Understanding Mania, Hypomania and Depression

This blog post provides an overview of mood disorders, focusing on the distinctions between mania, hypomania, and depression. The article also discusses the prevalence of bipolar and depressive disorders in India, explores the complex interplay of genetic, psychological, and social factors contributing to their development.

Emotions are an integral part of the human experience. While we all experience moments of joy, hope, sadness or despair, a person might experience these emotions more intensely for prolonged periods that can be debilitating in nature and could deteriorate one’s quality of life. Such concerns come under the umbrella term of “mood disorders”- a psychiatric condition that alters an individual’s emotional state and deeply affects one’s ability to function normally in different aspects of life, whether personal or professional. 

What are mood disorders?

According to ICD-11, two broad categories of mood disorders include Depressive and Bipolar Disorders. Someone with depression may report feeling extremely low or numb; lacking the motivation and energy to do basic tasks like bathing, getting dressed, interacting with people, difficulty concentrating and making simple decisions. Bipolar disorders, on the other hand, include episodes of both mania as well as depression. As a flipside to depression, someone experiencing a manic episode might report feeling overly energised and elated, which can lead to them being impulsive, making them susceptible to risky behaviours such as rash driving, excessive splurging or gambling. 

In the following sections, we’ll explore the diagnostic criteria, clinical features, prevalence, aetiology and intervention for each of the sub-categories of mood disorders, along with a case study for each (identity will be hidden or altered for confidentiality). Signs and symptoms of mood disorders can be categorised into emotional, cognitive, somatic and behavioural symptoms. 

Understanding mania and hypomania

N, a 21-year-old male and an undergrad student, reported feeling "high and unstoppable" for the past two weeks, followed by periods of extreme fatigue and sadness. Upon probing, he mentioned how a week back he felt really low and isolated himself from his friends, but now, there was a sudden, unexplainable switch in his mood and energy levels. He was skipping from one topic to another rapidly and shifting multiple times in his seat.

 “Compared to last week, I suddenly feel amazing! Like I’m invincible and capable of doing anything. My brain is going a million miles an hour. I can’t keep up with my thoughts. I just quit my job without thinking about it. It felt like the right thing to do at the time. I’ve also been spending a lot of money—buying things I don’t need, but it feels exciting. I just feel so good lately, like I'm on top of the world. I can't seem to calm down.”

Manic and hypomanic episodes

According to ICD 11, a manic episode is an extreme mood state lasting at least one week characterised by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior, and rapid changes among different mood states (i.e., mood lability). 

A hypomanic episode, on the other hand, is an episode of increased energy that is not sufficiently severe to qualify as full-blown mania. Someone who has experienced at least one manic episode would be diagnosed with Bipolar I, whereas a person who has experienced at least one major depressive episode, at least one hypomanic episode, and no full-blown manic episodes would be assigned a diagnosis of bipolar II disorder (Oltmanns & Emery, 2012). 

Unlike ‘joy’ or ‘happiness’, the euphoria experienced in mania can become ruinous when prolonged. It carries poor judgment and impulse control with it, leading to painful consequences in the short and long term. 

For instance, in N’s case, he made an impulsive decision to quit his job. It can also possibly turn into extreme irritability or even aggressiveness and hostility, especially if other people thwart their unrealistic and grandiose plans. Due to racing thoughts, people with mania can be easily distracted, which can impact the quality of their work. Reduced need for sleep is one of the earliest signs of the onset of an episode. During an episode, people are typically gregarious and energetic and can indulge in inappropriate flirtatious and provocative behaviour. 

According to the National Mental Health Survey published in 2016, the lifetime prevalence of bipolar disorders in India was 0.5%. It also reported that the prevalence of males was higher than that of females (0.6% as opposed to 0.4%). 

Although the aetiology of mania, and more generally, bipolar I disorder, is not known, there is strong evidence that the cause is a combination of genetic, psychological, and social factors. There have been multiple studies involving families which show a definite genetic component (Dailey & Saadabadi, 2023). Stressful life events have been majorly investigated in depression. However, research also suggests that weeks preceding the onset of a manic episode are marked by an increased frequency of stressful life events (Miklowitz & Johnson, 2009). 

Understanding depression

M, a 25-year-old female, has been preparing for competitive exams for the past year. She entered the room with her shoulders slouched and her eyes gazing at the floor.

“I don’t feel like doing anything. My exams are approaching, and I’m worried about it, but there’s no motivation to study at all. I can barely concentrate, no matter how hard I try. I feel so exhausted. I’ve stopped playing badminton, which I earlier thoroughly enjoyed. I find it difficult to sleep, and I’m binge eating comfort food all the time. My friends reach out to me, but I ignore their calls and then feel guilty about it. I’m a horrible person. I’m such a failure. Sometimes I wonder, what’s the point of living?” 

Diagnostic criteria for depressive episodes

Based on ICD 11, a depressive episode is diagnosed when an individual experiences a depressed mood or diminished interest in activities for at least 2 weeks, accompanied by other symptoms such as change in sleep and appetite; mental and physical fatigue; difficulty concentrating; feelings of hopelessness, worthlessness and helplessness; excessive or inappropriate guilt and recurrent thoughts of death or suicide. 

In addition to feeling gloomy, dejected or despondent, people with depression also experience irritability and anxiety, due to which they might lash out at people, overthink and find it difficult to unwind. Depression not only impacts a person’s emotional state, but it also alters a person’s beliefs about themselves and their surroundings. They might believe that they are inadequate and unloved, which can lead to self-destructive ideas and death wishes. The thinking process slows down, and the person can find it hard to concentrate and get easily distracted. Basic physiological or bodily functions are also affected and can be manifested in the form of serious changes in appetite and sleep. An individual might sleep/ eat too much or too less. As seen in the above case, M was experiencing disturbed sleep and an increase in appetite. Constant fatigue can make routine tasks seem overwhelmingly difficult. 

A depressive episode can be experienced in isolation as unipolar depression or a part of bipolar disorder, along with episodes of mania or hypomania. Other forms include persistent depressive disorder (formerly known as dysthymia, it refers to low mood lasting for at least 2 years with symptoms relatively less intense compared to major depression), seasonal affective disorder or SAD (a type of depression experienced during winters as days get shorter affecting the circadian rhythm), perinatal and postnatal depression- that occurs during pregnancy and in the first 12 months after delivery respectively and premenstrual dysphoric disorder or PMDD, which is a severe form of premenstrual syndrome. 

According to a report released by the WHO in 2017, the estimated prevalence of depressive disorders in India is 4.5% of the population. It is 50% more common among women than men. 

Depression, like most mental health concerns, is not a direct product of a particular cause. It often results from a complex interplay between various social, psychological and biological factors. Social factors include the history of and/or ongoing abuse, and stressful life events such as getting fired from a job, loss of a loved one, dysfunctional home environment. Several psychological factors, such as an inherent predisposition to pessimistic thinking and maladaptive core beliefs about oneself (eg, “ I am unlovable”; “I am a failure”) developed as a result of adverse childhood experiences, can make a person more vulnerable to experiencing depression. Family history; dysfunction of the hypothalamic–pituitary–adrenal (HPA) axis; abnormal patterns of activity and structural changes in the limbic system and the interactive effects of certain neurotransmitters like serotonin, norepinephrine, dopamine and neuropeptides are some of the known biological factors involved in the development of depression (Stockmeier, 2003). Certain demographic factors, such as age, gender and socio-economic status, can also make one more susceptible to depression than others. For instance, the geriatric population, women, and those who belong to a low socio-economic background are more vulnerable to the same (Falghum, 2024). 

Intervention

Due to the complexity of aetiology and manifestation of symptoms, mood disorders often require a holistic treatment approach that encompasses medication, psychotherapy and lifestyle changes. 

Medication

Selective serotonin reuptake inhibitors (SSRIs), tricyclics (TCAs) and monoamine oxidase inhibitors (MAOIs) are often prescribed for unipolar depression, whereas mood stabilisers remain the first choice for treating bipolar (Bauer & Mitchner, 2004). Those who don’t respond to mood stabilisers are prescribed anticonvulsant drugs, particularly carbamazepine (Tegretol) or valproic acid (Depakene) (Walden et al., 1998). People with bipolar disorder are also prescribed antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel).

Psychotherapy

The route of psychotherapy varies depending on the school of thought from which depression is viewed. For instance, psychodynamic procedures emphasise the role of dysfunctional relationships with people as a presumable root of negative emotions, leading to hostility and frustration directed towards oneself. On the other hand, cognitive therapy targets on altering one’s negative perception of the environment and oneself (Dobson, 2008). Apart from bringing change to one’s negative thinking, the CBT model includes behavioural components such as behavioural activation that focuses on including tasks that bring pleasure (eg, hobbies) and a sense of mastery or achievement (eg, routine tasks like folding laundry). Interpersonal psychotherapy is a contemporary treatment approach that focuses on current relationships and helps one comprehend the interpersonal problems that presumably give rise to depression (Bleiberg & Markowitz, 2008). A variation on interpersonal therapy, known as interpersonal and social rhythm therapy, has been developed for treating bipolar (Frank, 2005) that facilitates people in leading more orderly lives, especially with regard to sleep–wake cycles, and to resolve interpersonal problems effectively.

Talk therapy might not be sufficient for those with severe depression or bipolar and they might require brain stimulation therapies such as electroconvulsive therapy (ECT). Transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) can also be used for treating severe depression. 

Lifestyle Changes

While lifestyle changes such as getting regular exercise, getting quality sleep, eating a healthy diet, avoiding alcohol (which is a depressant) and spending time with loved ones might be considered to be inadequate to treat mood disorders, they prove to be a vital adjunct to traditional intervention methods.