Suicidal thoughts bipolar

Bipolar Depression: The Lows We Don’t Talk About Enough

SEP. 22, 2021

By Katherine Ponte, JD, MBA, CPRP

The highs and lows of bipolar disorder can both be extremely challenging. The name of the illness itself recognizes these two sides (depression and mania), but many people don’t fully understand the role of depression in bipolar disorder. Those who do, like our caregivers and treatment providers, seem to focus solely on the “mania” component of the condition. They often view the highs of mania as the most dangerous states to be avoided and tamed — and they may even find the depressive side to be a relief from the unpredictable highs.

However, it’s during the lows that people with bipolar disorder are at the greatest risk of suicide. People with bipolar disorder experience high suicide rates — up to 19% of us die by suicide and up to 50% of us will make a non-fatal suicide attempt — and suicide risk is strongly associated with depressive phases.

Personally, I experienced extended periods of suicidal ideation due to prolonged periods of depression. I often explain the sides of bipolar disorder by saying, “It’s the mania that gets you into trouble, but it’s the depression that can kill you.”

Given that depression is the more pervasive symptom of bipolar disorder for most people, and given its detrimental impacts on so many areas of our lives, I believe caregivers and providers need to focus more on bipolar depression. Everybody's experience is different, but in my in my situation, overlooking depression has prolonged and worsened symptoms for many reasons:

Delays in Getting a Correct Diagnosis
A depressive episode preceded my first manic episode, so I was diagnosed with and treated for unipolar depression. It was a year before I was properly diagnosed. This is common for people diagnosed with bipolar disorder — and the typical delay in getting a correct diagnosis is six to eight years.

The Duration of Symptoms
I have experienced much longer depressive phases than manic phases, which are relatively short-lived. Depressive phases could last from a few months to years. They were relentless. While my manic phases could be quickly treated with medication, my depressive episodes were difficult to address with medication.

The Consequences of Mania
Typically, after my manic episode, deep depression would set in. In fact, studies show that depressive episodes frequently follow manic episodes. It was a steep fall from the highs of my mania into severe depression.

My depression was worsened by the deep shame and embarrassment, guilt and regret I experienced due to my actions while manic. This behavior included frantic rambling emails, often stemming for paranoid fixations, other destructive behaviors, interpersonal conflict and public humiliation. As my mania subsided, I appreciated just how bad my behavior had been, contributing to my depressive symptoms.

The Aftermath of Hospitalization
My three involuntarily hospitalizations due to manic episodes were extremely traumatic. People with mental illness experience some of the highest suicide rates after psychiatric hospitalization. During the first three months after discharge, their rate of suicide is 100 times the suicide rate of the general population, according to a meta-analysis of studies. The weeks and months following hospitalization were certainly among the lowest points I have experienced in my life.

Lack of Caregiver Attention
My caregiver expressed extreme alarm over my hypomanic and manic episodes, but relatively little concern over my lows. When I started to become more exuberant, my caregiver was hypervigilant and focused on controlling my activities, insistent that I seek treatment and remain in constant contact with my psychiatrist to prevent a manic episode.

During my lows, my caregiver seemed relieved with my inactivity. He seemed unaware of the extent of my struggles, even though he was aware that I was often unable to get out of bed. I felt uncared for, isolated and abandoned, which worsened my depression. He did not insist on treatment and intervention like he did during my manic phases. I believe this contributed to my depression being undertreated.

The role of a caregiver in identifying and encouraging treatment of bipolar depression is critical. When we are depressed, we may lack a will to live, we may neglect treatment (such as missing appointments). We can lose hope and even cease communication. Caregivers are the best placed to observe these changes in behavior and activities and encourage treatment.

Lack of Treatment Focus
Likewise, my then-psychiatrist focused their treatment on preventing the next manic episode and hospitalization. On multiple occasions, I explained how severe my depression was and asked them to address it. They largely ignored my concerns. In addition, their treatment approach was highly sedating medication to reduce the risk of mania. This approach further contributed to my depression.

I was so highly sedated that I could not work nor have normal social relationships. My psychiatrist also discouraged social activities out of concern for the stress they might cause me, possibly triggering a manic episode. I felt as though the treatment focus was minimizing the suffering of others who had to deal with me rather than actually helping me. I resigned myself to this lesser life, which significantly contributed to my depression.

My psychiatrist refused to take calculated risks that could have improved the quality of my life. For example, they did not prescribe antidepressants which they feared might trigger a manic episode. As a result, I believe my depression was undertreated. I believed that there was no effective treatment for my depression which was incredibly disheartening.

However, bipolar depression can be effectively treated, and there are medications that have been specifically approved for bipolar depression — some of which have been very effective for me.

Activity Being Equated to Mania
Depression can lead to extreme lethargy and lack of motivation, which can make it extremely difficult to take part in the normal activities of life. Disappointingly, practitioners may view moments of optimism and activity that break through the depression and inactivity as a reason for concern.

Our caregivers and doctors may mistake these signs of life for early signs of mania. Their preemptive efforts to prevent the potential manic episode can also reinforce the inactivity. This can keep patients in a depressive state.

Ultimately, bipolar depression is ignored, minimized and dismissed all too often. I lost over a decade of my life to depression, which still causes me deep sorrow. It’s even more tragic that so many people lose their lives to suicide.

Too often, actions and factors that can worsen depression are considered acceptable in order to prevent mania. This only makes it significantly more difficult to overcome depression and extremely difficult to reach recovery. It is a vicious cycle.

I am now happily living in recovery, and I have been relatively depression-free for several years now. Now, my caregiver acts on my depression, my doctor cares equally about the highs and lows and I’m finally on the appropriate medication. Notably, acknowledging and treating my depression also addressed my mania. Since being effectively treated for my depression, I have not experienced a manic episode. I am living proof that the highs and lows deserve equal attention and respect and care.


Katherine Ponte is happily living in recovery from severe bipolar I disorder. She’s the Founder of ForLikeMinds’ mental illness peer support community, BipolarThriving: Recovery Coaching and Psych Ward Greeting Cards. Katherine is also a faculty member of the Yale University Program for Recovery and Community Health and has authored ForLikeMinds: Mental Illness Recovery Insights.

We’re always accepting submissions to the NAMI Blog! We feature the latest research, stories of recovery, ways to end stigma and strategies for living well with mental illness. Most importantly: We feature your voices.

Check out our Submission Guidelines for more information.


Suicide Risk in Bipolar Disorder: A Brief Review

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Get help & support for suicide

If you’re in emotional distress or suicidal crisis, find help in your area with Find a helpline.

If you believe that someone else is in danger of suicide and you have their contact information, contact your local law enforcement for immediate help. You can also encourage the person to contact a suicide prevention hotline using the information above.

Learn more about personal crisis information with Google Search.

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Important: Partnerships vary by country and region.

Korea Suicide Prevention Center
Country Hotline organization Website Phone number
Argentina Centro de Asistencia al Suicida (011) 5275-1135
Australia Lifeline Australia www. 13 11 14
Austria Telefon Seelsorge Osterreich 142
Belgium Center de Prevention du Suicide 0800 32 123
Belgium CHS Helpline 02 648 40 14
Belgium Zelfmoord 1813 1813
Brazil Centro de Valorização da Vida 188
Canada Crisis Services Canada 833-456-4566
Chile Ministry of Health of Chile www.hospitaldigital. gob 6003607777
China Beijing Suicide Research and Prevention Center 800-810-1117
Costa Rica Colegio de Profesionales en Psicologia de Costa Rica 2272-3774
France SOS Amitié 09 72 39 40 50
Germany Telefon Seelsorge Deutschland 0800 1110111
Hong Kong Suicide Prevention Services 2382 0000
India iCall Helpline 9152987821
Ireland Samaritans Ireland www. 116 123
Israel [Eran] ​​ער"ן 1201
Italy Samaritans Onlus 800 86 00 22
Japan Ministry of Education, Culture, Sports, Science and Technology 81-0120-0-78310
Japan Ministry of Health, Labor and Welfare of Japan www.mhlw.go 0570-064-556
Malaysia Befrienders KL 03-76272929
Netherlands 113Online 0800-0113
New Zealand Lifeline Aotearoa Incorporated www. 0800 543 354
Norway Mental Helse 116 123
Pakistan Umang Pakistan 0311-7786264
Philippines Department of Health - Republic of the Philippines 0966-351-4518
Portugal SOS Voz Amiga

213 544 545

963 524 660

912 802 669

Russia Fund to Support Children in Difficult Life Situations 8-800-2000-122
Singapore Samaritans of Singapore 1-767
South Africa South African Depression and Anxiety Group www. 0800 567 567
South Korea 중앙자살예방센터 www.spckorea.or 1393
Spain Telefono de la Esperanza 717 003 717
Switzerland Die Dargebotene Hand 143
Taiwan 国际生命线台湾总会 [International Lifeline Taiwan Association] 1995
Ukraine Lifeline Ukraine 7333
United Kingdom Samaritans 116 123
United States 988 Suicide & Crisis Lifeline 988lifeline. org 988

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Information about the unified all-Russian children's helpline

In September 2010, in the Russian Federation, the Foundation for Support of Children in Difficult Life Situations, together with the constituent entities of the Russian Federation, introduced a unified all-Russian children's helpline number 8-800-2000-122 .

When calling this number in any locality of the Russian Federation from landline or mobile phones, children in difficult life situations, adolescents and their parents, other citizens can receive emergency psychological assistance, which is provided by specialists of services already operating in the constituent entities of the Russian Federation that provide services for telephone counseling and connected to a single all-Russian number of children's helpline.

Confidentiality and free of charge are the two main principles of the children's helpline. This means that every child and parent can anonymously and free of charge receive psychological assistance and the secrecy of his call to the helpline is guaranteed.

Working hours of the children's helpline in the constituent entities of the Russian Federation

(as of October 1, 2013) Infographics. The principle of operation of a single federal helpline number for children, adolescents and their parents

Information from the regions about the work of the children's helpline


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Name of the constituent entity of the Russian Federation The operating mode of the children's helpline of trust
Russian Federation
Central Federal District
1 Belgorod region pon.pat.09.00-21.00
2 Bryansk Region pon.09.00-22.00 3 3 3 3 3 3 3 3 3 3 9ATH
4 Voronezh region around the clock
5 Ivanovo region Mon-Fri 11. 00-20.00 6 903
Southern Federal District
37 Republic of Adygea Clultwood
38 Kalmykia PON-PIT. 8.00-17.00
39 Krasnodar Territory 2 round-the-clock
40 Astrakhan Region AGROMOUSE
41 039
82 Jewish AO pon.pat.09.00-18.00
83 Chukotsky Autonomous Office Pon.09.00-22.00, OXIS. 16.00-22.00

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