"Have fun, and don’t worry about your work. As long as you don’t give an antidepressant to a patient with hypomania, you can’t go wrong.” It sounded easy at the time, as the attending welcomed us to the outpatient module of psychiatric residency. Fifteen years and over 10,000 structured interviews later, I can only attest to how hard it is to diagnose hypomania. Here are the top pearls I’ve learned along the way.
1 Calibrate your index of suspicion
Expert interviews suggest that hypomania is common among patients with depression. The rates range from 20% to 30% in primary care, 30% to 40% in psychiatric clinics, and, in those with treatment-resistant depression, 40% to 60%.1-4 Those numbers might suggest you need to raise your index of suspicion, or they may just trigger disbelief. My first reaction was the later, but when I started applying structured interviews to my work in a general adult private practice, I arrived at the same frequency: 40%.
2 Use a structured interview
Instruments like the MINI and the SCID are the closest we have to a gold standard in psychiatric diagnosis. Their hypomania sections, however, tend to suffer low reliability,5,6 so it’s helpful to augment them with paper-and-pencil screens that both the patient and a relative can complete. There are links to the SCID, MINI, and 3 screening tests (see http://www.moodtreatmentcenter.com/measurement).
3 Follow the clues
Psychologically, hypomania has a lot in common with addictions. Denial, lack of insight, and a tendency to minimize or forget these altered states get in the way of diagnosing them. When asking structured questions such as, “Have you ever had a period of time when you felt high, hyper, or full of energy?”, pay attention to vague answers like “not really,” “only when I’m excited,” or “not in a long time.” If your index of suspicion is high, those answers should prompt you to dig further.
Dr. Aiken is the Director of the Mood Treatment Center, Editor in Chief of The Carlat Psychiatry Report, and Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He does not accept honoraria from pharmaceutical companies but he receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, a book he coauthored with Jim Phelps, MD.
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