It’s the manic phase of bipolar disorder that attracts — no, demands — attention. But those who have the illness, or love someone who does, know it’s depression that most disrupts and devastates lives — and dominates the course of the illness.
“Few people understand [that] depression sucks the life out of you,” says C.A. of Oregon. “Desires, self-esteem, motivation, self-worth — any of those qualities that keep you going in life — disappear.” Since her 2002 bipolar diagnosis, she’s gone only 18 consecutive months without depression.
When P.S. of Halifax, Nova Scotia, is sad, she sometimes avoids bike riding with her daughter. The guilt she feels at withdrawing from her child only intensifies her depression.
“You look at the functional outcomes, such as the ability to work, family life, being an active participant in society — this is largely driven by depressive, rather than manic, symptoms,” notes Roger S. McIntyre, MD, FRCPC, professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network in Toronto.
One reason depression is more debilitating than mania is that it lasts longer; another is that it occurs more frequently. Research shows that episodes of depression last much longer than episodes of mania for individuals with both bipolar 1 and bipolar 2 diagnoses.
Bipolar depression is also difficult to diagnose and, therefore, to treat. As many as 50 percent of those with bipolar disorder are misdiagnosed with unipolar depression, according to Michael E. Thase, MD, a professor of psychiatry at the University of Pennsylvania School of Medicine and author of several books on bipolar, depression, and related topics.
It’s not surprising that misdiagnoses frequently occur. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), doesn’t distinguish between bipolar and unipolar depression. Rather, a bipolar diagnosis is made based upon whether the person has experienced mania or hypomania.
Studies show that people with bipolar depression typically experience an earlier onset of depression, have more episodes of depression, and are more likely to be medication-resistant. Further, those with bipolar depression are more likely to have a co-occurring psychiatric diagnosis, such as an anxiety disorder, borderline personality disorder, or substance abuse.
Because bipolar and unipolar depression can “look” so similar, psychiatrists must take care to get detailed family histories — and to ask patients if they have ever experienced symptoms of mania or hypomania, says Eric D. Caine, MD, chairman of psychiatry at the University of Rochester Medical Center. Otherwise, “the tendency is to treat it as if it’s unipolar depression, with antidepressants alone, which may serve as rocket fuel for a manic episode,” he adds.
How does one experience bipolar depression? That depends on who you ask. Many people undergo distinct periods of stability, mania, and depression. Yet other individuals can feel both depressed and manic at the same time — simultaneously feeling very sad and energized. This is generally referred to as “mixed features” (formerly “mixed state”) as a specifier in the DSM-5.
Holly A. Swartz, MD, a professor of psychiatry at the University of Pittsburgh School of Medicine, says it is relatively rare for people to meet the DSM-5 criteria for a mixed state, which requires a major depressive episode and a manic episode nearly every day for at least one week.
“However, individuals meeting diagnostic criteria for either a depressive episode or a manic episode often have a few subsyndromal symptoms of the opposite pole of the disorder that co-occur with their predominant mood episode,” Dr. Swartz says. “For example, someone will meet full criteria for a depressive episode but will also have racing thoughts.”
Rapid-cycling — as defined by the DSM-5’s diagnostic criteria — is having at least four distinct episodes of major depression, mania or hypomania, or mixed symptoms within a 12-month period. But it’s possible to experience more than one rapid-cycling episode a week, or “even within one day,” according to the National Institute of Mental Health.
Just because you’re feeling down when you wake up and hypomanic later in the day, however, doesn’t mean you are rapid-cycling, emphasizes Joseph R. Calabrese, MD, director of the Mood Disorders Program at Case Western Reserve University in Cleveland. He says individuals often confuse mood lability [instability] with rapid-cycling. Only about 15 to 20 percent of people with bipolar experience rapid-cycling, he adds.
Jennell A. of The Villages, Florida, says her moods shift quickly — sometimes from one hour to the next.
“Yesterday morning, I woke up at 5:30 a.m. and by 8:00 a.m., I knew I was in a hypomanic cycle,” she says. “I was running around nonstop, never stopped talking, and felt like I was running a marathon all day.” But the next morning, Jennell, who awoke early for a golf date, felt like she was “in a fog.”
“I knew I could either get up and get going, or spiral into the depressed side of me. I went golfing!”
As with mania, knowing what stressors leave you vulnerable to depression can help prevent recurrences. Lack of sleep, work-related stress, and traumatic events can all be triggers.
For T.L.’s husband, holidays are particularly difficult — they stir unhappy childhood memories. Vacations are also potential land mines.
“After a couple days, he becomes extremely irritable and annoying,” says T.L., who lives in Wayne, New Jersey. “He can’t relax, which is no vacation for either of us! It seems to have to do with breaking out of his work routine and structure. Even on weekends, he tends to be more symptomatic.”
Then there are the stress factors beyond one’s control — such as ill health or the death of a loved one. “The economy has greatly affected our finances and our work situations,” says Therese J. Borchard, a mother of two and author of several books, including the memoir, Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes. “It’s taken about nine months to navigate through that stress, but now that we have found a way to produce enough income, I think I will be less prone to fall into depression.”
The severity of the illness, one’s support system, the luck — or failure — of finding effective medication, a competent doctor, and a supportive partner — all affect how successfully bipolar depression can be stabilized.
Muriel H. of Easley, South Carolina, managed to teach for 32 years, in part because of her husband’s steady encouragement, but some days it took all her inner resources to make it through the day.
“Had it not been for my work ethic, I would have been home in bed,” Muriel says. “On many weekends, I would hole up in my apartment, not coming out again until Monday morning.”
Severe bipolar depression not only robs one of the ability to enjoy life but also may even interfere with basic acts of self-care. C.A. lives directly across the street from a grocery store but recalls one morning when even that short distance was too far to walk. She showered and applied some makeup, but found she couldn’t leave the house. “I stood at my bedroom window, looking across the way at the store and crying,” she recalls. “I felt helpless and stupid.”
It’s when we are in absolute despair that we most need the comfort of loved ones. The irony is this is also the time when we feel the most unlovable, are least able to return love, and tend to strain the devotion and patience of even the most steadfast caregiver.
T.L. knows her husband is depressed when he grows quiet, turns from sweet to “snappy,” has trouble sleeping, becomes overly critical, and begins obsessing over trivial things, like irritating TV commercials. As soon as she observes such symptoms, T.L. asks her husband how he’s feeling and whether anything is stressing him out.
“One time, I was on the computer and he came down to the office to say good night. I was in the middle of writing an email. He gave a big sigh, stomped up the stairs, and slammed the bedroom door. I went up and calmly asked what his problem was, and he snapped something about not kissing him goodnight … as if I could read his mind. I quickly realized this was an [irrational] conversation, told him so and to get some sleep, and we could have a rational conversation the next day, which we did.”
When the darkness doesn’t lift, despite the help of family and modern medicine, many people lose all hope. According to a review, 20 percent of people with bipolar disorder die by suicide and 20 to 60 percent of individuals with the illness attempt suicide at least once.
A mixed state can place an individual at a particularly high risk of suicide, says Dr. Caine. “In a mixed state, someone has the thinking and motor features that are much more like someone on the manic end of things,” he says. “But you can also be very suicidal then. It’s a time of impulsivity and very rapid actions. It may appear like suicide is sudden, but the person may have been thinking about it for a long time, and now they have the fuel to do it.”
The trick for doctors and caregivers is not to be fooled by body language — someone in a mixed state can be smiling and standing straighter yet still be capable of suicide.
Having a plan in place can help prevent minor symptoms from turning into a full-blown episode, says psychologist Elizabeth Saenger, PhD, an assistant professor at Columbia University’s department of psychiatry. She suggests: “Work with a mental health professional to put together a plan: ‘How will I recognize when I am beginning to get depressed? How will my family?’”
Dr. Saenger also recommends enlisting a trusted friend or family member who isn’t afraid to tell you, “I think you should go to the doctor.” And then do it.
Jennell has a rich support system — a caring husband who will play cards with her for hours to distract her from her depression, a therapist she sees every other week, and a psychiatrist she visits monthly. She also has her faith.
“God plays an important part in my life in everything I do,” Jennell says. “Having that as my main support gets me by.”
P.S. of Halifax says her psychiatrist is the “one constant” in her life. “I really rely on her. I respect her opinion. If she tells me to back off — that I’ve taken on too many projects — I might argue some, but eventually I realize she’s right.”
The light in what can — at times — seem like the endless darkness of depression, is that people do recover, find medications that work, and rebuild their lives. Two years ago, Borchard would have said that her depression “got in the way of everything.” Not anymore.
“Today I can honestly say that my illness has made me a better spouse, mother, and worker because I’ve had to learn how to use an incredible amount of discipline with just about everything: from sleeping to eating to exercising and communication, to workload and relationships,” Borchard says. “I take every step of life with much more deliberation and care. If I get lazy, it could literally cost me my life because my illness needs healthy relationships and healthy life habits.”
Editorial Sources and Fact-Checking
Tondo L et al. Depression and Mania in Bipolar Depression. Current Neuropharmacology. April 2017.
Donna R et al. Is It Depression or Is It Bipolar Depression? Journal of the American Association of Nurse Practitioners. October 2020.
Dome P et al. Suicide Risk in Bipolar Disorder: A Brief Review. Medicina (Kaunas). August 2019.
Depression (Major Depressive Disorder). Mayo Clinic. October 14, 2022.
UPDATED: Originally printed as “The Downside of Up,” Fall 2010
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I have an adult daughter 28 yrs old, married and she is pregnant with her 3rd child. She has been dx as bipolar/depressive , but, I am not sure if that is it. She had substance abuse issues and served some time over something that happened when she was abusing, and now we believe in a state of mania. I want to know how to help her the most. Her husband is supporting her too, but, we need to understand more. Especially when she is manic and wants to spend money they do not have. She is on medication now, but, it does not solve all her symptoms.
My son’s best friend has bipolar depression and this article has really helped me in understanding the condition. One of the challenges (among many others) is his friend has poor memory so has struggled at school. The self-help section is very insightful.
A sudden shift surfaces;
Fissure opens & thoughts explode.
Hijacked emotions, cascade outward
Security and reason; I cannot hold.
Yes, I understand. But must it always be?
Please read my comment of July 8.
Denise
I was diagnosed on the Bipolar spectrum about half way between Unipolar and Bipolar. This happened after I found out my son was diagnosed a year earlier, and was taking Seroquel at bedtime, Lamictal in the mornings. For the first time in twenty years, he felt stable and normal! His life went on a productive upswing for five years.
I was not successful with Lamictal (Lamotrigine)– it caused memory problems, stumbling and dropping things. The Nurse Practitioner then suggested Line-2 prescriptions of anti-psychotics or Lithium. I refused, knowing that hypomania was my only symptom, and had been with me since adolescence. Hypomania was only a Problem when I was faced with situations that were unfair, unjust, disrespectful, hypocritical, or harmful to children and animals. Those made me angry– or inspired me to actions that were bound to upset people in power. But the creative bursts from hypomania sometimes developed into Promising projects or exciting adventures for my family. When the Nurse Practitioner told me lithium would block ALL levels of mania, I said, “No, thanks.”
She recommended a book called “Bipolar, Not So Much” by Chris Aiken, M.D. and James Phelps, M.D.–that I am recommending to everyone on this website. The authors also have a website– psycheducation.org that is amazing in its depth, clarity, research, advice, and most current knowledge. I learned that I have a Mood Disorder, on the spectrum between Unipolar and Bipolar depression. I also learned that an OTC supplement, Lithium Orotate, 10 mg./day is all I need to stop the “excitatory neurons” from sparking a negative hypomanic response!
I was 66 years young and I liked the new peaceful feeling. I just wish I had convinced my 39 year-old son to try it immediately last fall, when he felt his medications were no longer working. Like his mother, (and maternal grandmother) he had what the APA now allows practitioners to diagnose: a “Mood Disorder,” not Bipolar 1, not Bipolar 2, but somewhere in the middle, with a history of mild depression and many hypomanic symptoms. Being unable to stay in town for a doctor’s appointment because of his travel schedule, he self-medicated with nitrous oxide, hoping for a solid night’s sleep –following weeks of two-hour naps throughout the day/night. Insomnia can cause anxiety. He had a long road trip scheduled for the next couple days– but he never woke up again. My son was intelligent, kind, generous– and a fearless risk-taker. I miss him. I am permanently changed. But I am not angry or depressed.
I want others to know about Lithium Orotate, a mineral supplement our bodies need, that could be lacking in the water your drink and the vegetables you eat, because it is found in soil. Do your research, visit the website, read the book– and don’t take risks with your life. You exist; therefore you are loved and needed by someone, somewhere.
Thank you for sharing and I’m so sorry for the loss of your son. I, too, take lithium Orotate for mood instability. My diagnoses are depression & anxiety and I’ve found it helps level things out for me. I’m a pharmacist and am currently studying functional & integrative medicine 🙌🏻💖
Hello, Lisa. I just found your message, a year later. Thank you for your condolences. I am happy to know of someone else who discovered the benefits of Lithium Orotate. We need many more integrative-medicine practitioners in our health care system. I wish you a satisfying career.
I just need to say this: I’m not sure, where I would be, or if id be writing to you today; had it not been , for BP HOPE articles . They are so rich in providing me with inspiration to be present, be not alone, learn about the things I do encounter daily; like too many mood swings, rapid cycling, severe depression, ADHD, Major anxiety, PTSD, no support system, no partner, no family , the only Three adult male children are estranged for 3 years now, NONE of my personal relationships were saved, divorced from a partner (undiagnosed ) expressing too many characteristics/traits of an abusive Narcissistic Psychopath.
Thanks to everyone who shares their battle scars of survival in this Negative Stigma on Mental Health individuals and our world. Thnx