Depression, Mania, and Hypomania: What You Need to Know

Knowing something about depression and mania makes it easier to recognize when you need to get help. It’s also valuable information if you’re worried that someone in your life has a mood disorder.

This article covers some of the vital facts about depression and mania, but if you’re keen to keep learning, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) offers a lot more detail about several different types of mood episodes, including depression, mania, hypomania, and mixed states.

Depression and Mania

Depression

For a lot of people, depression is about feeling sad, day in, and day out. But it’s not like that for everyone. Some people with depression will swear up and down that they don’t feel sad. What they do feel is empty, flat, or irritable. Sometimes even those feelings aren’t what sticks out. Instead, it’s the inability to get enjoyment out of anything. The activities or people that used to bring a smile to their face, simply don’t anymore. The world has become unrelentingly grey.

Depression doesn’t refer only to your mood – it also comes with physical and cognitive (thinking) symptoms. Changes to energy, appetite, and sleep are very common. It could be eating too much or not eating enough, ditto for sleep. And then there are the thoughts. Hopelessness, helplessness, worthlessness, thoughts of death and suicidality can all surface.

Mania

As a starting point, mania is sometimes thought of as the opposite of depression. Instead of sadness and low self-esteem, classic mania comes with an elevated mood and a high level of self-confidence. In some cases, instead of being overly happy, it’s again irritability that dominates the mood. Someone in a manic phase may find themselves arguing with friends, family, and strangers alike, for reasons that aren’t even that clear.

Mania is also about being much more active and energetic than usual. Many people amid a manic episode have much less need for sleep. They can get by on three hours a night and still wake up ready to rock and roll. Unfortunately, it’s not uncommon for some of the excess energy to be directed towards activities that cause more than a few problems. Spending way too much money, having affairs, impulsively quitting jobs, and losing your verbal filter can all be part of a manic episode. A manic episode can also include psychotic features like delusions of grandeur (I’m not an elementary school teacher, I’m an actor destined for Hollywood.”) Mania is not a condition to be taken lightly.

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Other Mood Episodes

Hypomania

In simple terms, hypomania can be thought of as a milder mania. Hypomanic episodes don’t last as long and aren’t as severe. Further, hypomania doesn’t interfere with your function, doesn’t include psychotic features, and doesn’t require hospitalization. All good, right? Well, it’s not that simple.

There are downsides to hypomania as well. The impulsivity seen in hypomania comes with an elevated risk of self- harm and risky substance use. Suddenly, behaviors that would be out of character when your mood was stable become considerably more likely.

It can be challenging to distinguish between a  hypomanic episode and being in a really good mood. So, what’s the difference? It turns out a hypomanic episode is not only obvious to those around you; it’s “uncharacteristic.” It isn’t just your regular, happy-go-lucky, I-just-got-a-massive-bonus-at-work state of mind. Hypomania is something that doesn’t look quite right to those around you. Of course, the person going through the hypomanic episode doesn’t always see it this way. Some people report enjoying getting by with only a few hours of sleep while finally starting all those projects on their to-do list.

Mixed Episode

As you can probably guess, a mixed episode includes features of both depression and mania. It can be a depressive episode with a few symptoms of mania or vice versa. Either way, it’s a very distressing emotional state.

Why recognizing depression mania and hypomania matters

Why does it matter if your irritability or problems sleeping is due to depression or mania? Why do doctors ask so many questions when you go to their office seeking help? The answer is this – different mood episodes require different treatments. Until medicine finds a way to diagnose mood episodes using a blood test or an MRI, the only option is to ask question after question to make sure the diagnosis is right. Even then, it’s not uncommon for a history of mania or hypomania to be missed. After all, when you’re depressed, it’s not always easy to give an accurate recounting of the time you felt so happy you didn’t sleep for a week.

Once questions have been asked and answered and extensive efforts made to get the right diagnosis, a discussion of treatment options can follow.

Why treat mood episodes? Well, if the distress they cause isn’t enough, then the other impacts associated with depression and mania provide a pretty compelling argument for seeking help.

Impact of mood episodes

The list of impacts associated with depression, mania, and related mood episodes is long and troubling. That’s one of the reasons why it’s so important to recognize the symptoms as soon as possible.

Outcomes like suicidal behaviors usually come as no surprise when discussing mood episodes. However, depression and mania can also wreak havoc on your marriage, your job, your friendships, and your finances. Depression is sometimes easier to hide than the over-the-top happiness seen in mania, but it still permeates your daily activities. You may find yourself staring blankly at the computer screen at work – not able to remember what you’re supposed to do or even how to do it. Suddenly daily tasks seem overwhelming, and your life falls into disarray.

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Principles of treatment for depression and mania

Early treatment of mood episodes leads to better results, but delayed treatment is still far better than none.

Mild to moderate depression can be treated with psychotherapy, such as cognitive-behavioral therapy or interpersonal therapy. Severe depression is most commonly treated with medication, although electroconvulsive therapy (ECT) and transcranial magnetic stimulation are other options.

If you’re in the midst of full-blown mania, it’s hard to slow your thoughts down long enough to engage in therapy sessions. That’s why medication is the mainstay of managing acute mania. ECT is sometimes used for mania as well.

Antidepressants are first-line treatment for a major depressive episode. But they certainly aren’t a first-line treatment for a manic episode. In fact, antidepressants can make mania or hypomania worse.  Mood stabilizers are the treatment of choice for mania full stop. Hypomania is commonly treated with mood stabilizers as well.  Mixed episodes may require a combination of medications and, perhaps not surprisingly, are often harder to treat than “pure” depression or “pure” mania.

Take home message

Depression, mania, hypomania, and mixed episodes are the core features of major depression and bipolar disorder. Knowing what to look for helps you pick up on the earliest indication that something needs fixing. Early detection allows for early treatment, and early treatment means better outcomes.

REFERENCES

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: Amer Psychiatric Pub Incorporated.

Bauer, M., Severus, E., Möller, H. J., Young, A. H., & WFSBP Task Force on Unipolar Depressive Disorders (2017). Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. International journal of psychiatry in clinical practice21(3), 166–176. https://doi.org/10.1080/13651501.2017.1306082

Lam, R. W., McIntosh, D., Wang, J., Enns, M. W., Kolivakis, T., Michalak, E. E., Sareen, J., Song, W. Y., Kennedy, S. H., MacQueen, G. M., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 1. Disease Burden and Principles of Care. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 61(9), 510–523. https://doi.org/10.1177/0706743716659416

McIntyre, R. S., Young, A. H., & Haddad, P. M. (2018). Rethinking the spectrum of mood disorders: implications for diagnosis and management – Proceedings of a symposium presented at the 30th Annual European College of Neuropsychopharmacology Congress, 4 September 2017, Paris, France. Therapeutic advances in psychopharmacology8(1 Suppl), 1–16. https://doi.org/10.1177/2045125318762911

Smith, L. M., Johns, L. C., & Mitchell, R. (2017). Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review. Bipolar disorders, 19(6), 417–433. https://doi.org/10.1111/bdi.12520

Steardo, L., Jr, de Filippis, R., Carbone, E. A., Segura-Garcia, C., Verkhratsky, A., & De Fazio, P. (2019). Sleep Disturbance in Bipolar Disorder: Neuroglia and Circadian Rhythms. Frontiers in psychiatry, 10, 501. https://doi.org/10.3389/fpsyt.2019.00501

Tondo, L., Vázquez, G. H., & Baldessarini, R. J. (2017). Depression and Mania in Bipolar Disorder. Current neuropharmacology15(3), 353–358. https://doi.org/10.2174/1570159X14666160606210811

Vázquez, G. H., Lolich, M., Cabrera, C., Jokic, R., Kolar, D., Tondo, L., & Baldessarini, R. J. (2018). Mixed symptoms in major depressive and bipolar disorders: A systematic review. Journal of affective disorders225, 756–760. https://doi.org/10.1016/j.jad.2017.09.006