Q. As a practicing psychiatrist, I believe I've encountered a number of patients with sustained hypomania without any clinical history of significant depression I can obtain. These people seem to be functioning quite well in general. Do you have any treatment suggestions?

A. Well, as the saying goes, "if it ain't broke, don't fix it." I suspect that some or most of the patients you are describing fall into a category described by Dr. Hagop Akiskal as hyperthymic temperament or personality (see Akiskal HS, J Clin Psychopharmacol 16 (suppl 1):4-14, 1996.

I also reviewed the bipolar spectrum in the July issue of the Journal of Psychiatric Practice). These individuals tend to be very energetic, jovial, extremely social, and very productive most of the time. They may never become frankly manic or even hypomanic by DSM-IV criteria, and some probably never experience a major depression. However, I suspect that many such patients actually do have brief down-swings in their mood that they do not report to us, perhaps because by the time we see them, their repressive mechanisms (or narcissism?) have kicked in and effaced the memory of the depression. (I suspect--but can't prove--that this tends to run counter to the usual pattern, in which bipolar II patients complain about their depressive periods and don't report their hypomanic bouts).

I also found an abstract from a Russian journal (Moroz IB, Nefed'ev OP, Zh Nevropatol Psikhiatr Im S S Korsakova 1982 Sep;82(9):73-9) describing patients for whom chronic hypomania may be part of "a residual pseudopsychotic state characterized [by] a combination of cycloid and schizoid features, with an invariably elated mood." However, I have not seen such patients personally.

I think a more important question is this: if these patients seem to be functioning quite well in general, why, specifically, do they find their way to your office? Do they have problems with co-morbid substance abuse or anxiety disorders? Do they have interpersonal problems stemming from their always-on, hyperthymic life-style? I believe in looking long and hard at these apparently high-functioning folks, to see if such co-morbid conditions exist, and to determine if they stem from an untreated soft bipolar spectrum disorder.

Having these patients keep a longitudinal journal or mood log for several months may be helpful, as may interviews with significant others. (I have been surprised at how many times the patient's history of mood symptoms differs from the reports of a spouse!). New bipolar mood questionnaires, such as the MDQ (Hirschfeld, 2000) may help detect these softer bipolar patients.

But, to answer your question more directly, I don't recommend treatment unless there are clearly problems to treat. Psychotherapy aimed at helping some hyperthymic individuals moderate their over-blown life-styles may be helpful. I generally avoid antidepressants for obvious reasons, but sometimes an anxiolytic like buspirone may be helpful if there is a co-morbid generalized anxiety disorder present. I think Akiskal tends to favor mood stabilizers in many of these folks, but I think we lack any well-designed, randomized, controlled studies that would guide us to the most effective treatment.

Nevertheless, if there is a strong family history of classic bipolar I or II disorder, I believe it is reasonable to consider a mood stabilizer in some of these individuals, particularly if there is a hint of brief depressive bouts. I might try using a very low dose of lithium, or perhaps gabapentin, but the data base for such choices is very shaky. We really need large, controlled studies of treatments for these folks, and right now, we don't have any!

November 2002

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