Bipolar depression: symptoms, causes, and treatment

Bipolar depression is a key symptom of bipolar disorder, a chronic mood disorder where people experience striking swings between periods of high energy and episodes of major depression.

Formerly known as manic depression, bipolar disorder affects more than around 1–3% of people worldwide and is one of the leading causes of disability (Pederson, 2014).

While episodes of elevated mood (known as mania or hypomania) must be present for a bipolar disorder diagnosis, people usually seek medical attention because of bipolar depression––an important indicator that can help lead to an accurate diagnosis.

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There are two types of bipolar disorder: bipolar 1 and bipolar 2. Patients experience elevated moods and periods of depression in both types, although there are some key differences.

The different types of bipolar disorder exist on a continuum. People with bipolar 1 typically experience bouts of depression and mania, while people with bipolar 2 experience depression and bouts of a less extreme form of mania, known as hypomania. 

During a manic episode, a person displays a highly elevated mood. They might be extremely talkative, demonstrate an inflated sense of self-esteem, and need little or no sleep at all. They can be easily distractible or agitated or suddenly become hyper-productive (like at work or school). Many people who experience mania engage in uncharacteristic reckless behaviors like major spending sprees, foolish investments, or extreme sexual behaviors. Very often, they can experience a flight of ideas or racing thoughts. In extreme cases, mania can have features of psychosis (with a break from reality) and need hospitalization.

A hypomanic episode is an elevated mood state that is less extreme than mania. For example, a person might have increased confidence, but not to the extreme of experiencing delusions of grandiosity. Thoughts are typically fast like in mania, but more coherent, organized, and more in touch with reality. 

While the heightened mood in hypomania can lead to significant productivity, behaviors in a person with mania are often too scattered to be productive. In some cases, people experiencing hypomania enjoy it because their heightened mood improves their productivity and raises their spirits for a short time.

Diagnosis 

For the most part, bipolar disorder is characterized by periods of depression and periods of mania, but the diagnosis can actually be made before a person experiences depression. A single manic episode that lasts for at least a week and disturbs a person’s ability to function or requires hospitalization is enough for clinicians to diagnose bipolar 1 disorder. To be diagnosed with bipolar 2, a person must experience at least one episode of hypomania lasting a minimum of four days, as well as one major depressive episode.

At the other end of the spectrum for people with bipolar disorder are symptoms of depression. Bipolar depression is characterized by extreme sadness or hopelessness and a loss of interest or pleasure in things a person used to enjoy. Many people with symptoms of major depression experience significant changes in weight and appetite (most commonly weight loss, but in some cases, weight gain) and changes in sleep patterns (sleeping far more or far less than they used to). Symptoms of major depression can also include an inability to concentrate or function on a day-to-day basis, as well as feelings of guilt. In many cases, people with depression have frequent thoughts about dying or death. 

If you or someone you know is having thoughts about suicide, help is available. You can call the suicide prevention lifeline 24 hours a day, seven days a week at 800-273-8255.

Depression can be a major component of bipolar disorder. For many people eventually diagnosed with bipolar disorder, the condition first presents with symptoms of depression only. As a result, they may be misdiagnosed and receive the wrong treatment. Certain medications used to treat depression can actually make bipolar disorder worse by precipitating a manic episode. That’s why proper treatment is crucial (Rolin, 2020).

About 60% of patients with bipolar depression are misdiagnosed with major depressive disorder. Only 20% of patients with bipolar disorder get the correct diagnosis within the first year of seeking treatment, and it can take 5–10 years for many to get the correct diagnosis (Rolin, 2020).

For some people, depressive episodes can be more dominant than manic ones. People with bipolar disorder who primarily experience depression have a higher risk of suicidal ideation, panic attacks, and psychosis than people who primarily experience mania (McIntyre, 2019).

Before a person has a manic or hypomanic episode, it can be hard to differentiate between bipolar depression and unipolar depression. Research has found that there are some key differences, though. In general, bipolar depression (Grande, 2016):

• Starts at an earlier age than unipolar depression

• Features shorter, more frequent depressive episodes that can start and stop more abruptly

• Is more likely to be accompanied by substance abuse issues

• Can be triggered by stress at a young age

• Appears in people with a family history of bipolar disorder

Diagnosing bipolar disorder can be very challenging. If symptoms are mild, it can be difficult to distinguish from ordinary mood changes or personality traits.

Because people are more likely to seek treatment for depression symptoms, which on their own are very similar to unipolar depression, challenges with diagnosis come as no surprise.

In a survey, 69% of people with bipolar disorder reported that a psychiatrist initially misdiagnosed them. They had an average of more than three other diagnoses and met with four psychiatrists before getting the correct diagnosis (McIntyre, 2019).

The key to an accurate diagnosis is collecting a thorough clinical history that includes any instances of mania or hypomania. This can be difficult because patients may not recognize episodes of hypomania or even enjoy them (McIntyre, 2019).

Healthcare providers can use a variety of screening tools to improve the accuracy of the diagnosis. Typically, with time, a pattern begins to emerge for people with bipolar disorder, making diagnosis easier.

There are two main goals when it comes to treating bipolar disorder. 

• The first is quickly handling and stabilizing symptoms to make sure the person is safe.

• The second is long-term management, where the goal is to prevent recurrence and help the person live a stable life. 

Let’s take a closer look at these treatment options (Grande, 2016; McIntyre 2019):

Medications

Antipsychotics and mood stabilizers are the foundations of treatment for bipolar disorder. There are several effective options to stabilize bipolar mania, but there are far fewer options for bipolar depression.

Antidepressants are commonly used even though there isn’t strong evidence to suggest they work. Antidepressants should only be used in combination with a mood stabilizer like lithium in patients with bipolar 1 because antidepressants can actually trigger manic episodes on their own.

Other medications like ketamine have been found to be effective against treatment-resistant depression in people with bipolar disorder (Kraus 2017).

Medication used to treat bipolar disorder can cause side effects that patients find difficult to manage, and some stop taking the medications as a result. This can make it harder to treat bipolar disorder. If you’re receiving treatment for bipolar disorder and aren't satisfied, speak with a healthcare provider before stopping treatment, as stopping abruptly can worsen symptoms.

Therapeutic treatment

Once bipolar disorder is stabilized with medication, there are therapeutic options to help with long-term treatment. 

Teaching people about their condition can be very helpful for people with bipolar disorder. Other interventions like cognitive behavioral therapy (CBT), functional family therapy, and interpersonal and social rhythm therapy have been shown to help––especially in the early stages of the condition. 

Bipolar disorder comes with substantial burdens and can make it challenging to live a normal life. Below are some of the most common issues people with bipolar disorder face.

Suicide risk 

Suicidal ideation and suicide risk are common among people with bipolar disorder and could be as much as 20 times higher than the general population, especially when it goes untreated.

Between 30–50% of people with bipolar disorder attempt suicide at least once, and up to 20% of those attempts are successful (Grande, 2016).

The highest risk for suicide comes during episodes of depression or mixed moods (both mania and depression) (Miller, 2014).

Problems at work

People with bipolar depression can have difficulty finding work or performing well at their jobs, especially compared to people with bipolar disorder who only experience mania or hypomania.

Those with bipolar disorder who’ve experienced at least one episode of depression are more likely to miss workdays or be unproductive during work than people who only have manic or hypomanic episodes (McIntyre, 2019).

Physical and mental health risks 

Other physical and mental health conditions are also more common in people with bipolar disorder. Heart disease, hypertension, obesity, and diabetes are often seen in people with the condition. They are also twice as likely to die from heart disease compared to the general population.

About 90% of people with bipolar 1 or 2 have other mental health conditions like anxiety, ADHD, personality disorders, eating disorders, and substance abuse issues (McIntyre, 2019). 

Scientists and doctors haven’t pinpointed a single cause for bipolar depression, but they do know that genetics play a significant role. A family history of bipolar disorder increases the likelihood of a diagnosis. 

However, a combination of genetics and environmental factors like childhood stress is thought to be the most likely factor in the appearance of bipolar disorder (Grande, 2016).

Bipolar disorder has tremendous costs for people with the condition and society as a whole, and bipolar depression accounts for a significant share of the burden. While everyone experiences mood changes in life, especially during times of stress, mood swings that impact a person’s ability to function can signify something more pervasive, like bipolar depression. To get the most effective treatment for both short and long-term symptoms, it’s important to seek a prompt diagnosis.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

August 02, 2021

Written by

John Quinn

Fact checked by

Yael Cooperman, MD

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About the medical reviewer

Yael Cooperman, MD, Ro

Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.