"Depression" is a state we have all experienced to some extent. However, in some cases, it can evolve into a more serious condition.

There are many types of depression, and one lesser-known type is bipolar depression. This condition primarily affects individuals with bipolar disorder (also known as manic depression) and is one of the most complex and challenging forms of depression.

Depression Symptoms

When diagnosing mental disorders, we examine symptoms on three levels: thoughts, behavior, and mood.

Since there are no definitive biological markers to diagnose mental disorders (except in experimental stages), we understand the problem and make the diagnosis by evaluating how the person presents themselves across these three levels—both in the present and in the past.

The feeling of sadness or depression, which we all recognize and refer to in daily conversation, is one of the main mood symptoms observed in a depressed patient. Another significant symptom is the loss of pleasure or anhedonia. Activities or friendships that once brought joy no longer provide the same satisfaction. Often, instead of sadness, there is intense anger directed at oneself or others.

At the thought level, depressive symptoms also shift but remain consistent with the mood. We begin to see things more negatively. Sometimes, we face harsh realities that we previously ignored or overlooked when we felt well. This could be the end of a relationship that never truly existed, the acceptance of a death, or any form of loss. Our thoughts also become guilt-ridden, with feelings that we are to blame for everything, that we’ve made many mistakes in the past, and that there is no future. Suicidal thoughts may also emerge. "If life has no meaning or value, why continue living?" In more severe cases, plans to end the suffering of depression may take shape.

Behaviorally, depression often manifests as procrastination, inaction, or sometimes agitation. There is a constant sense of fatigue and lack of energy. Even boiling an egg may seem like an overwhelming task. Sleep disturbances are common and vary from person to person. Some patients may need excessive sleep, falling into a lethargic state, while others may struggle with insomnia.

Generally, behavior in depression is marked by a reduction in activity. This is where behavioral therapy for depression plays a key role—by gradually increasing meaningful activities for the patient. However, this is not easy for patients or for mental health professionals not trained in this therapeutic model (behavioral activation).

What Is Bipolar Depression and How Is It Different from Regular Depression?

Diagnostically, bipolar depression presents with the same symptoms as unipolar depression. However, those with bipolar depression have a history of hypomanic or manic episodes. There are also qualitative differences in the way common symptoms appear and are experienced.

Over the past decades, studies have begun to distinguish these two types of depression, as they often differ in how they present and respond to both pharmacological and psychotherapeutic treatments.

Any mental health professional specializing in mood disorders should always consider whether a patient in depression is dealing with unipolar or bipolar depression. The first priority, of course, is to assess suicidality.

Mania is characterized by symptoms like an excessively elevated mood or irritability, grandiosity, excessive talking, hypersexuality, decreased need for sleep, racing thoughts, increased energy and activity, and often a lack of moral boundaries or inhibitions. Patients with mania, like the one we might see in old Greek movies claiming to be Napoleon, are experiencing manic episodes.

Mania is less about obsession, as is sometimes mistakenly believed, and more about the intense cluster of symptoms mentioned above.

When a patient has experienced mania and later enters a depressive state, we are dealing with bipolar depression. Since manic episodes are typically clear and easier to diagnose, bipolar depression can also be more readily identified.

However, this is not always the case when a patient has only experienced hypomania. In these cases, bipolar depression is often misdiagnosed as unipolar depression, leading to inappropriate treatments with antidepressants, which can worsen the depression or trigger manic episodes, creating confusion about the patient’s actual condition.

Phenomenologically, bipolar depression is quite different from unipolar depression. It tends to be more intense, marked by low energy, apathy, overeating, mood swings, irritability, and sometimes psychotic features that align with the mood. A patient might believe they are responsible for a global economic crisis or hear voices telling them they are bad and should die. Suicidal ideation can be much stronger in bipolar depression, and because mood and energy levels fluctuate, the risk of completed suicide is higher than in unipolar depression.

Treatment of Bipolar Depression

Treatment for bipolar depression differs significantly from unipolar depression. Both research and clinical experience have shown that many antidepressants can trigger hypomania or mania in bipolar patients. International guidelines do not prohibit antidepressants but recommend their use alongside a mood stabilizer. Antipsychotic medications with antidepressant properties are also commonly used, as they help prevent mood shifts into mania. It’s essential for patients to understand this, as they may mistakenly believe they are being treated for schizophrenia or that they are receiving incorrect treatment, when in fact, their doctor is carefully managing the risk of mania.

In psychotherapy, treatment also takes a different approach. The most scientifically supported therapy for depression is cognitive-behavioral therapy (CBT). Behavioral therapy focuses on initiating activities and teaching patients to monitor significant mood fluctuations. It also equips them with practical tools to manage suicidal thoughts. Cognitively, the patterns associated with bipolar depression can differ. Feelings of failure and worthlessness are often much more intense. Bipolar patients tend to have goal-driven thinking and behavior, and in depression, failure is experienced more deeply compared to unipolar patients who may not exhibit such goal-oriented patterns.

Triggers for bipolar depression are often different from those of unipolar depression. The loss of a loved one, an object, or a dream is a common trigger for all types of depression.

However, in bipolar depression, the trigger may not be as apparent. Upon closer examination, there may have been a preceding period of mania or hypomania. This changes the treatment strategy, and long-term treatment of bipolar depression is best achieved by addressing the mania—or, more challenging, the hypomania. Still, bipolar depression can also be triggered by the same mechanisms as unipolar depression, such as stress, loss, or trauma.

In Conclusion

Though bipolar depression may seem similar to unipolar depression at first glance, it is quite different in many respects. Both mental health professionals and patients must be aware of its nuances and take extra care with treatment. While it may not last as long as unipolar depression, it is often recurrent and requires continuous, long-term treatment, especially during periods when the patient appears to be doing well. The goal is always to prevent relapses and restore the patient’s functionality and quality of life as it was before the illness.

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Dr. Yanni Malliaris is a psychologist with a PhD in Clinical Psychology from the University of London (Institute of Psychiatry, King's College London). He is the founder and scientific director of BipolarLab.com and the Hellenic Bipolar Organisation (EDO). Growing up with a father who had bipolar disorder, he is dedicated exclusively to this field. He teaches his bipolar patients to embrace their condition, live well with it, and tap into their creativity.

Note: This article is free to republish as is, provided the source is credited.

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