NUR 647 Neuroscience of Psychopharmacology for Advance Practice Nurses
Differentiating Hypomania from Mania
Hypomania and mania share overlapping clinical features but differ in severity, duration, and impact. Hypomania is defined as at least four consecutive days of an elevated, expansive, or irritable mood accompanied by increased energy or activity. Symptoms include decreased need for sleep, rapid speech, distractibility, and risk-taking behavior. However, hypomania does not cause marked impairment in daily functioning, and hospitalization is not required. Psychotic symptoms are never present. Mania, in contrast, persists for at least seven days, or less if hospitalization becomes necessary, and significantly impairs work, social, or academic performance. Psychosis may occur in mania, adding to its severity (Parker et al., 2021). Clinicians assess symptom intensity, duration, and consequences on functioning to make a diagnosis. Recognizing the difference is essential because treatment approaches vary depending on whether a patient experiences hypomania or mania.
Role of Lamotrigine in Bipolar Disorder Treatment
Lamotrigine is a commonly prescribed mood stabilizer used in the treatment of bipolar disorder, particularly effective in preventing depressive episodes. Unlike lithium or valproate, it is not considered highly effective for acute mania. Its major advantage lies in its ability to stabilize mood and prevent relapses into depression, which is the dominant phase in bipolar II disorder. Lamotrigine works by inhibiting voltage-gated sodium channels and modulating glutamate release, helping stabilize neuronal firing. It is generally well tolerated with fewer side effects, such as weight gain or sedation, compared to other medications (Singh et al., 2025). The most important clinical consideration is the need for slow titration to reduce the risk of serious rash, including Stevens–Johnson syndrome. Lamotrigine’s favorable side-effect profile and strong effect on bipolar depression make it a valuable maintenance treatment option.
Antidepressants in Bipolar II Disorder
Antidepressants are prescribed cautiously in bipolar II disorder due to their potential to destabilize mood. Monotherapy with antidepressants increases the risk of triggering hypomanic or manic episodes, as the overstimulation of neurotransmitter systems may worsen cycling. Another concern is rapid cycling, where mood episodes occur more frequently, reducing treatment effectiveness. Clinical guidelines recommend avoiding antidepressant use without a concurrent mood stabilizer such as lithium, lamotrigine, or an atypical antipsychotic (Singh et al., 2025). When antidepressants are considered, they must be carefully monitored and only used in cases of severe or treatment-resistant depression. Combination therapy helps balance the benefits of symptom relief with the risks of switching. This cautious approach emphasizes the need to prioritize mood stabilizers first, reserving antidepressants for situations where depressive symptoms remain highly impairing despite other interventions.
Lifestyle Interventions to Reduce Relapse Risk
Lifestyle interventions are central to relapse prevention in bipolar disorder. Maintaining regular sleep and wake cycles supports the stability of the circadian rhythm, which in turn reduces vulnerability to mood swings. Structured daily routines provide predictability and minimize stress triggers. Physical activity has been shown to improve mood regulation, increase energy levels, and reduce depressive symptoms. Nutrition also plays a crucial role, with a balanced diet and adequate omega-3 fatty acids supporting brain function (Singh et al., 2025). Patients are advised to avoid alcohol and recreational drugs because these substances interfere with medications and contribute to mood instability. Building social support systems and engaging in psychoeducation empower patients to recognize early relapse signs. Incorporating mindfulness, relaxation practices, and therapy further enhances coping skills. These lifestyle approaches complement pharmacological management and significantly reduce the frequency and severity of relapses.
Screening Tools for Tracking Mood Changes
Several screening and monitoring tools assist in diagnosing and tracking mood fluctuations in bipolar disorder. The Mood Disorder Questionnaire (MDQ) is widely used to screen for bipolar symptoms, helping distinguish bipolar depression from unipolar depression. The Hypomania Checklist (HCL-32) is helpful in identifying subtle hypomanic features (Shen et al., 2024). Clinicians also use the Young Mania Rating Scale (YMRS) to measure the severity of manic or hypomanic symptoms. Depressive symptoms can be evaluated using the Patient Health Questionnaire-9 (PHQ-9). Additionally, mood charting methods and mobile applications enable patients to track daily changes in mood, sleep, and energy, providing both patients and clinicians with valuable insights. These tools support accurate diagnosis, track treatment progress, and improve patient engagement by fostering awareness of mood cycles, ultimately reducing relapse risk and improving outcomes.
References
Parker, G., Spoelma, M. J., Tavella, G., Alda, M., Hajek, T., Dunner, D. L., & Manicavasagar, V. (2021). Differentiating mania/hypomania from happiness using a machine learning analytic approach. Journal of Affective Disorders, 281, 505–509. https://doi.org/10.1016/j.jad.2020.12.058
Shen, G., Chen, H., Ye, X., Xue, X., & Tang, S. (2024). Machine learning-driven simplification of the Hypomania Checklist-32 for adolescents: A feature selection approach. International Journal of Bipolar Disorders, 12(1), 42. https://doi.org/10.1186/s40345-024-00365-4
Singh, B., Swartz, H. A., Cuellar-Barboza, A. B., Schaffer, A., Kato, T., Dols, A., & Frye, M. A. (2025). Bipolar disorder. The Lancet, 406(10506), 963–978. https://doi.org/10.1016/S0140-6736(25)01140-7
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Case Study: Bipolar II Disorder – NP Review
Patient Name: Maria S. (fictional)
Age: 25
Sex: Female
Occupation: Graduate student in graphic design
Marital Status: Single
Living Situation: Rents an apartment with two roommates
Insurance: Student health plan
Chief Complaint
“I’ve been feeling really down again, but a couple of weeks ago I couldn’t stop working on my art and barely slept.”
History of Present Illness (HPI)
Maria presents to the campus mental health clinic for worsening depressive symptoms over the past 3 weeks — low mood, fatigue, excessive guilt, and difficulty concentrating. She reports oversleeping (10–12 hours per night), withdrawing from friends, and eating less than usual.
Two months ago, she experienced a period of elevated mood lasting 6 days where she:
- Slept only 3–4 hours per night but did not feel tired
- Completed multiple creative projects at once
- Spent over $800 on art supplies she didn’t need
- Spoke quickly and felt “unstoppably confident”
She states that the elevated mood did not cause major problems at the time, but friends noticed she was “talking a mile a minute.” No psychosis was reported.
Psychiatric History
- Diagnosed with Bipolar II disorder at age 23 after similar mood pattern
- Previous medications: lamotrigine (helpful), sertraline (caused rapid mood cycling)
- One prior psychiatric hospitalization at age 22 for suicidal ideation during a depressive episode
- Currently prescribed lamotrigine 100 mg PO daily, but admits to missing several doses last month
Medical History
- Migraine headaches (managed with PRN sumatriptan)
- No chronic medical illnesses
- No known allergies
Family History
- Mother: Major depressive disorder
- Father: Alcohol use disorder
- Paternal aunt: Bipolar disorder
Social History
- Non-smoker
- Drinks alcohol socially (1–2 drinks/week)
- No recreational drug use
- Supportive friend group; close to her mother
- Enjoys painting and hiking when well
Mental Status Examination (MSE)
- Appearance: Well-groomed, casual clothing
- Behavior: Cooperative but slowed psychomotor activity
- Speech: Low volume, slowed rate
- Mood: “Low and unmotivated”
- Affect: Constricted
- Thought Process: Linear and goal-directed
- Thought Content: No hallucinations or delusions; reports feelings of worthlessness
- Insight/Judgment: Fair insight into illness; good judgment regarding safety
- Cognition: Alert and oriented ×3; concentration mildly impaired
Assessment
Primary diagnosis: Bipolar II disorder – current episode: major depression
Differential diagnoses to consider:
- Major depressive disorder (single or recurrent)
- Cyclothymic disorder
- Borderline personality disorder
- ADHD (for overlapping distractibility symptoms)
Plan
- Medication Management
- Continue lamotrigine; consider titration to 200 mg/day for better mood stabilization.
- Discuss possible addition of low-dose quetiapine for bipolar depression if symptoms persist.
- Avoid antidepressant monotherapy due to risk of mood switching.
- Psychoeducation
- Review importance of medication adherence.
- Discuss early warning signs of hypomania and depression.
- Therapy/Support
- Continue weekly cognitive behavioral therapy (CBT).
- Encourage structured daily routine and regular exercise.
- Safety Planning
- Review crisis resources and develop a plan for worsening depression or suicidal thoughts.
- Follow-up
- Reassess in 2 weeks to evaluate mood changes and medication tolerance.
Discussion Questions
- How do you differentiate hypomania from mania in clinical assessment?
- What is the role of lamotrigine in bipolar disorder treatment?
- Why should antidepressants be used cautiously in bipolar II disorder?
- What lifestyle interventions can help reduce relapse risk?
- Which screening tools can be useful for tracking mood changes in bipolar disorder?