Bipolar Depression: Signs of the Lows and How It's Treated

Bipolar depression is the low phase of bipolar disorder: weeks of deep sadness, emptiness or hopelessness, little energy and loss of interest in almost everything. It can look like ordinary depression, but it happens in someone who also has manic or hypomanic episodes. That difference matters, because the treatment plan is not the same.

This article is for adults and teens who have bipolar disorder or wonder if they might, and for families trying to understand the lows. It explains the signs, how the lows differ from other depression, how treatment usually works and when to get help right away. This article is general information, not a medical recommendation. Do not start, stop or change any medication without talking to your prescriber.

What does a bipolar depressive episode feel like?

A depressive episode in bipolar disorder often feels heavy, slow and joyless, as if the color has drained out of daily life. Many people describe it as worse than sadness, because motivation and hope seem to disappear too.

The National Institute of Mental Health (NIMH) lists symptoms such as feeling very down, sad or anxious and losing interest in almost all activities, along with feeling hopeless or worthless and thinking about death or suicide. Other common signs include:

• Sleeping much more or much less than usual.
• Feeling slowed down, or restless and unable to settle.
• Trouble concentrating, remembering or making decisions.
• Changes in appetite or weight.
• Pulling away from friends, work or school.

NIMH notes that these symptoms tend to last most of the day, nearly every day, during an episode.

How is bipolar depression different from regular depression?

The lows themselves can look nearly identical. The key difference is history: a person with bipolar disorder has also had periods of mania or hypomania, with unusually high energy, less need for sleep, racing thoughts or risky behavior.

MedlinePlus describes bipolar disorder as a mood disorder that causes intense mood swings, formerly called manic depression. NIMH explains that people with bipolar II may seek help only for depressive episodes, which can delay recognition of the condition. That is why a clinician will ask about past energetic or "wired" periods, even if you came in only because you feel low. Related reading: bipolar 2 vs. depression.

What is the difference between bipolar I and bipolar II lows?

Both types include depressive episodes; they differ in how high the highs go. Lows can be severe in either type.

NIMH states that bipolar I involves manic episodes that last at least 7 days, while in bipolar II the hypomanic episodes are less severe than the manic episodes of bipolar I. In bipolar II, depressive episodes are often the part that causes the most distress. In practice, many people with bipolar II spend more time feeling low than feeling high, which is one reason the condition can be mistaken for depression alone.

What causes the lows?

No single cause explains why depressive episodes happen. Brain biology, genetics and life circumstances all seem to play a part, and triggers differ from person to person.

MedlinePlus notes that the exact cause of bipolar disorder is unknown, and that genetics, brain structure and function, and environment may all contribute. Common triggers people notice include:

• Disrupted sleep, such as late nights, shift work or travel across time zones.
• Major stress, conflict or loss.
• Alcohol or drug use.
• Stopping or changing treatment without a plan.
• Seasonal changes, for some people.

How is bipolar depression treated?

Treatment usually combines medication with psychotherapy and steady daily routines, and it is planned with the whole illness in mind, not just the current low. NIMH notes that bipolar disorder usually requires lifelong treatment, even during periods of feeling well.

NIMH explains that treatment involves medications, psychotherapy or a combination. Mood stabilizers and certain antipsychotic medications are commonly used, and antidepressants may be added for some depressive episodes. NIMH also cautions that antidepressants are not used alone in bipolar disorder because they can trigger a manic episode or rapid cycling. Decisions about any medication belong with your prescriber. Therapy can help with routines, early warning signs, family communication and the stress that often surrounds the illness.

What can you do during a low? Step by step

Small, steady actions can help you get through a low and give your care team better information. They work alongside treatment, not instead of it.

1. Tell your prescriber. Let them know the low has started, how long it has lasted and how severe it feels.
2. Protect sleep timing. Keep the same wake time each day, even when you want to stay in bed.
3. Keep a mood chart. NIMH suggests a life chart or mood journal to help recognize mood swings.
4. Do one small task a day. A shower, a short walk or one message to a friend counts.
5. Avoid alcohol and drugs. They can deepen lows and interfere with treatment.
6. Stay connected. Agree with one trusted person that you will check in daily.
7. Review your safety plan. Know whom you will call if thoughts of self-harm appear.

What helps prevent the next low?

Prevention usually rests on staying with treatment between episodes, keeping daily rhythms steady and catching early warning signs. Many people find that their lows start in a familiar way, such as sleeping later, skipping plans or feeling flat for several days.

NIMH recommends that people keep a routine for eating, sleeping and exercising. Other habits that help:

• Write down your personal early warning signs and share them with someone you trust.
• Agree in advance with your care team on what to do when those signs appear.
• Keep follow-up appointments even when you feel well.
• Plan ahead for disruptions such as travel, holidays or a new work schedule.

What should family members say and do?

Family members help most by staying calm, patient and present, and by noticing changes early. You do not have to fix the low; you do have to stay connected.

NIMH encourages loved ones to offer emotional support, understanding, patience and encouragement and to be alert to major mood changes. Things you might say:

• "I've noticed you've been sleeping a lot and skipping things you usually enjoy. How are you doing?"
• "You don't have to explain it. I'm here, and I'm not going anywhere."
• "Would it help if I sat with you while you called your doctor?"
• "Are you having any thoughts of hurting yourself? You can tell me."

Avoid telling someone to "snap out of it" or comparing their low to ordinary sadness.

When should you get help right away?

Get help right away if there are thoughts of suicide, a plan, or talk of being a burden. Thoughts of death or suicide can be part of a bipolar low, so these signs should never wait for a routine appointment.

NIMH lists warning signs of suicide such as talking about wanting to die, feeling hopeless or trapped, withdrawing, giving away possessions and increased substance use. The 988 Lifeline notes that warning signs are more concerning when they are new or increased.

Also seek urgent care for signs of mania or a mixed state, such as days without sleep combined with agitation, or seeing or hearing things others do not. Lyte Psychiatry is an outpatient practice. It does not provide inpatient care, crisis or after-hours coverage, medically supervised detox, or intensive outpatient or partial hospitalization programs.

What should Texans know about bipolar care?

Bipolar disorder is usually managed over years, so Texans benefit from a care setup they can keep up with, such as a mix of in-person and video visits. Telehealth is generally tied to where you are physically located during the visit, so plan to be in Texas when you join a Texas provider's video appointment. Lyte Psychiatry offers telehealth visits to patients who are physically located in Texas at the time of the visit.

Practical points for Texas families:

• Keep a written list of medications, past episodes and what helped, and bring it if you change providers.
• Ask whether visits and family sessions are available in Spanish if that is your household's language.
• Confirm insurance coverage and network status directly with both the practice and your plan.
• Save local and national crisis numbers in every family member's phone.

Getting support in Texas

If you are living with bipolar depression or think a loved one might be, a psychiatric evaluation is a good next step. Lyte Psychiatry offers therapy, psychiatric evaluation and medication management in Texas. In-person visits are available at Lyte Psychiatry's clinic in Pantego, in the Dallas–Fort Worth area. Lyte Psychiatry offers telehealth visits to patients who are physically located in Texas at the time of the visit.

All Lyte Psychiatry services are available in Spanish. Most new patients are seen within 1–2 business days. Weekend appointments are limited. Availability, insurance and clinician fit require confirmation.

Learn about depression care and medication management. For more on bipolar disorder, read our guide to the highs and 8 things people often don't know about bipolar disorder.

If you are in a mental-health crisis in the United States, call or text 988. Call 911 for immediate danger.

Educational information, not a diagnosis or individual treatment plan.