of bp-ii may overlap significantly with those of other conditions. thus, a comprehensive history, medication review, and laboratory work are key to diagnosing bp-ii and differentiating it from other conditions. the differential diagnosis of bp-ii is as follows: unipolar major depression, borderline personality disorder, posttraumatic stress disorder, substance use disorders, and attention deficit hyperactivity disorder.: 1653–7 in clinical practice, the difficulty of diagnosing bp-ii depends on the accurate detection of hypomania, which is frequently dismissed by patients. patients can present with increased productivity and energy with the absence of signs of instability or disturbance. as such, there is a risk that bp-ii is misdiagnosed as generalized anxiety disorder or unipolar major depression. an accurate evaluation of differential diagnoses are crucial, as they guide treatment and prognostic implications. major differences between bp-i and bp-ii have been identified in their clinical features, comorbidity rates and family histories. during depressive episodes, bp-ii patients tend to show higher rates of psychomotor agitation, guilt, shame, suicidal ideation, and suicide attempts. bp-ii patients have shown higher lifetime comorbidity rates of phobias, anxiety disorders, substance use, and eating disorders. in addition, there is a higher correlation between bp-ii patients and family history of psychiatric illness, including major depression and substance-related disorders compared to bp-i. the occurrence rate of psychiatric illness in first degree relatives of bp-ii patients was 26.5%, versus 15.4% in bp-i patients. management although bp-ii is a prevalent condition associated with morbidity and mortality, there has been an absence of robust clinical trials and systematic reviews that investigate the efficacy of pharmacologic treatments for the hypomanic and depressive phases of bp-ii. thus, the current treatment guidelines for the symptoms of bp-ii are derived and extrapolated from the treatment guidelines in bp-i, along with limited randomized controlled trials published in the literature.: 1697 the treatment of bp-ii consists of the following: treatment of hypomania, treatment of major depression, and maintenance therapy for the prevention of relapse of hypomania or depression. as bp-ii is a chronic condition, the goal of treatment is to achieve remission of symptoms and prevention of self-harm in patients. treatment modalities of bp-ii include medication-based pharmacotherapy, along with various forms of psychotherapy. medications lamotrigine (lamictal) is an anticonvulsant that can be used as a mood stabilizer to treat bp-ii. the most common pharmacologic agents utilized in the treatment of bp-ii includes mood stabilizers, antipsychotics, and antidepressants. mood stabilizers further information: mood stabilizer mood stabilizers used in the treatment of hypomanic and depressive episodes of bp-ii include lithium, and the anticonvulsant medications valproate, carbamazepine, lamotrigine, and topiramate. there is strong evidence that lithium is effective in treating both the depressive and hypomanic symptoms in bp-ii, along with the reduction of hypomanic switch in patients treated with antidepressants. furthermore, lithium is the only mood stabilizer to demonstrate a decrease in suicide and self-harm in patients with mood disorders. due to lithium's narrow therapeutic index, lithium levels must be monitored regularly for prevention of lithium toxicity. there is also evidence that the anticonvulsants valproate, lamotrigine, carbamazepine, and topiramate are effective in the reduction of symptoms of hypomanic and depressive episodes of bipolar disorder. potential mechanisms contributing to these effects include a decrease in brain excitation due to blockage of low-voltage sodium-gated channels, decrease in glutamate and excitatory amino acids, and potentiation of levels of gaba. there is evidence that lamotrigine decreases the risk of relapse in rapid-cycling bp-ii. it is more effective in bp-ii than bp-i, suggesting that lamotrigine is more effective for the treatment of depressive rather than manic episodes. doses ranging from 100 to 200 mg have been reported to have the most efficacy, while experimental doses of 400 mg have rendered little response. a large, multicenter trial comparing carbamazepine and lithium over two and a half years found that carbamazepine was superior in terms of preventing future episodes of bp-ii, although lithium was superior in individuals with bp-i. there is also some evidence for the use of valproate and topiramate, although the results for the use of gabapentin have been disappointing. antipsychotics further information: antipsychotic quetiapine (seroquel) is an antipsychotic that is used to treat acute bp-ii depression antipsychotics are utilized as a second line option for hypomanic episodes, typically indicated patients who do not respond to mood stabilizers. however, quetiapine is the only antipsychotic that has demonstrated efficacy in multiple meta-analyses of randomized controlled trials for treating acute bp-ii depression, and is a first-line option for patients with bp-ii depression.: 1697 other antipsychotics that are used to treat bp-ii include lurasidone, olanzapine, cariprazine, aripiprazole, asenapine, paliperidone, risperidone, ziprasidone, haloperidol, and chlorpromazine. as a class, the first generation antipsychotics are associated with movement disorders, along with anticholinergic side effects compared with second generation antipsychotics. antidepressants further information: antidepressant there is evidence to support the use of ssri and snri antidepressants in bp-ii, but the use of these treatments are controversial. potential risks of antidepressant pharmacotherapy in patients with bipolar disorder include increased mood cycling, development of rapid cycling, dysphoria, and switch to hypomania. in addition, the evidence for their efficacy in bipolar depression is mixed. thus, in most cases, antidepressant monotherapy in patients with bp-ii is not recommended. however, antidepressants may provide benefit some patients when used in addition to mood stabilizers and antipsychotics, as these drugs reduce the risk of manic/hypomanic switching. however, the risk still exists, and should be used with caution. non-pharmaceutical therapies further information: therapy and psychotherapy although medication therapy is the standard of care for treatment of both bp-i and bp-ii, additional non-pharmaceutical therapies can also help those with the illness. benefits include prevention of relapse and improved maintenance medication adherence. these include psychotherapy (e.g. cognitive behavioral therapy, psychodynamic therapy, psychoanalysis, interpersonal therapy, behavioral therapy, cognitive therapy, and family-focused therapy), social rhythm therapy, art therapy, music therapy, psychoeducation, mindfulness, and light therapy. meta-analyses in the literature has shown that psychotherapy plus pharmacotherapy was associated with a lower relapse rate compared with patients treated with pharmacotherapy alone. however, relapse can still occur, despite continued medication and therapy. people with bipolar disorder may develop dissociation to match each mood they experience. for some, this is done intentionally, as a means by which to escape trauma or pain from a depressive period, or simply to better organize one's life by setting boundaries for one's perceptions and behaviors. prognosis there is evidence to suggest that bp-ii has a more chronic course of illness than bp-i. this constant and pervasive course of the illness leads to an increased risk in suicide and more hypomanic and major depressive episodes with shorter periods between episodes than bp-i patients experience. the natural course of bp-ii, when left untreated, leads to patients spending the majority of their lives with some symptoms, primarily stemming from depression. their recurrent depression results in personal distress and disability. this disability can present itself in the form of psychosocial impairment, which has been suggested to be worse in bp-ii patients than in bp-i patients. another facet of this illness that is associated with a poorer prognosis is rapid cycling, which denotes the occurrence of four or more major depressive, hypomanic, and/or mixed episodes in a 12-month period. rapid cycling is quite common in those with bp-ii, much more so in women than in men (70% vs. 40%), and without treatment leads to added sources of disability and an increased risk of suicide. women are more prone to rapid cycling between hypomanic episodes and depressive episodes. to improve a patient's prognosis, long-term therapy is most favorably recommended for controlling symptoms, maintaining remission and preventing relapses. with treatment, patients have been shown to present a decreased risk of suicide (especially when treated with lithium) and a reduction of frequency and severity of their episodes, which in turn moves them toward a stable life and reduces the time they spend ill. to maintain their state of balance, therapy is often continued indefinitely, as around 50% of the patients who discontinue it relapse quickly and experience either full-blown episodes or sub-syndromal symptoms that bring significant functional impairments. functioning the deficits in functioning associated with bp-ii stem mostly from the recurrent depression that bp-ii patients experience. depressive symptoms are much more disabling than hypomanic symptoms and are potentially as, or more disabling than mania symptoms. functional impairment has been shown to be directly linked with increasing percentages of depressive symptoms, and because sub-syndromal symptoms are more common—and frequent—in bp-ii, they have been implicated heavily as a major cause of psychosocial disability. there is evidence that shows the mild depressive symptoms, or even sub-syndromal symptoms, are responsible for the non-recovery of social functioning, which furthers the idea that residual depressive symptoms are detrimental for functional recovery in patients being treated for bp-ii. it has been suggested that symptom interference in relation to social and interpersonal relationships in bp-ii is worse than symptom interference in other chronic medical illnesses such as cancer. this social impairment can last for years, even after treatment that has resulted in a resolution of mood symptoms. the factors related to this persistent social impairment are residual depressive symptoms, limited illness insight (a very common occurrence in patients with bp-ii), and impaired executive functioning. impaired ability in executive functions is directly tied to poor psychosocial functioning, a common side-effect in patients with bp-ii. the impact on a patient's psychosocial functioning stems from the depressive symptoms (more common in bp-ii than bp-i). an increase in these symptoms' severity seems to correlate with a significant increase in psychosocial disability. psychosocial disability can present itself in poor semantic memory, which in turn affects other cognitive domains like verbal memory and (as mentioned earlier) executive functioning leading to a direct and persisting impact on psychosocial functioning. an abnormal semantic memory organization can manipulate thoughts and lead to the formation of delusions and possibly affect speech and communication problems, which can lead to interpersonal issues. bp-ii patients have also been shown to present worse cognitive functioning than those patients with bp-i, though they demonstrate about the same disability when it comes to occupational functioning, interpersonal relationships, and autonomy. this disruption in cognitive functioning takes a toll on their ability to function in the workplace, which leads to high rates of work loss in bp-ii patient populations. after treatment and while in remission, bp-ii patients tend to report a good psychosocial functioning but they still score less than patients without the disorder. these lasting impacts further suggest that a prolonged period of untreated bp-ii can lead to permanent adverse effects on functioning. recovery and recurrence bp-ii has a chronic relapsing nature. it has been suggested that bp-ii patients have a higher degree of relapse than bp-i patients. generally, within four years of an episode, around 60% of patients will relapse into another episode. some patients are symptomatic half the time, either with full on episodes or symptoms that fall just below the threshold of an episode. because of the nature of the illness, long-term therapy is the best option and aims to not only control the symptoms but to maintain sustained remission and prevent relapses from occurring. even with treatment, patients do not always regain full functioning, especially in the social realm. there is a very clear gap between symptomatic recovery and full functional recovery for both bp-i and bp-ii patients. as such, and because those with bp-ii spend more time with depressive symptoms that do not quite qualify as a major depressive episode, the best chance for recovery is to have therapeutic interventions that focus on the residual depressive symptoms and to aim for improvement in psychosocial and cognitive functioning. even with treatment, a certain amount of responsibility is placed in the patient's hands; they have to be able to assume responsibility for their illness by accepting their diagnosis, taking the required medication, and seeking help when needed to do well in the future. treatment often lasts after remission is achieved, and the treatment that worked is continued during the continuation phase (lasting anywhere from 6–12 months) and maintenance can last 1–2 years or, in some cases, indefinitely. one of the treatments of choice is lithium, which has been shown to be very beneficial in reducing the frequency and severity of depressive episodes. lithium prevents mood relapse and works especially well in bp-ii patients who experience rapid-cycling. almost all bp-ii patients who take lithium have a decrease in