Case briefing
The working hypothesis is a mood disorder, with the primary differential being between Bipolar II Disorder and Recurrent Depressive Disorder. The client, a 33-year-old male, presents with a one-year history of cyclical 'heavy depressive states,' significant hopelessness, and disrupted sleep, which supports this hypothesis. The most critical gap in the current data is the nature of the intervening 'okay' periods; it is essential to screen for hypomanic symptoms to rule a bipolar diagnosis in or out. His own uncertainty about whether life events are the cause warrants exploration of psychosocial stressors. Further assessment is needed to quantify the full range of depressive and anxiety symptoms and to assess for suicide risk given his stated hopelessness and feelings of meaninglessness.
6A61.1 Bipolar type II disorder, current episode depressed · working (50%)
Still to find out · 42 (questions to answer at the next visit)
Complete a safety plan with the client
Crisis indicators are present and no safety plan is on file.
Administer PHQ-9 + GAD-7 to set a baseline
Progress can only be measured against a starting point.
You mentioned that 'sometimes I become okay'. Can you describe what those 'okay' periods are like? Do you ever have times with much more energy than usual, where you need less sleep but don't feel tired, or your thoughts are racing?
To directly screen for hypomanic episodes, which is the key differentiator between Bipolar Disorder and Recurrent Depression.
During the 7-8 day periods when your sleep is poor, what is your energy level like during the day? Do you feel exhausted from lack of sleep, or do you feel surprisingly energetic and productive?
To differentiate between insomnia with fatigue (common in depression) and a decreased need for sleep with high energy (a hallmark of hypomania).
You mentioned 'heavy hopelessness' and a feeling that life has no meaning. Have you had any thoughts that life is not worth living, or thoughts of harming yourself?
To directly assess for suicidal ideation, which is a critical safety concern indicated by his statements.
Can you tell me more about your work as an entrepreneur? What have the last year's challenges and successes been like?
To explore potential life stressors that could be contributing to or triggering his mood episodes, relevant to the Adjustment Disorder differential.
Has anyone in your family—parents, siblings, or other relatives—ever struggled with their mood, been diagnosed with depression or bipolar disorder, or had periods of being unusually high or low?
To assess for a family history of mood disorders, which is a significant risk factor.
How do these mood cycles affect your work, your ability to make decisions, and your relationships with others?
To assess the level of functional impairment during both depressive and potentially hypomanic phases.
You mentioned anxiety. Can you tell me more about what that feels like for you and when it tends to show up?
To better characterize the nature and severity of his comorbid anxiety symptoms.
Do you ever use alcohol, cannabis, or any other substances to manage your mood, help you sleep, or give you energy?
To screen for a substance-induced mood disorder and understand coping mechanisms.
Assess for history of hypomanic episodes (e.g., elevated mood, increased energy, decreased need for sleep, racing thoughts, impulsivity).
Tests 6A61 Bipolar II disorder.
Clarify what 'being okay' feels like in terms of mood, energy, and behavior.
Tests 6A61 Bipolar II disorder.
Explore family history of mood disorders, particularly bipolar disorder.
Tests 6A61 Bipolar II disorder.
Assess functional impairment during both depressive and 'okay' periods.
Tests 6A61 Bipolar II disorder.
Systematically rule out any lifetime history of manic or hypomanic episodes.
Tests 6A71 Recurrent depressive disorder.
Establish a detailed timeline of depressive episodes, including duration and severity.
Tests 6A71 Recurrent depressive disorder.
Confirm that periods between episodes are a return to baseline (euthymia).
Tests 6A71 Recurrent depressive disorder.
Assess for full symptom criteria for a depressive episode (e.g., changes in appetite, concentration).
Tests 6A71 Recurrent depressive disorder.
Assess if depressive and elevated periods meet the full criteria for major depressive or hypomanic episodes.
Tests 6A62 Cyclothymic disorder.
Determine if symptom-free intervals are shorter than two months at a time.
Tests 6A62 Cyclothymic disorder.
Clarify the intensity and duration of both the 'down' and potential 'up' periods.
Tests 6A62 Cyclothymic disorder.
Identify specific life stressors in the past year (e.g., work-related, personal).
Tests 6B43 Adjustment disorder.
Establish a clear temporal link between any identified stressors and symptom onset.
Tests 6B43 Adjustment disorder.
Assess if symptoms are a disproportionate reaction to stressors.
Tests 6B43 Adjustment disorder.
Rule out a primary mood disorder that is merely exacerbated by stress.
Tests 6B43 Adjustment disorder.
You mentioned periods where the depression 'comes and goes' and you feel 'okay'. During those 'okay' times, have you ever felt unusually energetic or 'on top of the world', needed much less sleep than usual, had racing thoughts, or been more talkative or impulsive?
To directly screen for hypomanic episodes, which is critical for differentiating Bipolar II Disorder from Recurrent Depressive Disorder.
You mentioned feeling hopeless and that life feels meaningless. When you feel this way, have you had any thoughts that life is not worth living, or any thoughts about harming yourself?
To directly assess for suicidal ideation, which is a critical safety concern given his reported hopelessness.
When you are in the 'heavy depressive state,' can you tell me more about what that's like? Besides feeling hopeless and having sleep problems, do you notice changes in your interest or pleasure in activities, your appetite or weight, your energy levels, or your ability to concentrate?
To gather evidence for the full diagnostic criteria of a Major Depressive Episode as per ICD-11.
You wondered if life events might be the cause. Can you tell me about any significant changes or stressors at work or in your personal life over the last year?
To explore the client's own hypothesis and assess for an Adjustment Disorder, and to understand the psychosocial context.
You mentioned anxiety. What does that feel like for you? When does it typically occur and what seems to trigger it?
To better understand the nature and severity of the comorbid anxiety symptoms.
How have these mood changes impacted your work as an entrepreneur, your daily routine, and your relationships with family or friends?
To assess the level of functional impairment caused by the symptoms.
Can you describe the sleep problem in more detail? During the 7-8 day cycles of poor sleep, is it difficulty falling asleep, staying asleep, or waking up too early? What is your sleep like during the 'okay' weeks?
To better characterize the sleep disturbance, which is a key symptom and potential target for intervention (e.g., social rhythm therapy).
Has anyone in your family (parents, siblings, etc.) ever been treated for depression, bipolar disorder, or other mental health conditions?
To assess for a family history of mood disorders, which can be a risk factor.
Screen for history of hypomanic episodes (elevated mood, increased energy, decreased need for sleep, racing thoughts, impulsivity).
Tests 6A61.1 Bipolar type II disorder, current episode depressed.
Clarify the nature of the 'okay' periods.
Tests 6A61.1 Bipolar type II disorder, current episode depressed.
Establish a clearer timeline of mood episodes over the past year.
Tests 6A61.1 Bipolar type II disorder, current episode depressed.
Assess for family history of bipolar disorder.
Tests 6A61.1 Bipolar type II disorder, current episode depressed.
Systematically rule out any history of manic or hypomanic episodes.
Tests 6A71 Recurrent depressive disorder.
Assess for full symptom criteria for Major Depressive Episodes (e.g., anhedonia, appetite/weight changes, psychomotor changes, concentration difficulties).
Tests 6A71 Recurrent depressive disorder.
Determine the frequency, duration, and severity of depressive episodes.
Tests 6A71 Recurrent depressive disorder.
Assess if depressive periods meet full criteria for a major depressive episode.
Tests 6A62 Cyclothymic disorder.
Assess if 'okay' periods contain hypomanic symptoms that do not meet full criteria for a hypomanic episode.
Tests 6A62 Cyclothymic disorder.
Do next
1.Set a baseline — administer PHQ-9 + GAD-7
This sessionAdminister the recommended screeners so every later session measures change.
Why: You can only show progress against a starting point.
Administer now2.Next session — close an open diagnostic question
Next sessionAsk: "Assess for history of hypomanic episodes (e.g., elevated mood, increased energy, decreased need for sleep, racing thoughts, impulsivity)."
Why: Tests 6A61 Bipolar II disorder.
Next session: in ~7 days
Weekly during assessment keeps the differential narrowing.
A structured second opinion when you’re stuck — what’s been tried, what the data shows, options to consider, and questions to bring to supervision. Therapist-facing only.
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