The symptoms of bipolar disorder that most grab our attention are the elevated mood states of hypomania and mania. The impulsivity, high energy, rapid speech and euphoria of someone experiencing elevated mood are far more unusual or aberrant than the pessimism, low energy and low self-esteem of depressed mood. So it may be surprising to learn that for those with bipolar disorder, particularly bipolar II, upwards of two thirds of experience is located on the depressive end of the bipolar continuum. Essentially, depression is pretty common for people with bipolar disorder.

Typically, bipolar depression isn't any different from what we might think of as garden-variety depression. Exceptions entail those instances where we see agitated depression or depression with strong irritability. These symptoms are low frequency but do reflect the unique mixed mood state where depressed mood blends with more intense energy. Yet for most that are bipolar, depression is mostly depression. Anergic, gloomy and painful.

The depressed person sees the world through a set of lenses or a filter that makes it difficult to access positive thoughts. Optimism and hope give way to pessimism. Energy feels depleted. The motivation "to do" and "to manage" one's life is replaced with lethargy and ennui. Essentially one turns inward and disengages from the external world.

Perceptions of self are also strongly affected. Most who are depressed experience low self-esteem. When filled with negative perceptions of self, it becomes equally difficult to imagine that others would find you to be likable or desirable. The world feels like a crappy place and your psychic house becomes a painful and inhospitable residence.

Sometimes depression is precipitated by external events that cause painful emotions (e.g. - rejection by a lover, career-related disappointment or financial insufficiency). And then there are other times when depression just sort of creeps into one's psyche, like invasive weeds. It's not that anything specifically is wrong on the outside. It's more like your sense of resiliency and optimism has lost its foothold. Your progression forward has transitioned to a gradual slide downward.

If there's any hope in this bleak experience it's that depressed mood is usually transient. Most people who experience depression aren't depressed forever. In fact, when depression occurs as a function of situational stressors, it usually resolves once the situation improves. The rejected lover finds a new relationship. The individual with a stagnating career finds a new job. And even for those who seem to be stuck in a depressive rut that has no clear or obvious explanation, there is still hope for treatment-related improvement. Good psychotherapy can yield change; so can the right antidepressant, regular exercise, good sleep and healthy living.

But this equation doesn't necessarily apply to those with bipolar disorder because they face a unique risk that most with unipolar depression do not; that is, the medications most often prescribed for moderate to severe depression, the antidepressants, can sometimes precipitate rapid progression towards hypomania and mania. In this regard they can be dangerous, like trying to smother a smoldering fire with dry sawdust. Just add enough oxygen and you've got much more than you bargained for.

And the psychiatric alternatives? Well, mostly they are the mood stabilizers as well as the few atypical antipsychotic medications that have been approved for adjunctive treatment of depression. Sometimes these combinations can be effective. But there are many other times when depressed bipolar individuals don't feel adequately helped by their medication. Their escape from depression feels blocked and their helpers, the psychiatrists and psychotherapists, seem only to be offering snake oil remedies. At least so things can seem through a set of depressed lenses.

When bipolar depression sets in there are two elements essential for change and improvement: these are willfulness and patience. A close cousin of willfulness is intentionality and both need to be applied to get moving. Unfortunately, from the middle of depression, the thought of exercise may seem as doable as defying gravity. Despite the enormity of the endeavor, the process of getting there is as basic as putting one foot in front of another while moving towards the gym, the track, the exercise bike or the swimming pool. And once there, you do it, regardless of how difficult or pleasure-less the experience may be. Put differently, when you're overtaken by inertia you must try to get yourself moving; and you try, and you try and you keep trying until movement begins to happen.

There are many other aspects of movement and activation that are similarly applicable: moving out of bed and out of the house; moving towards your "to do" list; moving towards improved self-care; moving towards support and professional help; and beginning to move towards change, even when your depressed lenses filter out such options. Granted, when motivation is depleted, these can seem like monumental endeavors, but they truly do make a difference.

Let's also look at this notion of patience. An analogy we can all relate to is the experience of being sick with a really bad cold or possibly even the flu. Think of how miserable you feel the second day into your illness. If you thought the same experience would continue indefinitely, it would feel intolerable. Feelings of helplessness and hopelessness would wrap around your experience of a sore throat, fever and body aches. That's exactly what happens with depressed mood. Now feels like forever... but it's not. Depression will end as certainly as mood variability is the essence of bipolar illness. Such needs to be written on the eyelids of people with bipolar depression.

Let there be no illusion that living through bipolar depression is easy. The depressive end of the bipolar continuum can feel really awful. And what's worse is that's a place you may visit many times over the years. But despite this awfulness you can hold hold on to the reality that your depression is not here to stay. 

And when your depressed lenses make this all look like a bunch of inspirational garbage, then you've also got the benefit of rationality to help you recognize that your take on reality may not always be accurate. With sufficient commitment your willfulness and your patience will help you endure your depression while moving towards something better.

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Russ Federman, Ph.D., ABPP is Director of Counseling and Psychological Services at the University of Virginia. He is also co-author of Facing Bipolar: The Young Adult's Guide to Dealing with Bipolar Disorder (New Harbinger Publications).

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