Diagnosing and Treating Subtle Bipolar II

A Perspective on "Depression Plus"

James Phelps

Many of our clients struggle with depression or anxiety, but a fair number suffer from both conditions. Faced with this particular mix of symptoms, therapists may apply lots of different diagnostic labels—PTSD, ADHD, generalized anxiety disorder, borderline personality disorder—but what’s often missed is another condition altogether, a subtle form of bipolar II, which can lead to years of debilitating mood swings that can make a person feel desperately out of control.

Treatment for bipolar disorders used to focus on medication, but like many other mood specialists, I’ve found that most clients don’t get the help they need with medication alone, or even with established therapy approaches in combination with medication. Instead, a combination of new, lesser-known therapies plus medications has been shown to produce substantial gains in mood stabilization and daily functioning.

Teasing Out the Problem

Maria, a 34-year-old high-school teacher, came in for her first appointment looking exhausted. She told me that she’d been depressed and anxious for nearly a year, with no relief after trying three antidepressants and two psychotherapists. There was no indication of trauma in her history, but her episodes of depression mixed with agitated anxiety—including the current one—had been severe. “I just want to get to the point where I don’t inflict my misery on my husband and two kids,” she sighed. “I’m constantly impatient and irritable with them.” Pressing her hands against her face, she whispered, “Sometimes I think about just ending it all. I’d never act on it, but I need some relief.”

As I delved into her history, it became clear that Maria had never experienced full manic episodes, but starting in college, she’d had periods of feeling revved up with energy, in which she’d often have trouble sleeping. Blushing a little, she added that during these periods she generally felt “more attractive” and had engaged in sexual activity more than usual. But were these episodes anything beyond normal? Lots of people experience phases of being more excited about things, engaging in more activities, being more social, and getting less sleep in the process. Yet if there’s any real line between normal experience and hypomania—the chief defining characteristic of bipolar II—Maria was close to it.

After completing the diagnostic phase of the first session, I shared my conclusion. “Maria, you don’t have bipolar I, the full manic-depression thing,” I told her, speaking gently and pointing to my outstretched little finger. “But your depression isn’t plain unipolar either,” I said, pointing to my thumb. “Because of your family history and your repeated depressions, you’re more over here.” I pointed at my middle knuckle. “So you have what we might call depression-plus. It’s not classic bipolar, but it’s more complicated than plain depression.”

Maria’s eyes stayed in that space between my thumb and little finger, her brow furrowed. She was silent for a few moments and then nodded. “Yeah,” she said. “I get it.”

I felt a sense of relief that we’d landed on a mutually satisfactory explanation, which now allowed us to explore treatment options. However, I knew those options would be bipolar-oriented, a loaded word implying all kinds of extreme behavior. I needed to prepare her for this, which would take more time, and we were at the end of our session. “I’d like you to read about this depression-plus thing before our next visit,” I said.

The Initial Approach

When Maria returned the following week, her step was a little more purposeful, her face a bit more relaxed. Almost as soon as she sat down, she said. “I can see why you wanted me to read that stuff. I think it might explain some things about how my life has gone.” She took a long breath. “But I’ve got to tell you, that bipolar word still scares the hell out of me.”

“Of course, that makes sense,” I said, especially given her sister’s version of the illness. “What you’re dealing with isn’t bipolar in the usual sense of that word,” I emphasized. “It’s like we’re just borrowing the term to throw light on your symptoms. So let me suggest a couple of treatment options that I think might help the depression you’re in now, lessen the chances of going into more depressions later, and stop this painful cycle you’re in, where you feel a little over-revved, and then drop down into depression.” She nodded, her eyes welling as I continued. “By using a medication and a nonmedication approach at the same time, we’ll have the best chance at this.”

After running through the pros and cons of the main medication options (which she’d be taking in conjunction with the antidepressant she’d been on for years), Maria picked lamotrigine, a mood stabilizer that has relatively few side effects and no significant long-term risks. We spent the rest of her second visit discussing other key therapeutic components of treatment, three approaches that research has shown to be effective with bipolar clients: a formal program of psychoeducation (which we’d already begun), social rhythm therapy (which helps establish regular patterns of activity and sleep), and bipolar chronotherapy (a bipolar-specific variation of CBT designed to treat insomnia).

From here, a therapist can cherry-pick specific tools most appropriate for a client’s particular needs. In Maria’s case, a discussion of her family and work relationships—generally strong—convinced me that treatment didn’t need to prioritize interpersonal issues. Her prior therapists had helped her recognize her automatic negative thoughts, such as her tendency to ruminate about perceived slights, and she told me that the mindfulness techniques she’d learned from them usually helped her a little from day to day. What stood out were her difficulties with sleep. For clients with bipolarity, sleep deprivation can induce hypomanic and manic symptoms, while too much sleep can worsen depression. So my initial intervention was a technique from bipolar chronotherapy called dark therapy.

“Research has shown that all wavelengths of light—blue, green, yellow, red—aren’t created equal,” I explained. “Only one sets circadian rhythm: blue. So blocking blue light creates the equivalent of circadian darkness.”

Maria’s eyes lit up. “Yeah, I think I read something about that!” she exclaimed. But she hadn’t heard how simple it is—a $9 pair of amber-tinted safety glasses can prevent blue light from reaching her retina, denying her brain the signal that says it’s daytime. So she could experience an artificial nighttime while still staying up to read a book or play games with her family. Using the amber lenses meant she didn’t have to turn off the lights at 6 p.m. “So what’s the plan?” she asked.

I’ve learned not to push my luck here. Most people can’t wear these things for more than two hours. So I instructed Maria to put them on about 8:30 p.m. and take them off when all the lights in the house were out, shooting for a bedtime around 10:30 p.m. I went on to warn her, “The amber lenses aren’t magic. They don’t work for everyone. And moving your bedtime earlier won’t happen right away: you’ll make the change gradually. But it’s an important ingredient in developing a more regular pattern of sleep.”

So Maria left our second visit with a prescription for lamotrigine, a pair of amber lenses (we sell them at cost at our front desk), a set of instructions for each, and the hope that these interventions would help her sleep better and alleviate her current depression. I asked her to come back in two weeks so we could evaluate how she was doing.

That’s How the Light Gets In

When Maria returned to my office, she readily admitted that she hadn’t worn the lenses every night. “But when I do wear them,” she said, “I fall asleep earlier, so I’m not up so late anymore.”

At this point, Maria and I reviewed treatment so far, confirming that she was making use of the amber lenses to try to move her bedtime earlier as much as possible, experiencing no difficulties with lamotrigine, and planning to add the dawn simulator to continue to work toward a more regular pattern of bedtime and risetime.

At our next appointment, Maria made eye contact with me immediately—a first. “Doc,” she said, “I can hardly believe it. I’m definitely getting better.” As she described her improvement—waking up with some energy, having a little more patience with her kids—I found myself relieved. It was too early to expect much change in her day-to-day functioning, such as reaching out to friends or getting more done at home, but we both felt encouraged by movement in the right direction.

Six months into our work together, Maria was no longer fearful that she’d plunge back into deep depression. “I’m really diligent about my bedtime and risetime: I even get up at the same time on weekends,” she told me. “If I feel a little revved up in the evening, I put the amber lenses on again.” To cement her circadian rhythm, she’d added a regular walk first thing in the morning. “I make myself do this no matter what. When I stopped for a few weeks, I could see myself start to slide.” She shook her head at the memory. “That freaked me out!”

As Maria solidified her gains, we started to meet monthly, until I felt Maria was ready to go it alone for a longer period of time. Six months later, she arrived in my office radiating a quiet vitality. She told me of a promotion at work and showed me a few photos of her kids playing flag football. With her mood stable and her anxiety much reduced, neither Maria nor I could identify a clear target for further psychotherapy.

Walking the Line

Maria’s story illustrates a number of things. Some clients with anxious depression actually have bipolar disorder. Of course, there are the risks in taking medications (other than lamotrigine) for bipolar disorder, most notably the major side effects of lithium, carbamazepine, and the atypical antipsychotics. Yet we need to make sure not to miss the opportunity to help people who are on the bipolar spectrum but whose symptoms tend to be overlooked. Many of these individuals spend years in therapy that may provide support but fails to get at the root of the problem: mood or energy cycling. Often those clients are even treated with antidepressants that may make things worse.

We see that bipolar disorder is no longer managed with medications alone, since several well-researched psychotherapies have been shown to improve outcomes. Among these is psychoeducation, starting with basic information about the condition that counters the stigma associated with bipolar illness, and then progressing to more complex issues, such as the possibility of a mixed state. All information is tailored to the client’s learning style and capacities. Chronotherapy techniques help shift and cement circadian rhythm—a mood-stabilizer unto itself. These and other bipolar-specific therapy techniques that can be easily incorporated into a therapist’s toolkit are powerful interventions, which can help our clients gradually reclaim their rightful, balanced place in the world.


This blog is excerpted from "Navigating the Bipolar Spectrum" by James Phelps. The full version is available in the March/April 2017 issue, Round Hole, Square Peg: If It Doesn't Fit, Don't Force It.

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Topic: Challenging Clients & Treatment Populations

Tags: 2017 | adhd | antidepressant | antidepressants | anxiety symptoms | bipolar | bipolar disorder | borderline personality | depression symptoms | medication | mood disorder | mood disorders | Mood Problems | prescription medication | psychiatrist | PTSD | sleep | sleep deprivation | sleep disorder | sleep disorders | suicidal | suicide

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1 Comment

Tuesday, May 9, 2017 7:07:21 PM | posted by
This article opened my eyes to a phenomenon in my practice that I had no understanding of: seriously depressed clients not responding to standard treatments, somehow emerging from their depressions--- and then hearing from them again years later in the same predicament. And their anxiety was through the roof! I knew about the concordance of boplar and enaxiety disorders---but until I read Dr. Phelps did I become aware that they can be part of the same illness! I have read through Dr. Phelps website and started his book, and I am tremendously impressed by his scholarship--and unusually thoughtful concern for his patients (it comes clearly through his writing). I am afraid that this "case study" might not be read by all the NETWORKER readers and urge the NETWORKER to make the spectrum approach to mood disorders a feature that all will see. Thank you do this excellent piece!