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Review Article | DOI: https://doi.org/10.31579/2578-8868/407
Neurobiology of Anxiety and mood disorders, Nantes University, 98 rue Joseph Blanchart, 44100 Nantes. France.
*Corresponding Author: Michel Bourin, Neurobiology of Anxiety and mood disorders, Nantes University, 98 rue Joseph Blanchart, 44100 Nantes. France.
Citation: Michel Bourin, (2026), Bipolar II Disorder: an Important yet often Difficult Diagnosis, J. Neuroscience and Neurological Surgery, 19(3); DOI:10.31579/2578-8868/407
Copyright: © 2026, Michel Bourin. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 04 March 2026 | Accepted: 09 March 2026 | Published: 17 March 2026
Keywords: bipolar ii disorder; hypomania; major depressive disorder; bipolar spectrum; misdiagnosis; atypical depression; mood disorders; diagnostic challenges; comorbidity; hyperthymic temperament; mixed states; prevalence
Bipolar II disorder (BD II) is a highly prevalent yet frequently underdiagnosed psychiatric condition, affecting an estimated 1-2% of adults worldwide. Despite its significant clinical and socioeconomic burden, including elevated suicide risk, chronic functional impairment, and high rates of misdiagnosis BD II was only recognized recently in diagnostic manuals. The disorder is characterized by alternating depressive and hypomanic episodes, with depressive symptomatology predominating, which often leads clinicians to mistakenly diagnose major depressive disorders or anxiety disorders. Recognizing BD II is further complicated by high comorbidity with anxiety disorders, substance-use disorders, eating disorders, and personality disorders, as well as by controversies surrounding the definition and duration of hypomania. The absence of established regulatory guidelines for BD II–specific pharmacological trials, combined with the complexity of individualized treatment regimens, has hindered evidence-based therapeutic development. Emerging research supports the existence of a broader bipolar spectrum, suggesting a continuum between unipolar depression and bipolar disorders, with BD II occupying a central transitional position. Improved diagnostic accuracy, clinician training, and recognition of atypical depressive features and subsyndromal bipolar symptoms are critical for reducing misdiagnosis and improving patient outcomes. This paper reviews the diagnostic challenges, epidemiology, clinical features, and spectrum conceptualization of BD II, emphasizing the urgent need for enhanced clinical awareness and standardized assessment tools.
The diagnosis of bipolar II disorder remains a diagnostic challenge, although it has been recognized as a distinct entity for almost 40 years [1]. It took 20 years for it to be formally incorporated into the DSM-IV. This is reflected in the epidemiology, where the prevalence is estimated at between 5 and 8%, depending on the school of psychiatry rather than the country. But traditionally lifetime prevalence is approximately 1%-2% in the general population; with 12-month prevalence around 0.5%–1%. More recent publications present a starkly contrasting view. Bipolar II disorder is considered a myth by some [2], while others argue that it is not [3].
Classically BD II is characterized by the alternation of major depressive episodes with hypomanic episodes, which may occur rapidly or evolve more slowly, depending on the individual . Despite the severity and chronicity of this condition, it remains widely under-recognized not by general practitioners, who are often the first point of contact, but even by specialists in psychiatry [4]. This diagnostic challenge has profound consequences: untreated or misdiagnosed BD II often results in devastating socio-economic impairments, such as divorce, impulsive and excessive financial spending, loss of employment, bankruptcy, and even legal problems leading to imprisonment. Most critically, the risk of suicide in BD II is markedly elevated, often higher than in Bipolar I disorder or unipolar depression. Many individuals are mistakenly prescribed antidepressants or other medications that can aggravate symptoms, precipitate mixed states, or rapid cycling, and thereby worsen the course of illness.
Why bipolar II disorder is so difficult to diagnose.
The complexity of BD II diagnosis is tied to several overlapping clinical features and very high rates of psychiatric comorbidity [5]. Patients frequently present various anxiety disorders such as panic disorder, generalized anxiety disorder, and social anxiety disorder as well as recurrent depressive episodes [6].
Because depressive symptoms dominate the clinical picture, especially early in the illness, the most common initial diagnoses include recurrent major depression, dysthymia, or generalized anxiety disorder. It is now estimated that patients wait an average of ten years between the onset of symptoms and a correct bipolar diagnosis [7].
Compounding this delay is the lack of large-scale clinical trials specifically addressing BD II. Because of the historical reluctance to distinguish BD II from other mood disorders and because regulatory agencies have not yet provided clear guidelines for drug development in BD II, clinicians face a major therapeutic impasse [8]. Many patients require complex polypharmacy, often a combination of a mood stabilizer (lithium, valproate, carbamazepine, lamotrigine) and an antidepressant or antipsychotic. These individualized therapeutic strategies, although clinically necessary, complicate standardized research methodologies [9]. To address this global difficulty, collaborative efforts such as joint training programs for general practitioners developed with Australian colleagues have emerged to improve recognition and diagnosis of BD II in community settings [10].
Clinical characteristics and diagnostic challenges
BD II shares several diagnostic features with Major Depressive Disorder [MDD]: both require the presence of a current or past major depressive episode. The essential distinction, however, is the presence of current or past hypomanic episodes in BD II [11]. It was demonstrated the low inter-rater reliability of BD II diagnosis, highlighting the need for systematic assessment instruments. While BD I is usually diagnosed with relative ease due to overt manic episodes, BD II and its variants require more careful, longitudinal, and structured evaluation [12]. Among the major reasons for diagnostic inconsistency in BD II is that these patients could present features of atypical depression and lifelong history of anxiety states, bulimia, substance abuse and personality disorder. However, hypersomnia, weight gain and related atypical features often represent an important marker of BD II. Such features may serve as a clinical marker for BD II [13].
The controversy surrounding hypomania
The definition of hypomania remains a topic of debate. In European clinical practice, hypomania is often used loosely to refer to mild mania. However, in DSM-IV, hypomania is defined as a distinct period of elevated or irritable mood lasting at least four days, accompanied by observable behavioral changes [14]. Critics argue that this duration requirement is arbitrary and excludes clinically meaningful brief hypomanic states. On the other hand, hypomania can be defined as a milder form of mania. It is a period of persistently elevated, expansive, or irritable mood that lasts for at least four days and up to a week [15].
Studies using broader or modified definitions have found even higher prevalence of BD II. It was reported that 5.3% of community volunteers met “hard criteria” (hypomania with consequences) while another 5.7% met “soft criteria” (hypomanic symptoms without major consequences), yielding a total prevalence of 11%. Notably, the two BD II subgroups differed significantly from MDD but not from each other, supporting the idea that they belong to a unified bipolar diagnostic category [16].
Bipolar II disorder and the mood disorder continuum
A critical unresolved question in modern psychiatry is whether psychiatric syndromes exist as discrete categories or lie along continuum-based spectrums. Growing evidence suggests the latter, particularly for the relationship between BD II and MDD [17]. Even a single bipolar symptom within a depressive episode such as irritability, racing thoughts, or psychomotor agitation may tip the diagnosis toward BD II. Recurrent MDD is especially likely to evolve into bipolarity over time [18].
Up to 40% of patients with recurrent MDD report significant lifetime hypomanic symptoms, despite never having been diagnosed with BD II [19]. Conversely, long-term follow-up studies of patients with diagnosed bipolar disorders show that depressive symptoms dominate the illness course far more frequently than manic or hypomanic symptoms [20], a pattern particularly pronounced in BD II. Furthermore, patients with unipolar depression who later convert to bipolarity commonly present with retarded depressions, characterized by hypersomnia, psychomotor slowing, lethargy, and, in some cases, psychotic features [21]. These findings strengthen the view that BD II may sit mid-continuum between unipolar depression and Bipolar I disorder.
The bipolars spectrum concept
Increasingly, researchers recognize that BD includes a broader spectrum of disorders than the traditional BD I and BD II classifications [22]. Debates surrounding the definition of pathological mood elevation and the reluctance to pathologize elevated or “high functioning” mood states have created challenges in defining the full bipolar spectrum. Young & Klerman [23] proposed six clinical states, while Akiskal & Pinto [24] proposed seven subtypes, encompassing milder or subsyndromal bipolar variants not captured by DSM-IV or ICD-10 .
Importantly, the bipolar spectrum model does not discard existing diagnostic categories but extends them, accommodating a wider range of mood dysregulations. This model also helps address the high rates of comorbidity seen in categorical systems by recognizing that many overlapping symptoms may reflect bipolarity rather than entirely separate disorders (25).
Family studies strongly support this spectrum. The relatives of BD probands show not only higher rates of full bipolar disorder but also increased prevalence of milder bipolar features and other psychiatric conditions [26]. A study reported that two-thirds of bipolar probands may fall somewhere within the bipolar spectrum [27].
Prevalence estimates for the broader bipolar spectrum range from 3% to 6.5% [28] and, in some studies, as high as 10–12% [29]. Remarkably, up to 30% of primary care patients presenting with anxiety and/or depressive symptoms meet criteria for a bipolar spectrum disorder [30]. Even subsyndromal depressive symptoms can lead to significant functional impairment for individuals on the bipolar spectrum [31].
The bipolar spectrum concept encompasses not only major episodes—mania, hypomania, and major depression but also mixed states, hyperthymic temperament, and depressive mixed states, characterized by severe irritability, racing thoughts, extreme fatigue, panic attacks, and suicidal impulses [32].
Hyperthymic temperament, often seen in BD II and bipolar spectrum disorders, is associated with high energy, sociability, ambition, and productivity but also with risk-taking behavior and interpersonal conflict [33]. These “milder” or temperament-based forms of bipolarity may in fact be more common than Bipolar I disorder [34].
The spectrum model also helps explain misdiagnosis and underdiagnosis. Patients frequently present with atypical depressions, lifelong anxiety, eating disorders, or substance misuse, which may obscure the underlying bipolarity. Recognizing these bipolar spectrum states may bridge the conceptual and diagnostic gap between unipolar and bipolar disorders, supporting the notion of a unified mood disorder continuum.
Bipolar II disorder remains a profoundly underrecognized and diagnostically challenging condition despite four decades of clinical acknowledgment. Its predominance of depressive episodes, high psychiatric comorbidity, and often subtle or retrospective hypomanic features contribute to frequent misclassification such as unipolar depression or anxiety disorders. These diagnostic complexities carry substantial clinical consequences, including prolonged delays to accurate diagnosis, inappropriate treatment with antidepressants, and heightened risks of chronic functional impairment and suicide.
Emerging research underscores that BD II rarely exists as an isolated phenotype; rather, it occupies a central position within a broader bipolar spectrum characterized by mixed features, subthreshold symptoms, hyperthymic temperaments, and atypical depressive presentations. This dimensional perspective provides a more comprehensive framework for understanding the heterogeneity of mood disorders and may help reconcile the inconsistencies inherent in strict categorical systems.
At the same time, the absence of regulatory guidance for BD II specific therapeutic trials and the prevailing reliance on individualized polypharmacy highlight the urgent need for more rigorous, standardized research. Improving diagnostic precision will depend on enhanced clinician training, systematic use of structured assessments, and increased awareness of atypical and mixed depressive features that frequently signal underlying bipolarity.
A better integration of spectrum-based models with contemporary diagnostic criteria, combined with sustained efforts to educate clinicians and refine treatment strategies, will be essential to reducing misdiagnosis and improving outcomes for the substantial number of individuals living with Bipolar II
disorder. Ultimately, recognizing BD II not as a rare or ambiguous variant but as a common, clinically impactful mood disorder is critical to advancing both research and patient care.
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Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
Dear Grace Pierce, Editorial Coordinator of the journal IJCCR, I had a very positive experience with Auctores - Journal throughout the publication process. The Editorial Team was highly responsive, professional, and supportive at every stage. I would like to extend my sincere thanks to the Editor: Grace Pierce, for her guidance and assistance. The peer-review process was smooth and constructive, helping improve the quality of my work. I would gladly recommend Auctores Journal to fellow researchers and authors. Dr. SABITA SINHA, Medical Oncologist, MD (Electro Homeopathy).
Dear Maria Emerson, Editorial Coordinator of - Journal of Clinical Research and Reports. ''I am pleased to provide this testimonial following the publication of our recent case report in this journal. The peer review process was rigorous, constructive, thorough, and conducted in a timely manner. The reviewers’ comments were thoughtful, detailed, and highly constructive, contributing substantially to the refinement, clarity, and scientific robustness of our manuscript. The process was conducted with professionalism and academic integrity throughout. The support provided by the editorial office was exemplary. Communication was consistently prompt, clear, and courteous at all stages of the submission and publication process. The editorial team demonstrated a high level of organization and responsiveness, ensuring that all queries were addressed efficiently and that the process remained transparent and well-coordinated. The overall quality of the journal is reflected in its strong editorial standards, commitment to scientific excellence, and dedication to publishing clinically meaningful research. It has been a privilege to publish our work in this journal, and we would welcome the opportunity to contribute further in the future.'' Best wishes from, Dr. Efstratios Trogkanis, Cardiologist.
Dear Reader: We have published several articles in the Auctores Publishing, LLC, journal, Clinical Medical Reviews and Reports in recent years (CMRR). This is an ‘open access’ journal and the following are our observations. From the initial invitation to submit an article, to the final edits of galley proofs, we have found CMRR personnel to be professional, responsive, rapid and thorough. This entire process begins with Catherine Mitchell, Editorial Coordinator. She is simply outstanding, and, I believe, unparalleled in her capacity. I cannot imagine a more responsive and dedicated Editorial Coordinator. As I read the dates and timing of her correspondence with us, it seems that she never sleeps. I hope Auctores Publishing, LLC, appreciates her efforts as much as these authors do. Thank you to Auctores Publishing, LLC, to the Editorial Staff/Board, and to Catherine Mitchell from a grateful author(s).
