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Can you have depression and bipolar: What Is Substance Abuse Treatment? A Booklet for Families

Is This Depression and Bipolar Disorder Mania?

Two separate diagnoses. So how is it you’re seeing symptoms of both depression and bipolar disorder mania at the same time?

It might look like irritability, racing thoughts, or a feeling of inner tension or agitation. At the same time, you might have lost interest in things you previously enjoyed and are persistently sad.

It’s essentially like having a low mood with high levels of energy.

So what does this mean? Is it bipolar disorder or depression?

In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), someone may be described as having “mixed features” if they have symptoms of both depression and mania or hypomania.

Previously this was called mixed episodes and only applied to bipolar disorder. Now, someone can have mixed features in bipolar disorder and depression.

Someone diagnosed with major depressive disorder (MDD) could be described as having mixed features if they’ve had at least 3 symptoms of mania or hypomania during a depressive episode.

This newer addition to the DSM-5 is still a bit controversial.

Bipolar disorder IMarked by episodes of mania and calm state, euthymia (you-thigh-me-uh), lasting weeks or months. Depression isn’t needed for diagnosis, but possible. Could develop into psychosis.
Bipolar disorder IIMarked by alternating episodes of hypomania, major depression, and euthymia lasting days or weeks. Could develop into psychosis.
Major depressive disorder
/clinical depression
Marked by low mood, loss of interest in daily activities, and despair that lingers throughout the day, almost every day for at least 2 weeks. Can be the most severe form of depression. Could develop into psychosis.

When symptoms of depression occur at the same time as hypomania symptoms, it might look like:

  • racing thoughts
  • inner tension, irritability, or agitation
  • excessive talking
  • unprovoked rage
  • crying spells
  • trouble falling asleep
  • strong emotions

According to 2015 research, mixed features occur in about:

  • 34% of people with bipolar I
  • 33. 8% of people with bipolar II
  • 26% of people with MDD

The researchers suggest that mixed features may fit into a continuum — ranging from pure mania to pure depression.

They also note that people who experience mixed features are often younger. Younger folks with mixed features also tend to experience more rapid cycling between depression and mania.

The researchers also found that people of all ages who have mixed features may:

  • encounter greater problems with everyday functioning and substance use
  • be more likely to be unemployed
  • be more likely to have co-occurring heart disease

Major depressive disorder and bipolar disorder are two separate conditions — you can’t be diagnosed with both at the same time. But that’s because diagnostic criteria for bipolar disorder II includes MDD.

Of course, it is possible to be misdiagnosed. It can sometimes be difficult to tell the difference between the two conditions, even for healthcare professionals.

Although the symptoms of depression are often fairly straightforward to spot, it can be more challenging to recognize the symptoms of mania, and particularly hypomania (the less severe form of mania). Plus, someone may be more likely to seek help when experiencing depression than mania.

About 13–20% of people who have MDD with mixed features will eventually meet diagnostic criteria for bipolar disorder I or II.

Misdiagnosis can also happen for other reasons. For example, depression with mixed features can look like depression with borderline personality disorder. Or depression combined with a substance use disorder can resemble hypomania or mania symptoms.

Receiving a misdiagnosis may set back a person’s recovery, since depression and bipolar disorder are typically treated with different medications.

To figure out if you have MDD, bipolar disorder, or another condition altogether, a mental health professional must conduct a thorough evaluation to determine which best fits your symptoms.

Mania in bipolar disorder with mixed features may actually be more common than in bipolar disorder without this specifier.

A 2017 study notes that while about 30% of people with bipolar disorder have recurring episodes of mania, approximately 40% have mania with mixed episodes.

The same research also suggests that mixed states may be linked to an imbalance in the catecholamine-acetylcholine system.

Catecholamines are a type of hormone produced by the adrenal glands. They help the body respond to stress or fear and prepare it for “fight-or-flight” reactions. Hormones of this type include epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine.

Acetylcholine is a chemical messenger in the brain (aka a neurotransmitter) that plays a role in motivation, learning, and memory.

People with bipolar disorder tend to have repeated episodes of the same type. So those with mixed episodes are likely to keep having more mixed episodes.

The study indicated mixed features in bipolar disorder tend to:

  • lead to more severe outcomes
  • have a more inconsistent treatment response
  • result in more frequent suicide attempts

People experiencing mixed states are usually treated with more than one type of medication. Treatment usually involves atypical antipsychotics and mood stabilizers.

Electroconvulsive therapy (ECT) — a procedure that sends electrical impulses through the brain — is sometimes used in treatment-resistant cases that haven’t responded to medication.

It’s typically only used for severe depression or bipolar disorder with depressive episodes. Though less conventional, some people choose ECT since it’s fast and effective. However, it does come with side effects.

Many people associate bipolar disorder with its highs and lows, and depression as only lows. But mental health is far more complex than that.

We now know that depressive symptoms can happen at the same time as manic symptoms.

If you’re having low moods for days to months, coupled with aggravated energy — despite little to no sleep — don’t hesitate to reach out to a doctor or mental health professional. No matter the condition or symptoms you have, seeking support can help you cope.

Bipolar Disorder vs.

Depression: What’s the Difference?

Written by Barbara Brody

Medically Reviewed by Poonam Sachdev on April 05, 2023

  • Bipolar Disorder vs. Depression
  • Bipolar Depression vs. Bipolar Mania
  • Other Ways to Tell If You Might Have Bipolar Disorder 
  • The Right Treatment

Bipolar disorder and depression have many similarities. But they also have some key differences. It’s important to know how to tell one from the other to get the right treatment.

Depression is more than just feeling low. It’s a deep sadness or emptiness you can’t shake. You might feel hopeless, worthless, and restless. You might lose interest in things that you used to enjoy. Depression (also called major depressive disorder or MDD) often goes hand-in-hand with sleep problems, changes in appetite, and trouble concentrating. It can lead to suicidal thoughts or actions. People with depression might have some days that are better than others. But without proper treatment, their mood tends to remain low.

Bipolar disorder (sometimes called manic depression) is different. If you have it, you have extreme mood swings. You may go through periods of depression (similar to MDD). But you also have periods of great highs.

Bipolar refers to the opposite ends, or poles, of the emotional spectrum — the highs (mania) and the lows (depression). You might be severely depressed for a period of hours, days, weeks, or even months before entering a manic period. The mania could range from several days to 2 months or longer. It’s also possible to have a type of bipolar disorder in which you have manic and depressive symptoms at the same time. You might feel sad and hopeless but also be very agitated and restless.

The highs of bipolar disorder might feel enjoyable. But they also can be dangerous. Risky behavior could put you in physical danger. And mania is usually followed by extreme depression.

About 6 million American adults have bipolar disorder. That might sound like a lot. But bipolar disorder is much rarer than depression, which affects slightly over 17 million American adults in a given year.

The symptoms of bipolar depression are the same as those for major depression. They show up in different ways for different people. You might have trouble sleeping. Or you might sleep too much and even find it hard to get up. The smallest decisions can seem huge. Overwhelming feelings of failure, guilt, or deep loss can trigger suicidal thoughts.

Other signs to look for:

  • You feel like you can’t enjoy anything.
  • You find it hard to focus.
  • You eat too little or too much.
  • You’re weary, and your movements seem slow.
  • You’re forgetful.

For a diagnosis of major depressive disorder, you must have several depression symptoms that make it hard for you to function every day for at least 2 weeks. It’s possible to have bipolar disorder without ever having a depressive episode. 

People with depression don’t have episodes of mania. But those with bipolar disorder have periods of either mania or a milder form called hypomania.

Mania is a high that goes way beyond “happy” or “joyful.” When you’re having a manic episode, you might be very energetic, get very little sleep because you’re so wired, and find yourself talking faster because your thoughts are racing. You might feel like the world’s best multitasker. You might also take risks that you normally wouldn’t take. Examples could include going on a spending spree or driving recklessly.

Sometimes this kind of behavior is easy to spot, but not always. That’s especially true if you have hypomania. You might feel good, be happy that you’re extra energetic, and think that you’re just being productive. Friends and family members may be better able to notice that you’re acting out of character. Hypomania doesn’t turn into psychosis (which is when you lose touch with reality) like mania can, but it’s part of a bipolar diagnosis. 

Some people have mania often, others hardly ever. People with bipolar disorder can also go through times when they’re neither manic nor depressed.

Signs of manic behavior include:

  • Your mood isn’t comfortable. It might feel good at first, especially after depression. But it quickly becomes erratic and out of control.
  • Your judgment swerves way off. You take extreme risks. You make bad decisions with no thought for what might happen. For instance, you might spend money recklessly or have risky sex.
  • You get bad-tempered and angry.
  • You feel strung-out or edgy.
  • You find it hard to sleep.
  • You feel like your mind is a freeway. You might talk super-fast and hop subjects, or think you can do too many things at once.

People with hypomania may:

  • Talk fast
  • Have lots of energy
  • Need less sleep than usual

Bipolar disorder usually comes on at about age 25, but it can happen earlier. (By contrast, the average age for symptoms of major depression to start is 29.) There are different types of bipolar disorder, too, so it’s not always easy to diagnose. Symptoms can happen — or not happen — along a wide spectrum.

Also, some bipolar disorder symptoms are a lot like other conditions. For example, mania can feature psychotic symptoms. You might think you’re famous or have superpowers. On the flip side, with manic depression, you might think you’ve ruined your life in some dramatic way.

People with bipolar disorder may also have other conditions that make both diagnosis and treatment more challenging, such as:

  • Anxiety disorder or ADHD
  • An eating disorder
  • PTSD, or posttraumatic stress disorder
  • A physical disorder such as diabetes, obesity, migraine, or thyroid or heart disease
  • Substance use problems

Keep in mind that the chance that you’ll have bipolar disorder goes up if your parents or brothers or sisters have it. But it doesn’t always happen that way. For example, studies of identical twins show that one twin might have the illness, while the other doesn’t.


Getting a diagnosis of bipolar disorder isn’t always easy. A mental health expert who only sees you at your low points might not know about your manic behavior unless you or someone who knows you well brings it up.

A “life chart” is a good way to track your moods and help your doctor diagnose whether you have bipolar disorder. You’ll record details about your moods, sleep patterns, and events in your life. If you’re on a manic swing, you might feel “up” and capable, but a look at the big picture will show you how a “down” will follow. The info also will give your doctor a window into your day-to-day — even hour-to-hour — life to decide how best to proceed with treatment if needed.

Certain phone apps can help you keep up, too. There are quite a few available to help you track your moods, medications, sleep patterns, and more. One even analyzes how you type on your phone: your rhythm and speed, mistakes, corrections, and other dynamics, but not your content. It then uses this data to gauge your mood and predict bipolar episodes. Just remember that these apps don’t take the place of following a treatment plan under your doctor’s care.

If you think you might have bipolar disorder, it’s important to raise your concerns with a mental health expert and work closely with them to arrive at the correct diagnosis. Bipolar disorder is a lifelong condition. Proper treatment is often a combination of counseling and medication. It’s the best way to manage your symptoms.

A mood-stabilizing medication, such as divalproex or lithium, is often used to manage bipolar disorder. Some people take antidepressants in addition to a mood stabilizer or an antipsychotic medication. Taking an antidepressant by itself could actually trigger a manic episode. That’s another important reason to figure out if you have bipolar disorder or depression.

Over time, your condition may shift and your medications may need to be tweaked. Your health care provider may encourage you to track your symptoms. Recording your daily mood, sleep patterns, life events, and other details may help you and your provider stay on top of your condition and make sure you get the most effective treatment.

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Bipolar Disorder | Symptoms, complications, diagnosis and treatment

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Episodes of mood swings may occur infrequently or several times a year.

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When the mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, alertness, judgment, behavior, and the ability to think clearly.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medication and psychological counseling (psychotherapy).


There are several types of bipolar and related disorders. These may include mania, hypomania, and depression. The symptoms can lead to unpredictable changes in mood and behavior, leading to significant stress and difficulty in life.

  • Bipolar disorder I. You have had at least one manic episode, which may be preceded or accompanied by hypomanic or major depressive episodes. In some cases, mania can cause a break with reality (psychosis).
  • Bipolar disorder II. You have had at least one major depressive episode and at least one hypomanic episode, but never had a manic episode.
  • Cyclothymic disorder. You have had at least two years – or one year in children and adolescents – many periods of hypomanic symptoms and periods of depressive symptoms (though less severe than major depression).
  • Other types. These include, for example, bipolar and related disorders caused by certain drugs or alcohol, or due to health conditions such as Cushing’s disease, multiple sclerosis, or stroke.

Bipolar II is not a milder form of Bipolar I but is a separate diagnosis. Although bipolar I manic episodes can be severe and dangerous, people with bipolar II can be depressed for longer periods of time, which can cause significant impairment.

Although bipolar disorder can occur at any age, it is usually diagnosed in adolescence or early twenties. Symptoms can vary from person to person, and symptoms can change over time.

Mania and hypomania

Mania and hypomania are two different types of episodes, but they share the same symptoms. Mania is more pronounced than hypomania and causes more noticeable problems at work, school, and social activities, as well as relationship difficulties. Mania can also cause a break with reality (psychosis) and require hospitalization.

Both a manic episode and a hypomanic episode include three or more of these symptoms:

  • Abnormally optimistic or nervous
  • Increased activity, energy or excitement
  • Exaggerated sense of well-being and self-confidence (euphoria)
  • Reduced need for sleep
  • Unusual talkativeness
  • Distractibility
  • Poor decision-making – for example, in speculation, in sexual encounters or in irrational investments

Major depressive episode

Major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in daily activities such as work, school, social activities, or relationships. Episode includes five or more of these symptoms:

  • Depressed mood, such as feeling sad, empty, hopeless, or tearful (in children and adolescents, depressed mood may manifest as irritability)
  • Marked loss of interest or feeling of displeasure in all (or nearly all) activities
  • Significant weight loss with no diet, weight gain, or decreased or increased appetite (in children, failure to gain weight as expected may be a sign of depression)
  • Either insomnia or sleeping too much
  • Either anxiety or slow behavior
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Decreased ability to think or concentrate, or indecisiveness
  • Thinking, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorder may include other signs such as anxiety disorder, melancholia, psychosis, or others. The timing of symptoms may include diagnostic markers such as mixed or fast cycling. In addition, bipolar symptoms may occur during pregnancy or with the change of seasons.

When to see a doctor

Despite extreme moods, people with bipolar disorder often do not realize how much their emotional instability disrupts their lives and the lives of their loved ones and do not receive the necessary treatment.

And if you are like people with bipolar disorder, you can enjoy feelings of euphoria and be more productive. However, this euphoria is always accompanied by an emotional disaster that can leave you depressed and possibly in financial, legal, or other bad relationships.

If you have symptoms of depression or mania, see your doctor or mental health professional. Bipolar disorder does not improve on its own. Getting mental health treatment with a history of bipolar disorder can help control your symptoms.

Bipolar affective disorder and everything you need to know about it

More than 60 million people in the world suffer from bipolar affective disorder (BAD). The essence of the disease is that a person has alternating periods of altered mood throughout his life: from a state with a minus sign to a state with a plus sign. How and why is this happening?

Marina KINKULKINA, psychiatrist of the highest category, head of the department of psychiatry and narcology, director of the Institute of Electronic Medical Education, First Moscow State Medical University. I. M. Sechenova, Corresponding Member of the Russian Academy of Sciences, Professor, Doctor of Medical Sciences

Moreover, it is often not just about sadness or fun, as is often the case with emotional people, but about extreme degrees of either despair or euphoria. The change in these moods can take place both gradually and suddenly, and often for no apparent reason. This disease is attributed to Byron and Hemingway, Virginia Woolf and Edgar Poe, Van Gogh, Schumann, Vivien Leigh and many others. There is an assumption that even “our everything” suffered from a mild degree of BAD (contemporaries often mentioned mood swings) A. S. Pushkin. Modern stars – Catherine Zeta-Jones and Mel Gibson – openly admit to having this mental disorder. And rapper Kanye West even put the inscription on the cover of his album: “I hate being bipolar, it’s amazing.” A very accurate description of the essence of this disease.

Genetics does not solve everything

BAD affects both men and women, but the weaker sex – more often. As for the age of onset of the disease, this disorder can also appear in a teenager (especially if there is an appropriate heredity), and in an adult, and even in an elderly person. Everything is individual. The main risk factor is genetics, but a specific gene that would be responsible for the development of bipolar disorder has not been identified. This is a polygenic disorder, and it makes no sense to take genetic tests to find out how great the risk of getting sick is, because scientists still do not have a consensus on what specific combination of genes can lead to a violation. But even if there is a genetic predisposition, it is not certain that the disease will develop. This was proven by studies on identical twins, one of which developed bipolar disorder over the years, while the other did not. Accordingly, there must be some other predisposing moments. Science knows about some of them: life at the limit of possibilities with constant hands-on work, stress and chronic lack of sleep, as well as night shift work, frequent flights with a significant change in hourly flights and, of course, the use of psychoactive substances contribute to the development of the disease. Therefore, they should be avoided. Scientists have yet to learn about other factors.

But not boring?

The number of people suffering from bipolar disorder among the population, according to various estimates, varies from fractions of one percent to several percent. Recently, psychiatrists note, the proportion of affective disorders has increased significantly, which can be explained by improved diagnostics. At first glance, the BAR does not look like something scary and dangerous. To ignorant people, this disorder even seems attractive – sometimes sad, sometimes fun, in general, you won’t get bored. In addition, being different from everyone else is now fashionable. And then, there is an opinion that people with BAD have higher intelligence and creative abilities than the “gray masses”. But even if this is so, then none of those who suffer from it will definitely call BAD a pleasant thing. It is especially difficult for those patients who do not seek medical help on time. Without treatment, both phases of bipolar disorder can last for months (although sometimes the disorder occurs with frequently alternating phases). Moreover, it is impossible to say which of the periods of the disease is more difficult, manic or depressive.

Bad when very bad

Those who have experienced real depression say that this is the worst thing that can happen in life. In this state, the whole world is seen in black, the mood is depressed, self-esteem drops, life loses its meaning. A person suffering from BAD in the depressive phase perceives his very existence as a chain of tragic mistakes, constantly blaming himself for all the troubles and sins, even those that do not even exist. In addition to mental suffering, physical ones also arise: a person even moves with difficulty, as if swimming against the current, it is difficult for him to perform the most familiar actions. In addition, he can feel tension throughout the body, experience various pain sensations. With an average degree of depression, people often complain of debilitating pain in the abdomen and other parts of the body. On this occasion, they turn to doctors, but the diagnosis cannot be made. And the daily pain continues to harass. Psychiatrists call this somatoform symptomatology. With severe depression, many have the so-called atrial depression. Patients complain of pain and heaviness in the chest, they say that “a stone lies on the heart.” But even an in-depth examination does not reveal cardiac causes.

Often, with depression, patients (especially the elderly) complain of difficulty in thinking, memory impairment, they say that they have become stupid, they believe that they are developing dementia, they are afraid of “losing their mind”. In fact, affective disorders do not destroy the intellect. When treated with antidepressants, when the mood stabilizes, abilities are restored.

But the worst consequence of depression is suicide. Most suicide attempts are made in this state. Sometimes people in a very pronounced depression, believing that they have done something irreparable, and believing that the consequences of their actions can harm loved ones, decide on extended suicides, in which they settle scores not only with their lives, but also take their loved ones with them ( more often children).

Too bad when too good

The manic stage of BAD is subjectively more pleasant. Patients are not just in a very good, but in a great mood: they love the whole world and themselves in it. The reflection in the mirror pleases, there is not the slightest doubt about one’s own talents and mind, there is more than enough strength and energy, a bonus is accelerated mental activity. Many in this stage sleep for an hour a day, but do not experience fatigue. Sometimes they don’t sleep for whole days – and at least they are cheerful, like an “energizer”. It seems to be great. But no. With mania, desires and new ideas arise too quickly, so a person grabs at each new business, but, as a rule, does not bring any to the end. So productivity at this stage is no more than during depression. But it would be nice if that was the only thing.

The main danger of mania is that a person has no criticism at this moment, and he can do things that he will later regret very much. For example, he can give away all his property to others (sometimes to unfamiliar people or scammers who specifically use this state of his). Or, say, take out loans to go on a trip to the other side of the world, and take a bunch of friends with him. Maybe even steal something – for example, to make an expensive gift. Many patients at these moments enter into hasty intimate relationships, mistaking a chance meeting for the love of their life (and completely “forgetting” that family and children are waiting at home). Finally, often with mania, people, experiencing euphoria, ignore their severe somatic symptoms, as a result, they do not go to the doctor for a long time, and thus trigger a serious illness (pneumonia, for example). In addition, not all patients in the manic phase are “darlings.” Often they show unreasonable aggression if, for example, others do not agree with their “brilliant” advice. As a result of such “angry mania”, conflicts and even situations arise that require the intervention of law enforcement agencies and the hospitalization of the patient without his consent in a psychiatric hospital.

Good intentions…

The worst thing that relatives and friends of a person with bipolar disorder can do is ignore his problem, devalue suffering, while blaming the patient himself and appealing to his conscience. For example, they can call on a depressed person to “pull himself together, not become limp”, say that he is “mad with fat”, etc. A patient at the stage of mania is most often accused of immorality, irresponsibility, frivolity, promiscuity in relationships, etc. However, doing so is like blaming a person with diabetes for not being able to eat sweet cake, or a patient with heart failure for not running a marathon. BAD is a disease like many others. And she needs to be treated. The sooner you start the right therapy, the sooner you can stabilize the patient’s condition and the better the further prognosis will be.

Psychiatrists don’t bite

Despite the fact that recently people (especially young people) have ceased to be afraid to turn to psychiatrists, not everyone still decides to go to the doctor. Indeed, on the Internet in the public domain, you can find hundreds of questionnaires to test yourself for any mental disorder. And then, after reading various tips, you can also “cure”. Doctors strongly advise against doing this. The smallest harm of self-treatment is that it will not help or lead to incomplete improvement, but it can also worsen the condition. For example, inadequate intake of antidepressants in bipolar disorder can lead from a depressive phase into a severe manic state, from which it will then be difficult to get out. Only a psychiatrist (and not a psychologist, neurologist or doctor of any other somatic profile) can identify bipolar disorder and choose the right treatment. Treatment should be strictly individual, that is, the doctor selects it based on the characteristics of a particular patient and taking into account a specific moment in the course of the disease. The goal of therapy is not only to equalize the patient’s mood, but also to prevent recurrence. In the treatment of bipolar disorder, the main role is played by drugs for stabilizing mood – mood stabilizers (lithium salts, some anticonvulsants (anticonvulsants) and antipsychotics of new generations). Modern drugs are much better tolerated than their predecessors, have fewer side effects, as they are designed for long-term use over many years. Against the background of their intake, women can even become pregnant and give birth. In depression, antidepressants are prescribed in exceptional cases, given the danger of changing the depressive stage to manic.

You won’t be able to forget

The insidiousness of BAD is that this disease cannot be cured once and for all. But, alas, often, when the patient’s mood can be balanced by medication and he begins to feel good (such a state – intermission – is completely indistinguishable from a state of complete health), he can stop taking the drugs. This is a big mistake that does not allow to achieve a stable result of treatment. Sometimes it is required to use medicines (necessarily under the supervision of a doctor) for several months, but more often for years (with periodic visits to the doctor). It is the long-term use of maintenance therapy individually selected by the doctor that allows patients to achieve a stable good condition and feel the joy of life for many years.

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