Major Depressive Episodes in Bipolar Disorder

The Low Side of Bipolar Disorder

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In order for a diagnosis of bipolar disorder to be made, a patient has to have a history of at least one major depressive episode or be in one at the time of diagnosis. There must also be a history of or a current manic or hypomanic episode. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a list of specific symptoms that may be present and specifies several rules about those symptoms.

First, the symptoms have to be continuous for at least two weeks (of course, they often continue much, much longer). In addition, at least one of the first two symptoms listed below must be present; at least five or more of all the symptoms listed must be present.


The symptoms listed in the DSM-5 that your doctor will look for are:

  • Depressed mood most of the day, almost every day, during the minimum two-week period. Feelings of sadness, emptiness, hopelessness or depression, or crying for no apparent reason may be reported by the individual or by family and friends. Although irritability is listed as a symptom of depressed mood in children but not adults, it is still true that adults may be abnormally bad-tempered, cross and touchy.
  • Loss of interest in most or all normally enjoyable activities, continuing for most of the day nearly every day. For example, someone who really likes to take walks will start staying at home; a person who loves particular television shows watches them with no enthusiasm or doesn't even turn the TV on; somebody who adores cooking now can't be bothered and just sticks food in the microwave.

Reminder: One of the previous two mood symptoms has to be there for a major depressive episode to be diagnosed. Then, in addition, three to four of the following symptoms also need to be present:

  • Increase or decrease in appetite most days, or a significant increase or decrease in weight over a month (more than 5% of body weight).
  • Insomnia or hypersomnia almost every day (difficulty sleeping, or sleeping far too much).
  • Unusual agitation or restlessness OR being sluggish and hesitant and/or confused in speech nearly every day (psychomotor agitation or psychomotor retardation).
  • Fatigue or loss of energy almost every day. This might take the form of being too tired to do normal daily activities like housework, or not having the energy to go to work. It may be quite severe and even disabling.
  • Feelings of worthlessness and/or feelings of guilt that are excessive or not related to anything a person who isn't depressed would feel guilty about. Again, this must occur almost every day during a two-week period.
  • Trouble concentrating and/or making decisions nearly every day. For example, an employee told to make a plan for getting a bunch of work done might be unable to evaluate the situation properly or make any decisions about it.
  • Recurring thoughts of death or of being dead; imagining committing suicide without making a plan (suicidal ideation); a suicide attempt or the making of plans to commit suicide.

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database.

Factors That Rule Out a Depressive Episode

If a patient is experiencing five or more of the above symptoms, including one of the first two, there are still some factors that would either rule out a major depressive episode or would lead to a different diagnosis.

  • The symptoms must not be caused by a substance such as an illegal drug or a medication.
  • The symptoms can't be caused by a medical condition, such as thyroid disorder, lupus, or a vitamin deficiency. 
  • Symptoms of psychosis (hallucinations and/or delusions) may occur in severe depression. However, if the symptoms are mood-incongruent (that is, they aren't related to anything in the person's life), another disorder may be diagnosed. Some of the possibilities are schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder.
  • If depressive symptoms are present a majority of the time for two years, but they don't meet enough of the above criteria for a major depressive episode, a patient may be diagnosed with dysthymia. If a patient's depression is dysthymic and he or she also has hypomanic episodes, the patient may be diagnosed with cyclothymia.
  • The symptoms are not better accounted for by bereavement due to the loss of a loved one.
  • The symptoms don't also include those that would lead to the diagnosis of a mixed episode, which is currently defined as occurring only in bipolar I disorder and contains both manic and depressive symptoms.

Depressive vs. Hypomanic or Manic Episodes

One study found that depression is three times more common than mania in bipolar I disorder, and another study found that over the natural course of bipolar II disorder, the amount of time spent in depression was up to 39 times more common than the time spent in hypomania.

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Article Sources
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  1. Culpepper L. The Diagnosis and Treatment of Bipolar Disorder: Decision-Making in Primary Care. Prim Care Companion CNS Disord. 2014;16(3). doi:10.4088/PCC.13r01609

  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th edition. 2013.

  3. Kennedy SH. Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues Clin Neurosci. 2008;10(3):271-277.

  4. Gupta R, Lahan V. Insomnia associated with depressive disorder: primary, secondary, or mixed? Indian J Psychol Med. 2011;33(2):123-128. doi:10.4103/0253-7176.92056

  5. Quello SB, Brady KT, Sonne SC. Mood Disorders and Substance Use Disorder: A Complex Comorbidity. Sci Pract Perspect. 2005;3(1):13-21. doi:10.1151/spp053113

  6. Figueiredo-Braga M, Cornaby C, Cortez A, et al. Depression and anxiety in systemic lupus erythematosus: The crosstalk between immunological, clinical, and psychosocial factors. Medicine (Baltimore). 2018;97(28):e11376. doi:10.1097/MD.0000000000011376

  7. Pies RW. The Bereavement Exclusion and DSM-5: An Update and Commentary. Innov Clin Neurosci. 2014;11(7-8):19-22.

  8. Kupka RW, Altshuler LL, Nolen WA, et al. Three times more days depressed than manic or hypomanic in both bipolar I and bipolar II disorder. Bipolar Disord. 2007;9(5):531-535. doi:10.1111/j.1399-5618.2007.00467.x

  9. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry. 2003;60(3):261-269. doi:10.1001/archpsyc.60.3.261

Additional Reading
  • Judd LL, Akiskal HS, Schettler PJ, et al. The Long-term Natural History of the Weekly Symptomatic Status of Bipolar I Disorder. Arch Gen Psychiatry 2002;59:530-537.

  • American Psychiatric Association, DSM-IV-TR. 4th ed. Washington, DC: RR Donnelly & Sons, 2000.