Signs of mania, hypomania and bipolar depression

Bipolar disorder is a mental illness that causes big shifts in mood, energy, activity and the ability to think clearly. It used to be called manic-depressive illness.² A person has times of feeling very "up" or wired, and times of feeling very low. In between, many people feel like their usual selves.¹

Knowing the signs helps you catch an episode early, when it is easier to treat. It also helps families understand that these changes come from an illness, not from bad character. This page explains each kind of mood episode, the early warning signs, and when to get help.

What is a mood episode?

A mood episode is a stretch of time when mood and energy are clearly different from the person's usual self. Symptoms show up most of the day, nearly every day. Episodes often last a week or two, sometimes longer.¹

There are three main kinds of episodes in bipolar disorder:^1,4

• Manic episodes: very high or irritable mood and energy
• Hypomanic episodes: a milder, shorter version of mania
• Depressive episodes: very low mood and energy

Which episodes a person has helps decide the type of bipolar disorder. For example, bipolar I involves at least one manic episode. Bipolar II is a pattern of hypomania and depression, without the full mania of bipolar I.^1,9 See types of bipolar disorder for more.

Signs of mania

During mania, a person may feel on top of the world, or very edgy and short-tempered. Energy and activity rise far above normal.¹ Common signs include:^1,4,6

• Feeling extremely happy, high or "wired," or very irritable
• Needing much less sleep and still feeling full of energy
• Talking fast, talking a lot, or being hard to interrupt
• Racing thoughts, or jumping quickly from one idea to the next
• Being very easily distracted
• Starting many projects or tasks at once, or pacing and restlessness
• Feeling unusually important, gifted or powerful
• Risky choices, such as heavy spending, giving money away, gambling, risky sex, or drinking and drug use
• Poor judgment and a quick temper

For doctors to call it mania, the high or irritable mood and extra energy must last at least 7 days in a row. If symptoms are severe enough to need a hospital stay, any length counts.^4,5 The person also has several of the signs above. Mania causes serious problems at work, in relationships or with money.⁴

The person often does not see it. Mania can feel good, especially at first. People in a manic episode may not think anything is wrong and may not want help.^5,7 Family, friends or coworkers usually notice the change first.⁵

Signs of hypomania

Hypomania has the same kinds of signs as mania, but they are milder.^1,4 To count, the signs must last at least 4 days in a row.⁴

The change is clear enough that other people can see it. But it does not cause major trouble at work or at home, and it does not need a hospital stay. Hypomania never includes psychosis. If psychosis is present, the episode counts as mania.⁴

A person with hypomania may feel productive, sociable and full of ideas. They may not think anything is wrong.¹ For this reason, hypomania is easy to miss. Many people with bipolar II seek help only when they feel depressed.¹ Read about getting diagnosed.

Sources for this comparison: StatPearls reviews and NIMH.^1,4,5,9

Signs of bipolar depression

The low side of bipolar disorder looks much like other forms of depression. Symptoms last most of the day, nearly every day, for at least two weeks.^1,7 Signs include:^1,6

• Feeling very sad, empty, hopeless or anxious
• Losing interest or pleasure in almost everything
• Low energy, or feeling slowed down
• Feeling restless or on edge
• Trouble sleeping, waking too early, or sleeping too much
• Eating much more or much less than usual
• Trouble focusing, remembering or making decisions
• Feeling worthless or guilty
• Pulling away from friends and activities
• Thoughts of death or suicide

Even small choices can feel too hard. Getting out of bed may take great effort.⁷ Because the low side can look like ordinary depression, bipolar disorder is often mistaken for depression alone. This matters for treatment. Taking an antidepressant alone during a first depressive episode can sometimes set off mania or faster mood swings.¹ Never stop or change a medicine on your own. Talk with your doctor or pharmacist first.

Mixed states: highs and lows at once

Sometimes a person has signs of both mania and depression at the same time. This is called a mixed state, or an episode "with mixed features."^1,9

For example, a person might feel hopeless and tearful, but also restless, unable to sleep, and full of racing thoughts. Or a person in a manic episode may also feel deep guilt, very tired, or think about death.⁴ Doctors look for at least three signs from the "opposite" side, on most days of the episode.⁴

Mixed states can be confusing and very distressing. The person has the pain of depression along with the restless, driven energy of mania. If someone in a mixed state talks about death, feels hopeless, or wants to hurt themselves, get help right away (see below).⁶

Psychosis in bipolar disorder

During a severe manic or depressive episode, some people have psychosis. Psychosis means losing touch with what is real.^1,2 It can include:

• Delusions: strong false beliefs that do not change, even with clear proof
• Hallucinations: seeing or hearing things that are not there

These beliefs often match the mood.^1,7 During mania, a person might believe they are famous, have special powers, or are on a secret mission. During depression, a person might believe they are ruined, penniless, or guilty of a terrible crime.^1,4 Some people feel watched or targeted.⁵

Because of psychosis, bipolar disorder is sometimes mistaken for schizophrenia.^1,7 Psychosis is a sign that a person needs care soon. Seeing or hearing things that are not there is a reason to seek help right away.⁶

Early warning signs

Many people with bipolar disorder notice small changes before a full episode starts. These early signs are called a prodrome (the warning stage before an episode).⁸ Catching them early can make an episode milder, or sometimes prevent it.^7,8

Research reviewed by NAMI found that about half of people with bipolar disorder can name at least three of their own warning signs. Changes in sleep were one of the most important early signs of mania. The warning stage before depression lasted about 11 to 19 days on average. Before mania, it ranged from 1 day to about 4 months.⁸

Each person's warning signs tend to repeat in a similar way from one episode to the next.⁸ When you are well, write down your own signs as clearly as you can. Ask a trusted person what they noticed last time. Share the list with your doctor. A simple daily mood and sleep chart can help. See living well with bipolar disorder and the calm plan tool.

Things that can trigger an episode. Some people's episodes are set off by poor sleep, alcohol or street drugs, or childbirth.⁶ Some medicines, such as steroids or antidepressants, can also trigger symptoms.⁶ Caffeine and other stimulants can bring on manic symptoms too.⁵

Signs in later life

Bipolar disorder usually starts in the late teens or early adult years.¹ It is less common in older adults. In one large U.S. survey, about 7 in 1,000 adults aged 60 and older (0.7%) had bipolar disorder in the past year. For all adults, it was about 28 in 1,000 (2.8%).³

When mania appears for the first time after age 50, doctors look hard for another cause.⁴ Other warning flags include a recent change in health or medicines, an abnormal nerve exam, and no past or family history of mental illness.⁴ Possible causes of mania-like symptoms include:⁵

• An overactive thyroid
• Steroid medicines
• Dementia and other brain diseases
• Brain tumors
• Delirium (sudden confusion, often from an infection or illness)
• Stimulant drugs

For people over 60, an expert review suggests a brain scan (CT or MRI) to look for a physical cause. Basic blood tests, thyroid tests and a drug screen are also common.⁵ Read more in bipolar disorder in later life, treatable conditions that look like dementia, and medicines that can affect mood and memory.

Common questions

When to get help

See a doctor or mental health professional if you notice signs of mania, hypomania or depression that last more than a few days, or keep coming back. Bring someone who knows you well. They may remember changes you did not notice. Our page on finding geriatric mental health care may help older adults.

Call your doctor soon if symptoms are getting worse, if you have side effects, or if you are having trouble taking your medicine as prescribed.⁶

If you are a family member, see when a family member is in a mental health crisis and supporting someone with bipolar disorder. A safety plan made ahead of time can help everyone know what to do.

Bipolar disorder usually needs lifelong treatment, and treatment can help manage the symptoms.² Learn about medicines for bipolar disorder and therapy for bipolar disorder, or go back to the bipolar disorder overview.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.