Major depressive disorder affects an estimated 14.8 million people 18 and older, or about 6.7% of the U.S. population.1 Bipolar disorder affects an estimated 5.7 million of those 18 and older, or about 2.6% of the U.S. population.2 Multiple research studies have shown that women have a heightened risk of developing simultaneous or overlapping symptoms of mania and depression. When depression is the most pronounced symptom, manic episodes may be overlooked, which often leads to inaccurate diagnoses.
The American Psychiatric Association (APA) recognizes three primary types of bipolar disorder, which all involve distinct changes in mood, energy and activity levels. Although the different types have specific defining characteristics, there are some similarities. During a manic episode, people may feel exuberantly joyful or uncomfortably irritable; during a depressive episode, they may experience desperate sadness or hopelessness. The three types are as follows:
Bipolar I disorder: This is characterized by one or more manic episodes or mixed episodes (symptoms of both mania and depression) that last at least seven days. Typically, a person will also experience periods of depression with episodes lasting at least two weeks. It is common for episodes to be so severe that immediate hospitalization is warranted.3
Bipolar II disorder: This is characterized by a pattern of one or more major depressive episodes and at least one hypomanic episode. Patients do not experience the full-blown manic episodes that are indicative of bipolar 1. This type is sometimes misdiagnosed as major depression if hypomanic episodes go unrecognized or unreported.3
Cyclothymic disorder: This is a milder type defined by numerous alternating periods of hypomanic and depressive symptoms. The episodes generally have a duration of at least two years in adults and one year in children and adolescents. The severity of this type may change over time.3
There are several other terms commonly used to further define bipolar disorder. Cases that do not follow the above patterns are known as not otherwise specified. The term rapid cycling is used to describe four or more manic, hypomanic or depressive episodes in any 12-month period. Rapid cycling produces unusually frequent shifts in mood, can affect patients with any of the three types and may be temporary.3 While mixed bipolar disorder is not a type, the term is often used to indicate people who have episodes of mania with additional symptoms of depression or conversely, episodes of depression with additional symptoms of mania. The APA changed its official diagnostic term from “mixed episodes” to “mixed features” in 2013.4
Bipolar Disorder Patterns in Women
Although the overall incidence rates of bipolar are similar in men and women, there are some distinctive gender differences, as follows:
- Women develop bipolar II disorder, bipolar depression and rapid cycling more commonly than men with bipolar disorder.
- Women face major delays in treatment of up to 11 years from onset due to misdiagnosis or a failure to diagnose, compared to a seven-year delay in men.5
- Some experts believe the statistically higher prevalence of mixed bipolar symptoms in women may be attributed to their more demonstrative temperament.6
- Overall findings indicate that the risk of relapse in bipolar women during pregnancy and/or postpartum is considerable. Women who discontinue use of mood stabilizers during pregnancy are believed to be most at risk.7
- Bipolar women are quite vulnerable to postpartum depression and the more severe postpartum psychosis, which is thought to be a variant of bipolar disorder. A 2008 study of 56 women who received referrals for postpartum depression found that more than half had some type of bipolar disorder.6
Depression or Mixed Bipolar Disorder?
In a 2015 study published in Psychopathology in Women, researchers analyzed the possibility that at least some women diagnosed with depression actually had symptoms that met the criteria for a mixed bipolar diagnosis. The research team preliminarily identified anxiety and irritability as the most common distinguishing characteristics of mixed bipolar disorder in women. They also identified a range of more specific problems associated with irritability including panic attacks, phobia-related anxiety symptoms, a generalized sense of unease, loss of energy, recurring bouts of “down” or negative thinking, thoughts of suicide, withdrawal from social situations, decreased mental sharpness and a sense of detachment from self.
The authors concluded that in some cases, the existence of major depression with mixed symptoms may result in doctors diagnosing a depressive illness when bipolar disorder would be a more accurate diagnosis. For that reason, they urged doctors to perform a later follow-up evaluation on any person diagnosed with major depression with mixed symptoms in order to reassess the potential presence of bipolar disorder.8
- Depression Statistics. Depression and Bipolar Support Alliance website. http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_depression Accessed June 12, 2016.
- Bipolar Disorder Statistics. Depression and Bipolar Support Alliance website. http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_bipolar_disorder Accessed June 12, 2016.
- Types of Bipolar Disorder. Depression and Bipolar Support Alliance website. http://www.dbsalliance.org/site/PageServer?pagename=education_bipolar_types Accessed June 12, 2016.
- Help With Bipolar Disorders. American Psychiatric Association website. https://www.psychiatry.org/patients-families/bipolar-disorders Accessed June 12, 2016.
- Sit DK. Women and Bipolar Disorder Across the Life Span. J Am Med Womens Assoc. Spring 2004: 59(2): 91–100.
- Bipolar Disorder Is Different for Women. Health website http://www.health.com/health/condition-article/0,,20274376,00.html Updated May 1, 2009. Accessed June 12, 2016.
- A View of Bipolar Disorder Across the Life Span. Medscape website. http://www.medscape.org/viewarticle/458703 Published July 23, 2003. Accessed June 12, 2016.
- González-Pinto A, López-Zurbano S, López P. Mixed Forms in Bipolar Disorder and Relation to Gender. In Sáenz-Herrero M, ed. Psychopathology in Women. New York, NY: Springer: 2015:661-677.