The depression may look the same
Someone with bipolar disorder who is in a depressive episode can feel exactly like someone with major depression: sad or empty, slowed down, uninterested in almost everything, sleeping too much or too little, sometimes thinking about death. Looking only at the low period, there may be no way to tell them apart.
What distinguishes bipolar disorder is the other direction. The National Institute of Mental Health (NIMH) describes manic episodes, periods of unusually elevated mood in which a person may feel excessively happy, irritable or "up," with a marked increase in activity compared with their usual self. Some people have hypomanic episodes instead, which are similar but less severe and interfere less with daily life.
NIMH lists bipolar disorder among the types of depression for this reason: it involves depressive episodes as well as manic or hypomanic ones.
Ordinary ups and downs versus mood episodes
Everyone has good days and bad days. The American Psychiatric Association notes that ordinary mood changes typically last hours rather than days and do not come with extreme changes in behavior or functioning. Bipolar mood episodes last days to weeks. NIMH adds that during an episode, symptoms are present every day for most of the day, and the changes in behavior, energy or activity are noticeable to others.
What a manic or hypomanic period can look like
NIMH and the American Psychiatric Association describe signs such as:
- Feeling very up, high, elated, or extremely irritable and touchy
- Needing much less sleep and still feeling energetic
- Racing thoughts, or talking fast and jumping between topics
- Feeling able to do many things at once without getting tired
- Feeling unusually important, talented or powerful
- Risky or impulsive behavior, such as spending sprees or reckless driving
According to the American Psychiatric Association, a manic episode lasts at least a week, while a hypomanic episode needs to last only four days in a row. Mania often causes serious problems at work or at home and may require hospital care. Hypomania is milder.
Why the highs are easy to miss
NIMH notes that hypomanic episodes may make a person feel very good and productive, so they may not feel that anything is wrong. Family and friends may be the ones who notice the change. Few people book an appointment because they felt unusually confident and got a lot done.
NIMH also explains that some people have bipolar disorder for years before it is diagnosed. People with bipolar II disorder may seek help only for depressive episodes, and the hypomanic episodes may go unnoticed. NIMH notes that many people with bipolar II spend long periods in a persistent, low-grade depressive state, which can look a great deal like persistent depressive disorder.
The types, briefly
- Bipolar I: manic episodes lasting at least seven days, or severe enough to need hospital care, usually with depressive episodes as well.
- Bipolar II: depressive episodes and hypomanic episodes, without full mania.
- Cyclothymic disorder: recurring hypomanic and depressive symptoms that are not intense or long enough to count as full episodes.
These definitions come from NIMH. Sorting out which, if any, applies is a job for a qualified clinician, usually including a psychiatrist.
Why the distinction matters for treatment
This is the most practical reason to raise the question. NIMH notes that if subtle signs of bipolar disorder are missed and a first depressive episode is treated with antidepressant medication alone, without a mood stabilizer, a manic episode or rapid cycling may be triggered. That is why a prescriber will usually ask about past highs before recommending an antidepressant.
This is not a reason to avoid or stop any medication on your own. If you are already taking an antidepressant and notice a sudden change, such as much less need for sleep or racing thoughts, contact your prescriber promptly. Talk with your prescriber before changing anything. Antidepressants: What to Know Before and During Treatment covers other questions to ask.
Clues worth mentioning to a clinician
Diagnosis rests on the full history, not on how you feel today. NIMH notes that bipolar disorder is diagnosed based on the severity, length and frequency of symptoms over a lifetime, along with family history, and that clinicians look at the course of the illness rather than only current symptoms. Useful things to share:
- Any stretch of days when you needed far less sleep and felt wired rather than tired
- Periods when friends or family said you seemed "not like yourself" in an up direction
- Episodes of unusual spending, risk-taking or starting many projects at once
- Family members with bipolar disorder or depression. The American Psychiatric Association notes that 80 to 90 percent of people with bipolar disorder have a relative with bipolar disorder or depression.
- Whether alcohol, cannabis or other substances were involved, since NIMH notes some drugs can mimic or worsen mood symptoms
- A recent thyroid check, since NIMH notes thyroid disease can cause similar symptoms
It can help to bring someone who knows you well, or to ask them beforehand what they remember. They may recall periods you do not.
Where therapy fits
Bipolar disorder usually requires lifelong treatment, NIMH notes, and treatment helps many people. Care is typically led by a psychiatrist or other prescriber, often alongside psychotherapy. Dr. Lehmann does not prescribe and does not describe bipolar disorder as a focus of her practice. Her depression therapy is for adults working through depression, and if your history suggests a possible bipolar pattern, an evaluation with a psychiatrist is an important next step. Ask any therapist directly about their training and experience with bipolar disorder.