Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania

Background: The boundaries of bipolarity have been expanding over the past decade. Using a well characterized epidemiologic cohort, in this paper our objectives were: (1) to test the diagnostic criteria of DSM-IV hypomania, (2) to develop and validate criteria for the definition of softer expressions of bipolar-II (BP-II) disorder and hypomania, (3) to demonstrate the prevalence, clinical validity and comorbidity of the entire soft bipolar spectrum. Methods: Data on the continuum from normal to pathological mood and overactivity, collected from a 20-year prospective community cohort study of young adults, were used. Clinical validity was analysed by family history, course and clinical characteristics, including the association with depression and substance abuse. Results: (1) Just as euphoria and irritability, symptoms of overactivity should be included in the stem criterion of hypomania; episode length should probably not be a criterion for defining hypomania as long as three of seven signs and symptoms are present, and a change in functioning should remain obligatory for a rigorous diagnosis. (2) Below that threshold, ‘hypomanic symptoms only’ associated with major or mild depression are important indicators of bipolarity. (3) A broad definition of bipolar-II disorder gives a cumulative prevalence rate of 10.9%, compared to 11.4% for broadly defined major depression. A special group of minor bipolar disorder (prevalence 9.4%) was identified, of whom 2.0% were cyclothymic; pure hypomania occurred in 3.3%. The total prevalence of the soft bipolar spectrum was 23.7%, comparable to that (24.6%) for the entire depressive spectrum (including dysthymia, minor and recurrent brief depression). Limitation: A national cohort with a larger number of subjects is needed to verify the numerical composition of the softest bipolar subgroups proposed herein. Conclusion: The diagnostic criteria of hypomania need revision. On the basis of its demonstrated clinical validity, a broader concept of soft bipolarity is proposed, of which nearly 11% constitutes the spectrum of bipolar disorders proper, and another 13% probably represent the softest expression of bipolarity intermediate between bipolar disorder and normality.