mania with regard to signs and symptoms, but the term is usually used to describe briefer periods of mood dis-turbance that generally incur less functional impairment than in mania. The DSM-IV employs a somewhat arbi-trary cut-off of four days' duration to define hypomania, but in practice this is often difficult to apply. In practice the diagnosis of hypomania is less reliable than that of mania or depression and it is seldom spontaneously reported because it is usually mild and transient and construed as a pleasant experience. People with bipolar disorder often consider periods of hypomania to be ‘normal' and understandably regard them as desirable, and rarely present clinically with such symptoms. However, it is important to remember that hypomanic symptoms are, more often than not, functionally dis-abling and that it is critical

to screen for manic or hypo-manic symptoms even in patients presenting with depression. This is important because identifying previous hypomania distinguishes a subsequent depressive episode as bipolar rather than unipolar. It is therefore critical to inquire as to the presence of past hypomania in every person presenting with depression, otherwise the possibility of a bipolar diathesis is easily missed.

What is bipolar depression? Although mania is the hall-mark of bipolar disorder, it is the depressive phase of bipolar illness that is the pre-dominant component of this illness both in terms of time spent unwell and the associ-ated functional disability. This bias in morbidity towards depression is even more pronounced in bipolar II disorder compared with bipolar I disorder. Like unipolar depression, bipolar depression is associ-ated with an increased risk of suicide. However, bipolar depression differs from its unipolar counterpart in sev-eral ways. An abrupt, earlier age of onset is more likely in bipolar depression, com-pared with a more gradual onset and offset in unipolar depression. A family history of bipolar

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