Bipolar or Major Depression?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Depressed person

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Since episodes of depression are a feature of Bipolar Disorder, how would we know if this is indeed Bipolar Disorder? And does it really matter?

Yes, it does matter. People who have Bipolar Disorder are more likely to have major problems in many areas of their life. Certainly, depression is debilitating, it causes more disability than lots of physical disabilities but Bipolar cases more noticeable and life-threatening problems. Treating someone who has Bipolar Disorder for depression may result in creating manic episodes and make the condition worse. No professional ever intends to make the patient worse, at least I hope not, but not seeing the signs of Bipolar can result in incorrect treatment. Now in fairness to doctors and other professionals often the client, not knowing the differences, fails to report symptoms that might have helped in getting the correct diagnosis. Here are some things that might indicate that the condition under treatment was, in fact, Bipolar Disorder and not Major Depression.

1. Sudden onset of episodes.

Clients with Bipolar are more likely to have sudden episodes of depression and sudden remission of depressive symptoms. Major Depression is more likely to creep up on you. And Major Depression rarely just goes away suddenly without treatment or some other reason. Bipolar Disorder may strike suddenly and it may switch to an elated mood or mania all of a sudden.

2. Early age of first onset.

There was a time when we thought little kids did not get depression, not anymore. Very small children do indeed experience episodes of depression. One way we have found this out is that more and more people who struggled with depression or Bipolar Disorder as children have become professionals.

The younger the child is when they first experience a mood disorder episode the more likely they are to go on and develop Bipolar Disorder. Now we are not saying that the child is to blame for being moody. If they are able to control the mood swings then it is not Bipolar or Depression. We are also not talking about that day-to-day moodiness or event-triggered moods that all children experience. Each type of mood disorder, depression, Dysthymia, Cyclothymia, Bipolar one, and two each have a minimum length of time that is needed. This separates the events of living from a true episode of a mental illness.

3. Presence of Psychosis

With Bipolar Disorder there is almost always some disturbance of reality. This does not mean that the client is hallucinating. Psychosis also includes delusions, irrational thinking, and lots of grandiosity. During manic episodes, people with Bipolar simply try to do way too much. And they believe they can and should be able to do these things.

There is also a diagnosis of Major Depression with Psychotic Features, so the boundary between Depression and Bipolar gets blurry the closer you look. The good news is it doesn’t matter which label you get, the treatment is about the same. The bad news is that by sticking with the treatment for depression sometimes the diagnosis and treatment of Bipolar Disorder gets delayed. If you or those around you say you have thinking problems, grandiosity or delusions make sure to tell the professional who is treating you. If you don’t have someone treating you and experience delusions, seek help quickly. The sooner you get help the better the prognosis.

4. Presence of “Psychomotor retardation”

During episodes of depression some people get so tired they have trouble moving. Sometimes they literally can’t get out of bed. These extreme levels of impairment may signal that this is Bipolar and not Depression.

5. Having “Atypical features”

Many people with depression become very agitated. They can’t sleep and they can’t eat. People with atypical features are just the opposite. A shorthand way of explaining Atypical features is like a bear hibernating for the winter. These clients eat all they can. They may be over hungry at certain times of the day. Then once they get to bed they want to, need to, sleep far beyond what other people do. During extreme episodes of depression with atypical features, a client will be unable to do anything but sleep and eat.

These “Atypical” features can be seasonal as in Seasonal Affective Disorder or they can come and go with the rhythms of the year.  Having an episode of depression with atypical features increases the chances that an episode of mania or hypomania is just around the corner and with that episode comes a diagnosis of Bipolar Disorder.

6. Having a sudden overwhelming improvement in depression mood when given an antidepressant.

Antidepressant medications need time to work. Usually, the effects of antidepressants build up slowly over time. Antidepressants are not “happy pills” they do not suddenly make someone happy. They should usually be coupled with some form of therapy or addressing life’s problems.

When people with Bipolar Disorder take antidepressants they are sometimes propelled from depression to mania. A sudden huge response to antidepressants needs to be monitored for possible mania or delusional thinking. Too much response to an antidepressant suggests that this is, in fact, Bipolar disorder.

If you are unsure about this or think you may have Bipolar instead of depression talk with your doctor, psychiatrist, or therapist before making any changes in your meds. Your doctor needs to know what is happening in order to monitor your condition and there can be adverse results to suddenly stopping or changing a medication.

7. Family history of Bipolar Disorder, Psychosis, Schizophrenia, or excessive irrational behavior.

The more people on your family tree with an issue, especially close relatives, the more likely you are to have problems. Being Bipolar has had some advantages in some situations. Many people with Bipolar disorder are highly creative and productive as long as they can keep things on track.

Some families have avoided getting professional help and so there may be no formal diagnoses but most families have their stories about family members with mental health issues. Family trees with lots of depression in them seem to produce more people with a genetic risk factor for depression. Families with lots of people who had hallucinations, delusions or mania increase the risk for Bipolar Disorder. Lots of substance abuse in your family tree increases risks for substance abuse and mental illness, for a variety of reasons. Remember however that risk factor does not equal an illness. Lots of people grow up in high-risk families and have no problems, other people are the first in their family to get a diagnosis or have a problem. We are still trying to figure out why this happens.

Hope this was food for thought for you and that it encouraged some people to go for the professional help they need.

Till next time this is David Joel Miller, LMFT, LPCC saying so long.

If you have any thoughts on depression or Bipolar Disorder and the differences between them, please leave a comment on this blog.

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12 thoughts on “Bipolar or Major Depression?

  1. David,

    I stumbled upon your blog while doing research in preparation for an upcoming appointment with my mental health provider. I moved recently so I had to find a new one. Unfortunately, the new mental health provider authorized by my insurance is of the opinion that “bipolar is bipolar” and “hypomania means bipolar-even if it only occurred once while on Zoloft and stopped after the Zoloft was changed to something else.” She even told me that there is really no need to distinguish between BD I, BD II, and Cyclothymia.

    This is the third post I have read so far, and I am eager to read more. Your insights and style of writing are refreshing. I wish I lived in your area, because I would love to find a therapist like you. I had a forward thinking MHNP and a great primary doc before I moved, and our plan had been to come off all medication eventually and supplement with Omega 3s and lifestyle choices (it’s been four years since post pardum depression dx, after a hypomanic reaction to Zoloft, switched to Cymbalta and added Lamictal just to be safe because my biological mother has Bipolar I disorder). I have been in remission for three years, not a single episode. I go in to this new provider to see about coming off the Lamictal and eventually the Cymbalta. She tells me I should be on a mood stabilizer for the rest of my life, because my one hypomanic period on Zoloft makes me Bipolar. She did go ahead and agree to wean me off (I would never do so on my own without doc’s permission), but because she was so concerned with mania, she pulled me off Cymbalta in just three weeks, so I have been really physically sick. I hate this new provider. She doesn’t listen to anything I say and even accused me of not being honest with her about how many episodes I have had. Honestly, it was just the two–my husband is even coming with me to the next appointment to vouch for me. My current plan of action is to print out relavent journal articles and criteria from the DSM and discuss them with her in person. Anyhow, I apologize for the tume about my personal situation. Your blog is great… Keep doing what you are doing.


    • Thanks for sharing your experience. All professionals can be opinionated from time to time but the way I read the DSM-4-tr is, if the only time you have hypomania is as a result of taking meds, it is not used to establish a diagnosis of Bipolar. If this provider has her mind made up, taking in journal articles is not likely to help. If possible I would look for another provider. I have seen a lot of professionals lately accuse the client of lying, that mostly means the profession does not know how to help you. If they do not at least believe you are telling them what you think the truth is then there is little chance they will be helpful.


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