No matter how desperate it feels, there’s hope—and tools and support—for climbing out of bipolar depression.
When Sara F. of Massachusetts has a hypomanic episode, she copes OK. Her hypomania tends to be dysphoric rather than euphoric, so she gets more angry or irritable than usual—but she’s still able to function throughout the day.
The bigger problem, she says, is that her hypomanic episodes tend to be followed by depressive nosedives that can last from a few days to a few weeks, or longer. It’s those bipolar depressions that drop-kick her life.
At one point, she had to quit a job she loved after seven months of “depressive meltdowns” at work—in the bathroom or the parking lot, depending on the day. Unable to afford rent, she ended up homeless for the better part of a year. She was hospitalized multiple times. And that was after she’d been diagnosed with bipolar II disorder and was pursuing treatment.
“My depression has always ruled my life with an iron fist,” says Sara. “It’s like being in an abusive relationship, but with my own mind.”
Media portrayals often equate “bipolar” with “manic.” In lived experience, however, it’s depression that predominates for most people.
“We don’t fully understand the reason why this happens, but depression represents the majority of time that people with bipolar disorder tend to be ill,” says Dan Iosifescu, MD, director of clinical research for the Nathan Kline Institute for Psychiatric Research and an associate professor of psychiatry at the New York University (NYU) School of Medicine.
Referring to “the natural history of the illness,” he says manic episodes typically don’t run as long as depressive episodes, even in the absence of treatment.
Past research suggests that on average, people with bipolar I tend to experience depression three times as often as mania. In bipolar II, that ratio is nearly 40 to 1.
Of course, personal experience can vary widely from the average. Some individuals may stay on the elevated end of the spectrum with scarcely any time in depression, for example, or see their mood swings shift more heavily downward as they age.
The destructive force of mania can level relationships, careers, finances, and reputations. Severe depressive episodes can do the same.
Sara has learned skills that help her weather low moods with more poise than in the past, but she still grapples with the effects on her mind, body, and relationships.
She has trouble sleeping. She brushes her teeth but not her hair. When delivering frozen meals to senior citizens and people with disabilities at her most recent job, she would break into tears between appointments.
“It takes a lot for me to climb out of the hole that depression throws me in,” says Sara.
Bipolar Depression Recovery
Let’s be honest: Bipolar depressions can be devastating, all-devouring, a seemingly endless string of difficult days. Coming out of the shadows takes patience and persistence. Even in well-managed bipolar, there’s no guaranteed safeguard against recurring depressive dips.
That’s not to say all hope is lost. Both recovery and prevention hinge heavily on self-care strategies, ideally backed by a combination of psychotherapy and medication. Plus, forestalling shifts into hypo/mania can limit the mood drops that usually follow.
A body of research shows that exercise, yoga, meditation, and mindfulness practices ease depressive symptoms and improve mental wellness. Nourishing the brain with a healthful diet and avoiding junk food has a positive effect on mood. The role that good sleep plays in maintaining balance can’t be overstated.
Challenging the negative self-talk, pessimistic attitudes, and other mindsets that are characteristic of and contribute to depression often requires working with a psychotherapist.
Bipolar Depression Treatment with Talk Therapy
“The good news is there are psychotherapies that seem to be working for bipolar depression,” says Iosifescu. “They don’t work very fast, unfortunately, but they do work.”
“Even if the strategies don’t work, my therapist makes me feel better by saying I’m at least trying new things,” Sara says.
Admittedly, even making the attempt can feel impossible when she’s deep in depression’s grip. When she feels the slightest lift in her energy and attitude, she commits to navigating at least part of her day outside her comfort zone.
Past experiments include participating in a yoga-plus-reiki class and learning how to make wire-wrapped jewelry pendants.
“Instead of being like, ‘Oh, I don’t think that’s going to work for me,’ I try to be open to ideas on how to help myself,” she explains. “Even if it’s just a tiny bit.”
That “tiny bit” approach, formally known as behavioral activation, has documented benefits. The idea is that taking small actions breaks the paralysis of depression, boosts confidence and self-esteem, and creates a snowball effect making further activity more likely.
Jennifer S.-M., a mother of two from Missouri, notes that sometimes it took an assist to get that snowball rolling.
In her former career as a tax attorney, Jennifer’s lingering depressive episodes from her bipolar I disorder led to multiple medical leaves from her job at a busy firm. At her most immobile, when she hadn’t showered in five days, her mother would visit to run a bath. A friend started showing up at her door unannounced, instructing her to put on shoes for an impromptu walk around the neighborhood.
“Those things help because then you don’t have to think about them yourself,” Jennifer says, adding: “And the next time, you have that motivation and ability to talk yourself through, to push yourself.”
Depression Medication Options
A number of the standard medications prescribed to control hypomania and mania also moderate depression to varying degrees. Mood stabilizers used in treating hypo/mania include lithium (a naturally occurring mineral), anticonvulsants (developed to control seizures in epilepsy), and antipsychotics (almost all originally targeted to schizophrenia).
Lithium’s usefulness in stabilizing bipolar mania was documented in 1949. It came into use in the US in the 1970s and remains a “first-line” treatment. The other classes of medications were added to the treatment toolbox as their helpfulness in controlling mood episodes was discovered. Iosifescu notes that this kind of overlap is very frequent in medicine.
In that tradition, researchers continue to narrow in on how effectively existing formulations—alone or in combination with other drugs—work for depressive episodes in bipolar. So far, four medications have been approved by the US Food and Drug Administration (FDA) to treat bipolar depression, meaning they’ve met stringent standards of proof in clinical trials.
The two most recent approvals are for atypical antipsychotics that came on the market in the past decade. (“Atypical” means the formulation was developed after first-generation or “typical” antipsychotics. As a rule, newer meds tend to have fewer side effects.)
One was added to the official options for treating bipolar depression in 2013. The other OK from the FDA came just last year, extending use of that medication from acute mania and mixed episodes to bipolar’s depressive episodes as well.
The FDA has approved an array of medications for major depressive disorder. That seems hopeful, since episodes of major depression and bipolar depression don’t differ from a diagnostic standpoint. However, it turns out they should be approached quite differently when it comes to prescribing antidepressants.
An analysis of existing research, published in the December 2018 issue of the International Journal of Bipolar Disorders, looked at this controversial topic in bipolar treatment. The biggest concern is whether antidepressants induce a “switch” from depression into hypo/mania or a “mixed” state (both depressive and manic symptoms) in individuals with bipolar disorder—especially when not paired with a mood stabilizer.
Down on the front lines, many primary care doctors aren’t thinking about possible risks of switching when a patient seeks help for depressive symptoms. That’s what happened to Liz of Philadelphia.
After Liz started taking antidepressants her doctor prescribed, the medication bumped up her mood so much she felt “out of control. I’d start six projects at a time, and I’d wake up feeling electric,” she recalls. “At a certain point, I realized, ‘This isn’t safe.’”
Compared to her depressions, hypomania “is more sneaky and makes me irrational, but I do feel really good,” she reflects. “The depression feels insurmountable, and it lingers longer.”
She still slips into days-long depressions a couple of times a month, often accompanied by anxiety—for example, contemplating all sorts of potential catastrophes that could befall her 5-year-old son. Now that she’s properly diagnosed, her current medication does make her depressive episodes easier to handle, she says.
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