Bipolar disorder - depressed

Alternative names
Depression in bipolar disorder; Manic-depressive disorder - depressed phase


Depression in bipolar disorder is a mood disorder characterized by mood swings from mania (exaggerated feeling of well-being, energy, and confidence in which a person can lose touch with reality) to depression with the current or most recent episode of illness characterized by depression.

Causes, incidence, and risk factors

The disorder usually appears between the ages of 25 and 35 and affects men and women equally. The cause is unknown, but hereditary and psychological factors may play a role.

People with relatives that have bipolar disorders or depression are at greater risk. There are no other known risk factors for the disease itself, but lack of sleep may predispose one to a recurrence of symptoms.

Some of the symptoms that characterize the depressive phase:

  • Loss of self-esteem  
  • Withdrawal  
  • Helplessness  
  • Fatigue  
  • Inability to feel pleasure  
  • Difficulty concentrating or making decisions  
  • Loss of appetite or increased appetite  
  • Insomnia or hypersomnia  
  • Suicidal thoughts

In the manic phase:

  • Increase in goal directed activities  
  • Flight of ideas or racing thoughts  
  • Inflated self-esteem  
  • Decreased need for sleep  
  • Talkativeness

The two (manic and depressed) may appear together, in a “mixed” phase.

Signs and tests

A history of mood swings, and an observation of current behavior and mood are important in the diagnosis of this disorder. It is important to know if there is a family history of manic-depressive illness.

A physical examination, a history of medical problems, and current medications are important to rule out other potential causes of the symptoms.


Hospitalization may be required during an acute phase of either mania or depression to control symptoms, and for the safety of the patient. Mood stabilizers, such as valproic acid (depakote, which is also an anticonvulsant) and lithium carbonate are usually the first line of treatment.

Antipsychotics may also be needed in the acute phase to achieve fast relief of symptoms if a manic person has lost touch with reality (become psychotic). Antianxiety agents, such as Klonopin, can also be used.

A mood stabilizer is often used as maintenance therapy to relieve symptoms and prevent the onset of mood swings. Other anti-convulsants (such as Carbamazepine or Gabapentin) may also be used as mood stabilizers.

In some cases, antidepressants are added to a mood stabilizer, but this must be done with caution because some antidepressants can trigger mania in people with this disorder.

In one type of manic depression (Bipolar II), people experience primarily depression which alternates with periods of slightly elevated mood which are not full-fledged mania.

Such people may be wrongly diagnosed as having depression alone (unipolar depression) and be given antidepressants without mood stabilizers, which can cause problems with mania or manic-like states in some cases.

In severe cases, electroconvulsive therapy (ECT) may be used to treat persistent depression. ECT is a psychiatric treatment that produces a brief central nervous systemseizure by means of an electrical current.

Modern ECT is a far cry from the treatment depicted in the movies as a form of punishment or mind control - it is conducted under anesthesia and studies have repeatedly found that it is the most effective treatment for depression which hasn’t responded to medications.

Psychotherapy may also be needed for emotional support during the depressive phase. Cognitive/behavioral therapy has been found to be the most effective “talk therapy” for depression.

Support Groups
The stress of illness can often be helped by joining a support group where members share common experiences and problems.

Expectations (prognosis)

For some people, treatment with a mood stabilizer has reduced recurrence of symptoms, including depression. However, the disorder is usually life-long.


  • Suicide ideation/attempt  
  • Alcohol abuse and/or substance abuse  
  • Switch to mania - sometimes when people are treated for the depressive phase they may switch into mania

Calling your health care provider

Call your health care provider if:

  • You feel hopeless and helpless  
  • You are sleeping too much or too little  
  • Your eating patterns have changed  
  • You cannot experience pleasure from things that ordinarily feel good to you and feel like life is not worth living


Awareness of risk may allow early diagnosis and treatment. Good sleep may be crucial to preventing exacerbations.

Johns Hopkins patient information

Last revised: December 7, 2012
by Mamikon Bozoyan, M.D.

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