Bipolar Disorder and Depressive Episodes

What are Bipolar Depressive Episodes?

Bipolar disorder is a psychiatric condition characterized by alternating periods of elevated and depressed mood. A depressive episode in bipolar disorder involves a cluster of symptoms that persist for at least two weeks and interfere with daily functioning.

Some of the most common symptoms include:

• Emotional Disengagement: This can involve loss of interest or pleasure in nearly all activities.
• Low Mood: This can occur for most of the day, nearly every day.
• Appetite or Weight Changes: It’s important to note that these changes would not be due to dieting.
• Sleep Disturbances: This includes insomnia or oversleeping.
• Fatigue: This symptom encompasses having a generally low level of energy.
• Negative Feelings: People in a bipolar depressive episode may experience feelings of worthlessness or excessive guilt.
• Cognitive Challenges: These include difficulty concentrating or making decisions.
• Suicidal Thoughts: Thoughts of dying or ending one’s life can also occur in bipolar depressive episodes.

Subject matter expert

Simone Hoermann Ph.D.

Personality disorders, anxiety, and depression

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Bipolar Depression vs. Everyday Sadness

To qualify as part of a bipolar depressive episode, these symptoms must interfere with a person’s ability to function in their daily life. Bipolar depressive episodes are more than just everyday lows. The symptoms are more persistent and disruptive, and they affect thinking, physical energy, and emotional regulation.

While it’s normal to experience sadness after traumatic or upsetting events, bipolar depressive episodes are not caused by a specific life event. What’s more, unlike everyday sadness, they don’t resolve on their own.

How Bipolar Depression Differs from Unipolar Depression

Bipolar depression and major depressive disorder (MDD), sometimes referred to as unipolar depression, can look nearly identical on the surface. However, there are key differences that affect diagnosis, treatment, and long-term outcomes. Learning about the recognized types of bipolar disorder can also help people better understand their diagnosis and what to expect from treatment.

Symptom Differences

While both bipolar and unipolar depression share low mood, fatigue, and changes in sleep, bipolar depression is more likely to include:

• Atypical Features: Increased sleep and appetite are atypical symptoms present in bipolar depression.
• Mood Reactivity: In bipolar depression, it’s more likely that mood briefly improves in response to positive events.
• Psychomotor Changes: Bipolar depression can cause slowed movements and thoughts.
• Irritability: Excessive irritability is a symptom of bipolar depression which is especially prevalent in young people.

These features sometimes cause bipolar depression to be misdiagnosed as unipolar depression, or even as an anxiety or personality disorder.

Course of Illness

Bipolar depression often has an earlier age of onset, sometimes appearing in adolescence. It is more likely to involve recurrent episodes as well as periods of complete recovery. The presence of past manic or hypomanic bipolar episodes distinguishes it from unipolar depression or MDD.

Diagnostic Challenges

Oftentimes, bipolar depression is treated as unipolar depression simply because a manic episode hasn’t yet emerged or been recognized in a person. This delay in proper diagnosis can worsen symptoms and increase the risk of complications, including suicide⁠^[1].

That’s why it’s essential for clinicians and patients to look beyond the surface and consider one’s full mood history, while being aware of the nuances in how symptoms show up.

Lived Experience and Functional Impact of Bipolar Depression

Living with the depressive episodes that characterize bipolar depression often means struggling to function in ways others take for granted. Even when symptoms aren't outwardly visible, they can deeply affect a person’s ability to manage their personal relationships, maintain a job, or care for themselves.

Impact and Duration of Depressive Episodes

Everyday effects of bipolar depressive episodes can include fatigue, difficulty concentrating, loss of interest in social connections, and emotional numbness. These challenges can continue between episodes, even when one’s mood is stable. Over time, the combination of functional impairment and stigma can lead to isolation and a loss of confidence or sense of identity.

Depressive episodes in bipolar disorder can disrupt sleep, energy, concentration, and the ability to manage everyday responsibilities. In bipolar I disorder, these episodes typically last at least two weeks. Assessing both depressive and elevated mood symptoms is important for choosing appropriate treatment⁠^[2].

Understanding Mixed Episodes in Bipolar Disorder

Mixed episodes happen when symptoms of mania and depression overlap or shift rapidly. These episodes are less common than manic or depressive phases alone, but they tend to be more severe and harder to manage. Exploring the different kinds of bipolar disorder can offer helpful insight into how these episodes fit within the broader condition.

Defining Features

To be diagnosed with a mixed episode, a person may show symptoms of both mania and depression, either at the same time or in close sequence. They may experience significant distress or loss of functioning and cycle quickly between opposing moods, sometimes within hours. 

A person might feel restless but emotionally drained during a mixed episode. As an example, they may be driven to act impulsively while feeling overwhelmed by guilt.

Why Mixed Episodes Matter

Episodes with mixed features involve depressive and manic symptoms occurring together. A clinician needs to consider the full pattern of symptoms and the person’s history when planning treatment. Thoughts of suicide or immediate danger require urgent help⁠^[2].

Recognizing Suicide Risk During Depressive and Mixed States

Suicidal thoughts can surface during any phase of bipolar disorder, but they often intensify during depressive and mixed episodes. In mixed states, one experiences both manic and depressive symptoms at the same time. This creates a dangerous window where the impulsiveness from mania can collide with feelings of despair from a depressive episode.

Warning Signs of Suicide in a Depressive Episode

If someone with bipolar disorder is contemplating suicide during a depressive or mixed episode, there are some warning signs. Someone in this state may speak openly about feeling hopeless. Others show more subtle signs, like pulling away from daily life or taking sudden and uncharacteristic risks.

Other signals may include talking about being a burden or not wanting to exist. The person may withdraw from close relationships. They may also seem unusually calm after a period of visible distress. Another warning sign is taking steps to “get affairs in order” or giving away meaningful belongings. 

In a recent study, researchers identified two experiences that often occur just before a suicide attempt in people with bipolar disorder: overwhelming emotional pain and a feeling of being trapped with no way out. These states may not be obvious, but when they appear, they signal immediate risk and must be taken seriously⁠^[3].

Getting the Right Diagnosis for Bipolar Depression

A person may seek treatment for depression without recognizing previous hypomanic episodes. Diagnosis therefore depends on symptoms and experiences across the lifetime, not only the current mood. Missing bipolar symptoms matters because antidepressant treatment alone can trigger mania or rapid cycling⁠^[2].

Getting the right bipolar diagnosis involves:

• Reviewing Past Episodes: Keeping note of mood changes includes nuances in energy shifts and irritability, as they play a role in tracking episodes.
• Family History: It’s important to look at whether one has a family history of mood disorders, including bipolar disorder.
• Symptoms Over Time: For accurate diagnosis, symptoms should be monitored over a period of time, not just in isolated moments.

Next Steps Toward Treatment

If bipolar disorder is suspected, a referral to a psychiatrist or mood specialist is recommended. Treatment typically includes medication, therapy, and ongoing support. Education about all the main aspects of bipolar depression by a mental health professional can help individuals and families recognize triggers and stay engaged in care⁠^[4].

Moving Forward with Support

Bipolar depressive and mixed episodes can be emotionally exhausting and physically draining. These symptoms interfere with work, relationships, and a person’s self-worth. Moreover, they can increase the risk of suicide when left unrecognized.

However, recovery is possible with the right support, especially when one is guided by accurate diagnosis and evidence-based treatment. With the right tools and care, it becomes possible to manage symptoms, rebuild stability, and move forward with greater clarity and hope.

That said, it’s important to know when to take action regarding the risk of suicide. If you’re concerned that someone is considering suicide, ask them how they’re feeling. You don’t need to fix everything. Being present and taking a first step can make all the difference.