Major Depressive Episodes in Bipolar Disorder

The Low Side of Bipolar Disorder

Portrait of a sad young woman in her apartment, with a sun on her face, that is breaking through the window blinds

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In order for a diagnosis of bipolar disorder to be made, there must also be a history of or a current manic or hypomanic episode. In bipolar I disorder, there doesn't need to be a depressive episode, although most there is. In bipolar 2, there needs to be the presence of a hypomanic and a major depressive episode over the course of the illness. 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.

For a diagnosis of a major depressive episode in bipolar disorder, 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.

Symptoms

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 not formally listed as a symptom of a major depressive episode in depressed adults, the individual 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.

One or both 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 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; thinking about suicide without making a plan (suicidal ideation); a suicide attempt or the making of plans to take your own life.

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 person 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. 

Depressive vs. Hypomanic or Manic Episodes

One study found that days depressed were 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 even more significant than the time spent in hypomania.

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