NURS 647 Psychopharmacology Discussion 2: Bipolar II Case Study
Sample 1
- How do you differentiate hypomania from mania in clinical assessment?
It is important as a clinician to differentiate between different types of mania and hypomania. It can be challenging as discussed by Stahl (2021), especially since symptoms can present as unipolar depression by itself. The main difference in noting mania vs hypomania will come down to a few key factors. First the provider will need to collect a good family history. Things such as poor sleep, suicide attempts, as noted by Hafeman, D. M. et al. (2021), and family history can be key indicators.
- What is the role of lamotrigine in bipolar disorder treatment?
Mood stabilizers can be an important piece of treating the bipolar disorder puzzle. As noted by both Stahl (2021), Betchel NT. et al. (2023), Lamotrigine’s mechanism of action is not well understood. But it is thought to selectively inhibit gated sodium channels. This selective binding and inhibiting of glutamate can lead to a more stabilized mood, with less episodes of mania.
- Why should antidepressants be used cautiously in bipolar II disorder?
One big concern when using anti-depressants in bipolar disorder is the possibility of inducing mania and fast cycling, as reported by Gitlin MJ (2018). There is the possibility that anti-depressants may cause this phenomenon. However, some studies also suggest that it is appropriate to use anti-depressants with bipolar disorder. Another big concern is that anti-depressants may induce suicidal thoughts/ideation.
- What lifestyle interventions can help reduce relapse risk?
There are several lifestyle modifications that one can use to reduce relapses. Counseling would be an effective way to help manage your concerns. Following up with your MD is important. Using your support system such as family/friends when difficulties arise. Avoiding stressors is also key.
- Which screening tools can be useful for tracking mood changes in bipolar disorder?
There are several mood screening tools and questionnaires you can find on the internet. I googled it and came up with several of them. But it would be best to check in with a therapist or MD for official screening tools they would use.
References
Betchel NT, Fariba KA, Saadabadi A. Lamotrigine. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470442/
Gitlin MJ. Antidepressants in bipolar depression: an enduring controversy. Int J Bipolar Disord. 2018 Dec 1;6(1):25. DOI: 10.1186/s40345-018-0133-9. PMID: 30506151; PMCID: PMC6269438.
Hafeman, D. M., Goldstein, T. R., Strober, M., Merranko, J., Gill, M. K., Liao, F., Diler, R. S., Ryan, N. D., Goldstein, B. I., Axelson, D. A., Keller, M. B., Hunt, J. I., Hower, H., Weinstock, L. M., Yen, S., & Birmaher, B. (2021). Prospectively ascertained mania and hypomania among young adults with child- and adolescent-onset bipolar disorder. Bipolar Disorders, 23(5), 463–473. https://doi.org/10.1111/bdi.13034
Stahl, S. M. (2021). Stahl’s Essential Psychopharmacology Neuroscientific Basis and Practical
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Sample 2
Maria’s case demonstrates the complexity of Bipolar II disorder, where depressive episodes are more disabling and recurrent, while periods of hypomania alternate but do not reach the severity of mania. Addressing the discussion questions:
- 1. Differentiating hypomania from mania
Hypomania is a distinct period of elevated, expansive, or irritable mood lasting at least 4 consecutive days, with noticeable changes in energy and behavior. However, it does not cause marked impairment in functioning, psychosis, or hospitalization. Mania, in contrast, lasts at least 7 days (or shorter if hospitalization is required), produces significant impairment, and may involve psychotic features. As Dailey and Saadabadi (2023) note, the defining features of mania include increased talkativeness, rapid speech, decreased need for sleep, racing thoughts, distractibility, heightened goal-directed activity, and psychomotor agitation. Other hallmarks are mood lability, impulsivity, irritability, and grandiosity. - 2. Role of lamotrigine in bipolar disorder treatment
Lamotrigine is primarily used for maintenance therapy in bipolar disorder, with particular effectiveness in preventing depressive relapses. According to Lamotrigine (Lamictal) for Bipolar Depression: What You Should Know (2022), lamotrigine delays the onset of mood episodes by decreasing irregular electrical activity in the brain. This reduces the likelihood of recurrent or relapsing depressive and manic episodes. Long-term use provides stability by preventing or delaying mood shifts, making it a valuable option for patients like Maria. - 3. Why antidepressants should be used cautiously in Bipolar II disorder
Antidepressants, when used without a mood stabilizer, may trigger rapid cycling, hypomania, or mania. For this reason, guidelines recommend avoiding antidepressant monotherapy in bipolar disorders. Instead, mood stabilizers or atypical antipsychotics are preferred for bipolar depression. Hu et al. (2022) found that combining antidepressants with antipsychotics led to slightly improved outcomes compared to antipsychotics alone, but this effect was not observed when combined with mood stabilizers. This highlights the need for careful prescribing and monitoring. - 4. Lifestyle interventions to reduce relapse risk
non-pharmacologic strategies are essential in relapse prevention. Key interventions include maintaining a consistent sleep-wake cycle, adhering to medication, developing a structured daily routine, exercising regularly, avoiding alcohol or drugs, and using stress management techniques such as mindfulness or relaxation exercises. Psychoeducation empowers patients to recognize early warning signs and take proactive measures. - 5. Screening tools for tracking mood changes
Several validated tools support diagnosis and monitoring. The Mood Disorder Questionnaire (MDQ) is widely used to screen for bipolar disorder, while the Hypomania Checklist-32 (HCL-32) is helpful for identifying hypomanic symptoms. Daily mood charting, whether through paper logs or digital apps, allows patients to monitor fluctuations over time, facilitating early intervention and collaboration with providers.
Conclusion
Maria’s presentation underscores the importance of distinguishing hypomania from mania, carefully selecting pharmacologic treatments, and reinforcing adherence to maintenance medications such as lamotrigine. Equally vital are psychoeducation, lifestyle modifications, and the use of structured screening tools. A multimodal approach—integrating medication, therapy, and lifestyle management—offers the strongest foundation for long-term stabilization in Bipolar II disorder.
Reference:
Dailey, M. W., & Saadabadi, A. (2023, July 17). Mania. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493168/
Hu, Y., Zhang, H., Wang, H., Wang, C., Kung, S., & Li, C. (2022). Adjunctive antidepressants for the acute treatment of bipolar depression: A systematic review and meta-analysis. Psychiatry Research, 311, 114468. https://doi.org/10.1016/j.psychres.2022.114468
Lamotrigine (Lamictal) for Bipolar Depression: What You Should Know. (2022, August 12). Www.healthcentral.com. https://www.healthcentral.com/condition/bipolar-disorder-medications/lamotrigine
Sample 3
1. Differentiating Hypomania from Mania
Hypomania is characterized by a distinct period of elevated, expansive, or irritable mood lasting at least 4 consecutive days, with noticeable but not severe impairment in functioning. Mania, in contrast, lasts at least 7 days (or requires hospitalization) and is associated with marked impairment in functioning, possible psychosis, or need for inpatient care (American Psychiatric Association [APA], 2022). Maria’s elevated mood episodes are consistent with hypomania because they did not cause significant impairment, nor were psychotic features present.
2. Role of Lamotrigine in Bipolar Disorder
Lamotrigine is an anticonvulsant commonly used as a mood stabilizer in bipolar disorder. Its greatest efficacy is in preventing depressive episodes rather than acute mania, which makes it particularly valuable in bipolar II disorder, where depressive episodes are more frequent and impairing (Geddes & Miklowitz, 2013). Maria’s previous positive response supports its continued use, though adherence is critical for stability.
3. Caution with Antidepressants in Bipolar II Disorder
Antidepressants can induce mood switching or rapid cycling in individuals with bipolar disorder, especially when used without a mood stabilizer (Pacchiarotti et al., 2021). Maria’s history of rapid cycling on sertraline illustrates this risk. Clinical guidelines recommend avoiding antidepressant monotherapy and instead focusing on mood stabilizers or atypical antipsychotics.
4. Lifestyle Interventions to Reduce Relapse Risk
Structured daily routines, regular exercise, consistent sleep-wake cycles, and stress management strategies reduce relapse risk in bipolar disorder (Sylvia et al., 2019). Psychoeducation about recognizing early warning signs and maintaining social support networks are also protective. Maria may benefit from structured daily activities that support both her academic and creative work.
5. Useful Screening Tools for Bipolar Disorder
Mood charting is a practical tool for both patients and clinicians. Validated instruments such as the Mood Disorder Questionnaire (MDQ) and the Young Mania Rating Scale (YMRS) help identify and track mood symptoms, while the Patient Health Questionnaire-9 (PHQ-9) is commonly used for depressive symptoms (Hirschfeld et al., 2000; Young et al., 1978). Using these tools regularly can enhance early detection of mood changes and improve adherence to treatment plans.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.
Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. Lancet, 381(9878), 1672–1682. https://doi.org/10.1016/S0140-6736(13)60857-0
Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873–1875. https://doi.org/10.1176/appi.ajp.157.11.1873
Pacchiarotti, I., Anmella, G., Verdolini, N., Samalin, L., & Vieta, E. (2021). The role of antidepressants in bipolar disorder: A critical appraisal. Current Neuropharmacology, 19(12), 2001–2014. https://doi.org/10.2174/1570159X19666210318124318
Sylvia, L. G., Alloy, L. B., Hafner, J. A., Gauger, M. C., Verdon, K., Abramson, L. Y., & Nierenberg, A. A. (2019). Life events and social rhythms in bipolar spectrum disorders: A prospective study. Behavior Therapy, 50(3), 537–550. https://doi.org/10.1016/j.beth.2018.08.003
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity, and sensitivity. British Journal of Psychiatry, 133(5), 429–435. https://doi.org/10.1192/bjp.133.5.429