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Have you tried a couple different antidepressant medications for at least a month (e.g. Prozac, Zoloft, Wellbutrin, Cymbalta, or Lexapro) but still experience depressive symptoms, like anxiety, sleep disturbances, lack of interest in your hobbies?

Have antidepressant medications caused you to feel overly activated, increased restlessness, irritability, or higher levels of anxiety?

If this is the case, your depression or anxiety may actually be signs of a mood disorder that falls somewhere in between unipolar depression and hypomania/mania on the mood disorder spectrum.

chronic pain treatmentsDefining a few key terms:

Unipolar depression or “depression”: Although it usually involves a constellation of symptoms, it’s marked by feelings of hopelessness and sometimes a lack of interest in activities that you once enjoyed. For a complete list of diagnostic symptoms, click here.

Bipolar depression: Similar if not the same symptoms as unipolar depression.

Mania: Symptoms occurring for at least one week that can include a decreased need for sleep (or no sleep at all), elevated mood, racing thoughts and distractibility. [This mood state is always noticeable by others and often requires hospitalization.]

Hypomania: Sort of mania-lite occurring for at least four days, same symptoms as above but with less intensity, possibly noticeable by others, and usually does not require hospitalization.

Mixed bipolar presentation: When an individual experiences depressive and hypomanic/manic symptoms simultaneously. For example, you may feel sad/hopeless while experiencing increased energy and a quickened speed of thought.

Please don’t be frightened; having a bipolar depression, hypomanic or mixed-state diagnosis in the world of psychiatry does not necessarily mean that you’ll one day experience full-blown mania. You might just assume you’ll experience sleepless nights, a racing mind or grandiose thoughts that you’ll one day figure out how they get the cream so evenly distributed in Hostess Twinkies or why Jay Leno is considered a comic.

The diagnosis also doesn’t mean that you’re Jekyll and Hyde, or a person who cycles through mood states that can leave you and your friends dizzied and annoyed. Rather, it means that your symptoms don’t fall into the tidy diagnostic categories of unipolar depression (one pole of the mood spectrum) and bipolar disorder (the other pole).

It’s only in the last 20 years or so that mental health clinicians began diagnosing bipolar depression and mixed bipolar presentations with better accuracy by reconceptualizing mood disorder symptoms along a spectrum. We know now that approximately 40% of folks who have bipolar disorder experience a mix of depressive and hypomanic/manic symptoms simultaneously, and there are a significant number of folks who feel some depressive or hypomanic symptoms but don’t quite meet criteria for either diagnosis. I would add that number, anecdotally speaking, is much higher (perhaps 50% – 60%) in my practice at Well Clinic. James Phelps, M.D., a leading bipolar disorder expert, states that most individuals fall between the two extremes on the mood disorder continuum and there are variations found at all points in between, even though only some points have names (i.e. BPAD II, mild depression, major depression, etc.).

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Why is this reconceptualization of mood disorders relevant to you?

Treating traditional depressive symptoms, if there is a bipolar component to your mood, requires a different class of medications called “mood stabilizers.” In other words, the traditional antidepressant medications likely won’t cut it in terms of symptom relief and may actually aggravate symptoms by causing increased energy, greater mood instability, more frequent sleep disturbances and likely an increase in racing thoughts.

For example, instead of spending more time trying the many different antidepressant options, you and your psychiatric provider would explore a mood stabilizing medication such as Lamictal, low-dose lithium, or Abilify* to treat your depressive and/or mixed symptoms. Additionally, if you and your psychiatric provider identify a bipolarity to your mood, then you can focus on effective behavioral modifications, specifically around sleep and diet.

Exploring the possibility that your depression and associated symptoms fall somewhere on a bipolar spectrum may also help you better understand your associated anxiety and irritability. Many mid-spectrum individuals experience moderate-to-severe anxiety (imagine feeling depressed and sped up simultaneously) in which a traditional anti-anxiety medication would not be as safe or effective as a mood stabilizer, or the first-line treatment option for folks with bipolar disorder.

So, bottom line, if you can’t seem to shake your depression after a couple of antidepressant medication trials or if your symptoms fall into a couple different boxes, such as depression and hypomania, I propose the following steps that you can take relatively quickly:

  1. Develop a greater awareness around your mood states. A great way to do this is to keep a mood journal. Keep track of when you’re feeling low, increased energy with less need for sleep, or increased anxiety and irritability. There are great smartphone apps that make this quick and easy.
  2. Pay attention to your sleep! Mid-spectrum individuals often experience sleep disturbances or insomnia.
  3. Reduce your caffeine and sugar intake. Try and avoid the emotional and energy peaks and valleys that these substances almost always cause.
  4. Find a psychiatric provider that thoroughly explores your history of mood instability, energy levels and quickness of thoughts. Collecting a complete family history and response to previous antidepressant medications will be particularly important.
  5. Try and push through any stigma around symptoms or diagnosis. Perhaps think of diagnoses as a language that is not perfect but hopefully good enough to get you on the right path to improved wellness.

*Although Abilify medication is technically a neuroleptic, not a mood stabilizer, it’s a great option for bipolar maintenance therapy.

Phelps, James. A Spectrum Approach to Mood Disorders: Not Fully Bipolar But Not Unipolar–Practical Management 1st Edition, 2016, pg 11).


About the Author

Jeff Leininger is a Psychiatric Mental Health Nurse Practitioner at Well Clinic who believes that there can be better living through chemistry … sometimes: His goal is to help clients utilize psychiatric medications judiciously and safely so they can experience deeper, more connected and satisfying lives.

For more information about Jeff’s work at Well Clinic or to schedule a session, click here.


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