What is the difference in diagnosis and treatment between mania and hypomania in an adult patient with a possible history of mood disorders presenting with symptoms of elevated mood?

Mania versus Hypomania: Key Diagnostic and Treatment Differences

The critical distinction between mania and hypomania lies in duration (mania ≥7 days vs. hypomania ≥4 days), severity of impairment (mania causes marked functional impairment or requires hospitalization while hypomania does not), and presence of psychotic features (present only in mania). 1, 2, 3

Core Diagnostic Criteria

Mania

• Requires abnormally and persistently elevated, expansive, or irritable mood with increased energy lasting at least 7 days (or any duration if hospitalization is required) 1, 2
• Must include at least 3 additional symptoms (4 if mood is only irritable): inflated self-esteem/grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased goal-directed activity or psychomotor agitation, and excessive involvement in high-risk activities 2, 3
• Causes marked impairment in social or occupational functioning or necessitates hospitalization to prevent harm 3
• May include psychotic features such as paranoia, confusion, or florid psychosis 4, 3
• Represents a significant departure from baseline functioning that is evident across multiple life domains, not just reactions to specific situations 2, 4

Hypomania

• Requires the same symptom profile as mania but lasting only 4 days minimum 1, 3
• Observable change in functioning that does NOT cause marked impairment in social or occupational functioning 3
• Does not require hospitalization and lacks psychotic features 3
• Often associated with increased (rather than decreased) functioning, which helps distinguish it from mania 3
• Frequently goes unrecognized because patients may not feel ill or seek treatment during these episodes 5

Critical Diagnostic Pitfalls to Avoid

• Decreased need for sleep (not just insomnia) is pathognomonic for mania in adults, though this appears in less than 50% of juvenile cases 1, 6
• Irritability alone cannot distinguish between mania and hypomania—both can present with irritable mood, so duration and functional impairment become the determining factors 6, 3
• Hypomania is frequently missed in clinical practice: epidemiological studies show bipolar II disorder (which requires hypomania) has a 5% lifetime prevalence, yet it remains severely underdiagnosed, with up to 50% of depressed outpatients potentially having bipolar II 3
• Distinguish true mania/hypomania from behavioral activation caused by antidepressants: activation typically occurs within the first month of SSRI treatment and improves quickly with dose reduction, whereas true hypomania may appear later and persists despite medication changes 2
• Do not confuse brief mood reactivity with hypomania: mood changes in hypomania are sustained and autonomous over days, not merely reactive shifts lasting minutes to hours 6

Symptom Profile Differences

When comparing bipolar I (mania) to bipolar II (hypomania), mania shows significantly higher rates of reckless activity, distractibility, psychomotor agitation, irritable mood, and increased self-esteem—these five symptoms correctly classify over 80% of cases 7

Treatment Implications

For Hypomania

• Treat hypomania even when associated with increased functioning, as depression often follows quickly (the hypomania-depression cycle) 3
• Mood-stabilizing agents (lithium, valproate) and second-generation antipsychotics (olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole) are effective 2, 3

For Mania

• Aripiprazole, asenapine, carbamazepine, olanzapine, and ziprasidone show the strongest evidence for acute-phase treatment of mania, with quetiapine and divalproex/valproate also efficacious 8
• For maintenance treatment, olanzapine and quetiapine (alone or combined with lithium/divalproex) demonstrate the strongest evidence 8
• Lithium remains the only preventive treatment supported by multiple controlled studies for preventing both depression and hypomania recurrences 3

Mixed Features Considerations

• Depressed, manic, or hypomanic states occurring together carry increased suicide risk and require close monitoring, especially in the first months of treatment 2
• When treating mixed presentations, combination therapies with atypical antipsychotics and mood stabilizers should be considered in severe cases 8
• Antidepressants may worsen concurrent intradepression hypomanic symptoms in mixed states and should be used cautiously 3

Assessment Strategy

• Use a longitudinal life chart to map the temporal course of episodes, documenting duration, severity, functional impairment, and treatment response to distinguish episodic illness from chronic temperamental traits 4, 6
• Evaluate family psychiatric history, as strong genetic loading for bipolar disorder increases likelihood of true bipolar illness 4
• Probe specifically for history of overactivity (increased goal-directed activity) in addition to mood changes when screening for hypomania, as patients often don't recognize or report these episodes 3
• Assess whether symptoms are evident across different life domains versus isolated to specific settings or triggers 2, 4