When Depression Turns Out to Be Part of a Bigger Pattern

Why are people with bipolar disorder often seen for depression first?

Depression is usually what brings people in. The lows of bipolar depression can be so heavy that a person struggles to get out of bed or make small decisions, so it makes sense to ask for help then. The American Psychiatric Association notes that people with bipolar II disorder often first seek treatment because of depressive episodes, since hypomanic episodes can feel pleasurable and may even boost performance at work or school.

Nobody tends to book a visit because they felt unusually productive last spring. The National Institute of Mental Health (NIMH) says hypomanic episodes may go unnoticed, which is one reason some people have bipolar disorder for years before it is diagnosed. This is nobody's failure. It is a common gap in the story a provider gets to hear.

How can a bipolar low look the same as other depression?

The major depressive episode described for bipolar disorder lists the same kinds of symptoms people know from depression: deep sadness or loss of interest, fatigue, sleep and appetite changes, trouble concentrating, feelings of worthlessness, and thoughts of death or suicide. Depression is also diagnosed on symptoms lasting at least 2 weeks, the same time frame.

So a single snapshot may not separate the two. NIMH advises looking at the course of the condition over time rather than focusing only on current symptoms, and says diagnosis rests on symptoms over a person's lifetime and on family history. The difference tends to live in the history, not in how today feels.

What will a provider ask about your history?

Expect questions that go beyond the current low. None of these answers proves anything alone, and it is fine to say you are not sure. Here is what is often being asked and why.

Why does the difference matter for treatment?

Treatment plans differ. NIMH says bipolar depression is often treated with a mood stabilizer or an atypical antipsychotic medication, and that antidepressants may be added for some people but are not used alone, because alone they can trigger a manic episode or rapid cycling. The American Psychiatric Association likewise says antidepressants are used cautiously in bipolar depression. Therapy can be part of the plan too, and our mood disorders page says more about care for this group of conditions.

If you take an antidepressant today, please do not stop or change it because of this article. Antidepressants are widely used and helpful for depression, and stopping any medication should be planned with your prescriber. Bring your questions to the person who prescribes it.

Medication choices here are made after an evaluation. Not every medication can be prescribed at every kind of visit, some may require an in-person appointment, and we explain what applies to you. Our medication management page describes the follow-up.

How can family input help, and is it my choice?

Family members often see what the person living it does not. NIMH notes that family and friends may notice mood swings and changes in activity even when the person feels fine, and the American Psychiatric Association says manic changes must be clear to friends and family. A partner or parent may remember a summer of little sleep and big plans that you recall as simply a good time.

For adults, this is your choice. You decide who is involved and what they may hear, and information is generally shared only with your permission. The main exception is a serious and immediate safety risk. You can bring someone to a visit, ask them to write a few notes, or start alone and invite them later. For patients under 18, a parent or guardian must be present at appointments.

What can I do to prepare before a visit?

A little homework can give your provider a much clearer picture. You do not need perfect dates.

1. 1Sketch a timelineNote your lows and roughly when they happened, then add any periods when you slept little, felt unusually energetic, or took on much more than usual. NIMH calls this kind of record a life chart.
2. 2List your medications and what happenedWrite what you take now, what you have tried, and how each one seemed to affect your mood, sleep and energy. Include over-the-counter products and supplements.
3. 3Ask someone who knows youIf you are comfortable, ask a family member or close friend whether they recall times you seemed different. Write down what they say.
4. 4Find out what you can about family historyAsk about relatives with depression, bipolar disorder, hospital stays for mental health, or suicide. Partial answers still help.

What if I was told it is depression and now I wonder?

Raise it directly. You could say, for example, that you read about bipolar disorder and want to go over your history. A review of a diagnosis is a normal part of care, and NIMH notes that misdiagnosis may happen because some bipolar disorder symptoms are like those of other illnesses. A new question does not mean your earlier care was wrong.

This matters most when treatment has not helped as much as hoped, though there are many other possible reasons for that. Our guide on when treatment is not working covers what to track and who to talk to.

How does this work at DanShalom Behavioral Clinic?

A first evaluation takes about 60 minutes with Victor Onodjacha, MSN, PMHNP-BC, a board-certified psychiatric-mental health nurse practitioner whose main areas of experience include depression and bipolar disorder. You will see the same provider at every visit, which helps when a pattern takes time to become clear. Visits are at our Sugar Land office or by secure video if you are physically in Texas, Idaho, Arizona or Maryland.

You can request an appointment and check coverage on our insurance page. If you are in crisis, call or text 988, or call 911 if there is immediate danger. DanShalom Behavioral Clinic is not an emergency service, and our crisis resources page lists more places to turn.