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When to treat subthreshold hypomanic episodes

Vol. 11, No. 08 / August 2012

According to DSM-IV-TR, the minimal duration of a hypomanic episode is 4 days.1 Should we treat patients for hypomanic symptoms that last <4 days? Could antidepressants’ high failure rate2 be because many depressed patients have untreated “subthreshold hypomanic episodes”? Aripiprazole, quetiapine, and lithium all have been shown to alleviate depression when added to an antidepressant.3-5 Is it possible that these medications are treating subthreshold hypomanic episodes rather than depression?

The literature does not answer these questions. To further confuse matters, a subthreshold hypomanic episode may not be a discrete episode. In such episodes, hypomanic symptoms may overlap at some point and the duration of each symptom may vary.

When I administer the Mood Disorder Questionnaire,6,7 I ask patients about 13 hypomanic symptoms. Patient responses to questions about 7 of these symptoms—increased energy, irritability, talking, and activity, feeling “hyper,” racing thoughts, and decreased need for sleep—can help demonstrate the variability of symptom duration. For example, a patient may complain of increased energy and irritability for 3 days, increased activity and feeling “hyper” for 2 days, increased talking and a decreased need to sleep for 1 day, and racing thoughts every day.

Alternative criteria

Considering this variation, I often use the following criteria when considering whether to treat subthreshold hypomanic symptoms:

  • ≥4 symptoms must last ≥2 consecutive days
  • ≥3 symptoms must overlap at some point, and
  • ≥2 of the symptoms must be increased energy, increased activity, or racing thoughts.

However, some patients have hypomanic symptoms that do not meet these relaxed criteria but require treatment.8 I also need to know when these episodes started, how frequently they occur, and how much of a problem they cause in the patient’s life. I often treat subthreshold hypomanic episodes with an antipsychotic or a mood stabilizer. As with all patients I see, I consider the patient’s reliability, substance abuse history, and mental status during the interview.


Dr. Wilf reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

2. Pigott HE, Leventhal AM, Alter GS, et al. Efficacy and effectiveness of antidepressants: current status of research. Psychother Psychosom. 2010;79(5):267-279.

3. Nelson JC, Pikalov A, Berman RM. Augmentation treatment in major depressive disorder: focus on aripiprazole. Neuropsychiatr Dis Treat. 2008;4(5):937-948.

4. Daly EJ, Trivedi MH. A review of quetiapine in combination with antidepressant therapy in patients with depression. Neuropsychiatr Dis Treat. 2007;3(6):855-867.

5. Price LH, Carpenter LL, Tyrka AR. Lithium augmentation for refractory depression: a critical reappraisal. Prim Psychiatry. 2008;15(11):35-42.

6. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-1875.

7. The Mood Disorder Questionnaire. Accessed June 20 2012.

8. Angst J, Azorin JM, Bowden CL, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry. 2011;68(8):791-798.

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