This column offers a question-and-answer forum to help nurses maintain their knowledge of advances in prescribing and psychopharmacology, and implications for safe psychiatric care. Send your questions related to prescribing psychotropic medications to the Editor, Mary Paquette, at mary@artwindows.com. ********** Question: One of my clients presented with symptoms of major depression. I prescribed one of the novel antidepressants. During a case conference, I was asked if bipolar (BP) II had been ruled out, because the client developed hypomania shortly after initiation of antidepressant treatment. Please discuss treatment considerations for the client with BP II depression. Deborah Antai-Otong responds: Historically, BP II has been underused and misdiagnosed as unipolar major depressive disorder. Both the client and clinician have missed or minimized hypomania or mild mania if it occurred in clients with atypical depression. Differences between BP II depression and unipolar depression include lower age at onset, more atypical features, more recurrences, and higher heritability in the former (Benazzi, 1999; Rush, 1998). Additional differences between bipolar II and unipolar depression include a higher prevalence of and natural history of depressive mixed states in bipolar II, which is rare in unipolar major depression. Clinical implications from these differences are that monotherapy with antidepressants in BP II depression worsen depressive mixed states, and clients seem to respond better to mood stabilizers (Benazzi & Akiskal, 2001). By definition, clients with BP II have recurrent major depressive episodes with a lifelong history of one or more hypomanic episodes of at least 4 days duration, and never mania (American Psychiatric Association [APA], 2000; Cassano et al., 1999). In contrast, symptoms of unipolar major depression occur without a history of hypomania or mania. An estimate of lifetime prevalence of BP II ranges from 0.3% to 2.0% and is more commonly found in women than in men (APA, 1994, 2000). BP II depression seems more resistant to conventional treatment than BP I (history of mania). Depressive states account for high morbidity and are strongly linked with suicidal behavior and sustained psychosocial impairment, placing a tremendous toll and burden on clients and families, and economic cost to society (APA, 2000; Rush, 1998; Woods, 2000). A major challenge for psychiatric nurses is making an accurate diagnosis of BP II and implementing appropriate treatment. Predictably, a misdiagnosis of unipolar disorder often results in inappropriate treatment, such as monotherapy with an antidepressant, which induces mood instability in the absence of more suitable pharmacotherapy with mood stabilizers and atypical antipsychotics (Akiskal et al., 2000). Assessment and Diagnosis Considerations A complete psychiatric and medical workup must be performed to determine the diagnosis. A complete physical includes: * Vital signs * Complete blood count with differential * Chemistry profile ('include serum electrolytes, glucose, hepatic, renal, and thyroid panels) * Pregnancy test (when appropriate) * Urinalysis * Urine drug screens * 12-lead electrocardiogram (Suppes & Dennehy, 2002) The psychosocial evaluation includes a comprehensive mental status examination, and suicide and homicide assessment. It must include information about history of symptoms, to include age of onset, length of mood cycle, history of rapid cycling (e.g., 3-4 cycles within 12 months); frequency of hypomania; and questions such as Have you ever had a time in your life when you had a lot of energy, did not need a lot of sleep and felt creative? Clients with BP II infrequently consider their hypomanic symptoms to require treatment. Normally, they seek treatment during a depressive episode. …