Often overshadowed by mania, bipolar depression is widespread and frequently misdiagnosed, but coping skills can still help keep hope alive.
When he’s feeling low and the couch is the only place he wants to be, Jim B. might choose to work on his motorcycle or take a walk with his wife, children, or dogs. Distracting himself with tasks that require physical movement has been a critical tool for dealing with bipolar depression.
“I can’t emphasize too much that it’s a difficult thing to do,” Jim says of resisting the pervasive lethargy, “but I can feel the mood lifting. By the time I’m finished, the depression is not nearly as deep or dark. … It’s not a cure, but it does reduce the suffering.”
The Indiana resident taps into a list of coping skills he first learned in therapy during a five-month depressive episode in 2001 — an episode that eventually led to his bipolar 1 diagnosis.
Bipolar is much easier to diagnose during manic episodes, since behaviors like talking unusually fast, taking on multiple new projects, and plunging into risky activities tend to catch the eye.
Without an obvious “up” to clue in clinicians, the downside of bipolar mood swings — with symptoms like dragging slowness of brain and body, social withdrawal, and hopelessness — often gets (mis)treated as major depressive disorder.
Part of the problem is that people who have bipolar disorder spend, on average, far more time in depressive states than in elevated ones. Researchers at the University of California at San Diego calculated the ratio of time that people with bipolar 2 spend in depression versus hypomania at 37:1. Even in bipolar 1, they found, the depression-to-mania ratio is 3:1.
There are individual variations, of course. For some people, mood swings tend upward more often than down, or they begin to have severe depression only as they get older. Others rarely feel the bump of an elevated state. When episodes follow a seasonal pattern, depression can set in during fall or winter and not lift entirely until spring arrives.
The Burden of Bipolar Depression
Though it’s often overshadowed by mania’s expansiveness, bipolar depression can create a heavy burden. Whether it’s characterized by bone-deep fatigue or agitation, apathy or irritability, insomnia or oversleeping, the “black dog” (as Winston Churchill famously dubbed his depression) takes a toll on family life and social relationships, and can make it difficult to keep up with work and school responsibilities.
Jim, now in his early sixties, takes pride in what he is able to accomplish in the face of bipolar depressions marked by lack of energy and trouble concentrating. After being on disability for years, he returned to school, working toward a new career as a certified medical assistant. (One of the draws: The job should be much less stressful than his former position as a computer system administrator.)
“Having a purpose in life will get you up in the morning,” says Jim, who is also active in the National Alliance on Mental Illness (NAMI) and occasionally facilitates support groups. “I just decided that I was going to have a life that continually improves.”
Setting Small, Achievable Goals
Once the smothering blanket of bipolar depression drops upon you, it can seem like nothing will lift the gloom. That’s when baby steps can make all the difference.
Trapped in a cycle of bipolar depression, Joe T. of New Jersey had barely left his house in two weeks. He’d ventured out only for weekly therapy appointments and a trip to the library.
His therapist explained how increased activity of any kind creates momentum for more activity and how, over time, it decreases depressive symptoms and aids the return to a normal routine. So Joe decided on a trip to the beach.
“I had a very small goal, to get out to the ocean and put my feet in the water,” recalls Joe.
He got a slow start, walking out the door three hours later than he’d planned. He took two buses to get to a free beach an hour away. He reached the boardwalk, looked out over the ocean … and turned around.
In his forties, Joe lives on a fixed income, so thinking about the money he was spending for the bus ride made him feel guilty. Then he started thinking about how he overspends when he’s showing manic tendencies.
“That made me feel bad and I didn’t want to be there anymore,” he admits.
Joe may not have felt the sand between his toes after all, but he considers the trip a launching point.
“It was a baby step,” he says. “I accomplished something today, and maybe tomorrow I’ll accomplish something a little more.”
Go for Good Enough Rather Than Perfect
The “good enough” theory is the idea that you don’t have to go all out on a goal right out of the gate.
“You want to get out of the depression, but you want to do it piece by piece, little by little,” explains Washington, DC–area therapist Kathleen McNulty, LCSW.
Practically speaking, she explains, that might look like this: Instead of going on a hike, walk around the block. Instead of starting a garden plot, buy a basil plant. If you’re too depressed to brush your teeth, put water with dental rinse into a spray bottle.
“The more you pile up those “good enough” experiences, the faster you’ll find yourself in the flow of day-to-day life and coming out of the depression,” McNulty says.
Understanding Avoidance in Bipolar Depression
When her psychologist told Amy L. she was reverting to a childlike state of avoidance, she was initially both embarrassed and offended. But that insight was a breakthrough for Amy, who says talk therapy plus medication helped usher her out of a depression that lasted about 18 months.
Amy, who lives in British Columbia, saw that she hadn’t been taking the time to deal with stressful situations in her personal life and on the job.
“I was encouraged by his explanation because I saw that I had a choice,” recalls Amy, now in her early forties. “I was like, ‘Suck it up, cowgirl!’
“You really do have to decide to put yourself in a different head space. And you can’t do that unless you’re getting medical support. It has to be a package.”
According to Virginia therapist Ted Petrocci, LPC, the best way to get into that better head space is to recognize and accept what is — and what is not — within your control. “Most of it is not,” he adds.
To promote stability, focus on what you can control. Something as simple as switching up your vocabulary can be surprisingly powerful in shifting your perspective.
“Absolute” words such as “must,” “should,” “always,” and “never” — as in: “I will never get better,” or, “My life will always be like this” — can keep you trapped in a place where you feel powerless to change, Petrocci points out.
“These kinds of words are reflective of your belief system and affect how you emotionally respond,” Petrocci explains. “They set your body and mind in motion and contribute more to the helplessness.”
Whereas “should” sets us up for failure, “could” implies we have options.
Transitioning to a lexicon with fewer boundaries can take a while, Petrocci says. After all, ingrained patterns of thinking have developed over years. He suggests writing down one or two “absolute” watchwords in the morning and then checking in with yourself at different points throughout the day to see how often you’ve used them.
“The more we practice something, the better we get at it,” he notes.
It’s important to remember that looking for areas where you can take charge doesn’t mean you have to do it all alone. Sometimes the truest sign of strength is letting others lend a hand — or a bit of encouragement if nothing else.
Marisa L. of Quebec volunteers as an online content manager for Stigma Fighters Canada. During a months-long depressive episode that required a leave of absence from her fast-paced job in media relations, she turned to the peer organization’s online support group as well as to her therapist, who was willing to correspond via email between sessions.
“My husband, my friends, and my therapist are kind of like the buoys in the ocean,” says Marisa, who blogs about mental health at Mad Girl’s Lament. “They keep me oriented and help me know that I’m not going to be lost at sea forever.”
Bipolar Depression vs Unipolar Depression: Which Is Which?
In recent years, the field of psychiatry has come to recognize how serious the depressive phase of bipolar disorder can be. The challenge now is how to distinguish bipolar depression from “unipolar” depression more quickly in order to treat it more effectively.
The spectrum of depressive and bipolar disorders is grouped as “bipolar and related disorders” in the Diagnosis and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). Clinicians use a set of symptoms (known as criteria) to diagnose major depressive disorder — and the same criteria for depressive episodes in bipolar disorder.
If someone seeks help for depression, therefore, arriving at a correct bipolar diagnosis typically relies on probing for past occurrences of hypomania or mania — which tends to be more successful when a partner or other close relative comes along to share observations — and sifting family history for relatives with bipolar.
Research has yielded some other possible clues, but they’re far from clear-cut. When depressions arise early in life or in connection with pregnancy, there’s a higher likelihood that they’ll turn out to be part of a bipolar disorder. Psychotic symptoms are another strong marker, says James Phelps, MD, a semi-retired psychiatrist with 30 years of experience treating complex mood disorders.
Some evidence suggests that “atypical” depressive symptoms — oversleeping instead of insomnia, overeating rather than loss of appetite, increased sensitivity to rejection — may be more typical in bipolar.
Bipolar depression often proves more resistant to treatment, especially when standard antidepressants are prescribed due to misdiagnosis. In some cases, taking an antidepressant alone (without a mood stabilizer) triggers a switch to hypomania or mania, leads to more rapid cycling of mood episodes, or results in a “mixed state” when depressive and manic symptoms occur simultaneously.
What Does the Future Hold for Bipolar Depression?
In the misty future, bipolar may be diagnosed based on physiological markers that can be quickly seen in the blood or brain. In one project, scientists at Mayo Clinic in Minnesota are collecting DNA samples, blood tests, brain scans, and other clinical data in an effort to find biomarkers that identify bipolar depression versus major depression. Neuroimaging studies at the University of Pittsburgh Medical Center and elsewhere are seeking the same elusive goal.
One small study reported promising results based on variations in metabolites found in the urine of people with different diagnoses.
At the same time, however, some studies have identified genetic interrelationships among the major mental disorders. That’s more in line with a new model for psychiatric research that encourages an overarching “dimensional approach” — giving weight to the array and severity of an individual’s symptoms instead of adhering strictly to diagnostic categories.
“By using a dimensional lens, as well as the DSM lens, we can see the full spectrum of depression’s variations,” explains Dr. Phelps. “This is a tidal wave shift in the diagnostic process.”
Tips From the Trenches of Bipolar Depression
Recovering from bipolar depression is a team effort. You should work with your prescribing physician to adjust current medications or consider some of the other meds that target bipolar depression. Cognitive behavioral therapy and other psychotherapeutic approaches can be crucial in addressing underlying issues and patterns that fuel depressive episodes.
Peer support — encouragement and insight from others who’ve been where you are — often helps, too. Here’s a sampling of advice from those with experience:
- Accept where you are. “Don’t let yourself feel guilty for not being able to take a shower,” notes Amy. “You need to remember that you can be happy. Let [the depression] ride and know that it will pass as long as you get help.”
- Hold on to hope. Faith that things will get better keeps you moving forward. Buffeted by persisting bipolar depression, Joe didn’t give up even when he was homeless for two months at one point. “You may have to look very hard for hope, and you may need a magnifying glass to find it,” he says, “but it’s there somewhere.”
- Stay connected. Meghan S. of Arizona has gotten better at letting people know when she needs their company — even if it’s over the phone. “Some days, when it’s really easy to isolate myself, I make sure to call at least one person,” she says. “I’ll say I’m not feeling well and just want to talk to someone, or just listen to someone talk. It makes me feel like I’m not sitting here all by myself.”
Editorial Sources and Fact-Checking
- Judd LL et al. Long-Term Symptomatic Status of Bipolar 1 vs. Bipolar 2 Disorders. International Journal of Neuropsychopharmacology. June 2003.
- Peng D et al. Atypical Features and Bipolar Disorder. Shanghai Archives of Psychiatry. June 2016.
- Frye M et al. Feasibility of Investigating Differential Proteomic Expression in Depression: Implications for Biomarker Development in Mood Disorders. Translational Psychiatry. December 8, 2015.
- Redich R et al. Brain Morphometric Biomarkers Distinguishing Unipolar and Bipolar Depression. JAMA Psychiatry. November 2014.
- Chen JJ et al. Divergent Urinary Metabolic Phenotypes Between Major Depressive Disorder and Bipolar Disorder Identified by a Combined GC-MS and NMR Spectroscopic Metabonomic Approach. Journal of Proteome Research. August 2015.
UPDATED: Printed as “Letting the Light In,” Fall 2015