The Inner World: Understanding Bipolar Disorder

Living with Bipolar Disorder

Living with bipolar disorder means navigating a mind that can shift dramatically between extremes. If you have been diagnosed with bipolar disorder, you’ve probably experienced mood episodes that affect your emotions, thinking, focus, and memory. Perhaps you’ve tried multiple mood stabilizers and worked with therapists. You may still struggle through depressive episodes that make simple tasks feel overwhelming.

Understanding how bipolar disorder affects thinking isn’t just about clinical knowledge. It’s about recognizing that these cognitive changes are real, valid, and manageable. This article explores the inner experience of bipolar disorder. We’ll discuss racing thoughts during mania and cognitive fog during depression. We’ll also explain how IV ketamine treatment can help address the depressive phase of this complex condition.

Important Context on Evidence: While ketamine shows benefits for bipolar depression, those benefits are limited to the depressive portions of bipolar. Individuals managing bipolar disorder should ensure that they have a comprehensive treatment team and plan in place, which often includes adjunct treatments for mood stabilization during manic episodes. Like most medications for bipolar disorder, ketamine is FDA-approved, and administered off-label under the discretion of a medical team  to help affected individuals.

Understanding Bipolar Disorder

Bipolar disorder is a mental health condition defined by distinct episodes of mania or hypomania, and depression. The main difference between Bipolar I and Bipolar II lies in episode severity. Bipolar I involves full manic episodes lasting at least seven days [2]. Bipolar II involves shorter, often less intense hypomanic episodes, with the majority of a person’s symptoms consisting of depressive episodes [2].

Bipolar I vs Bipolar II Comparison

Note: Diagnosis of any mental health condition should be made by a qualified mental health professional based on comprehensive evaluation.

Most people understand that bipolar disorder affects mood. What’s less recognized is how much it impacts cognitive function. This includes the way you think, process information, and make decisions. During episodes, your ability to concentrate, recall information, and control thoughts can be significantly affected [3]. These aren’t character flaws or signs of weakness. They are neurobiological symptoms of the condition itself.

Understanding the full spectrum of bipolar disorder fosters empathy, improves communication with loved ones, and helps you recognize when episodes affect your perception of the world. This awareness is crucial because it allows you to seek appropriate support and treatment when you need it most.

Racing Thoughts: Understanding Mania

During a manic episode, the mind operates at an extraordinarily high speed. Thoughts race from one idea to the next so rapidly that finishing a single sentence can become difficult. This high mental energy can initially feel productive or even euphoric. You might experience bursts of creativity and feel capable of accomplishing anything. However, this accelerated thinking often leads to impulsivity. Actions happen without adequate reflection on consequences [4].

Common impulsive behaviors during mania include reckless spending, risky driving, increased sexual activity, or making major life decisions without considering long-term implications. For example, someone experiencing mania might suddenly quit their job to pursue a business idea that seemed brilliant at 3 AM. They might make large purchases they can’t afford because everything feels possible in the moment.

Hypomanic episodes in Bipolar II present similarly but with less intensity and shorter duration. The racing thoughts and increased energy are present. However, they don’t typically result in severe impairment or hospitalization [2]. Both manic and hypomanic episodes can strain relationships, create financial difficulties, and lead to regrettable decisions.

Important context: While understanding mania helps explain the full bipolar experience, Ember Health’s treatment specifically addresses bipolar depression. We treat the depressive phase of the disorder, not manic or hypomanic states. Mood stabilizers and other psychiatric treatments are essential for managing mania. This is why we require all patients to work with an outside licensed mental health provider to ensure a full and comprehensive care plan is in place for each person in our care.

‍

Cognitive Distortions: Understanding the Depressive State of Bipolar Disorder

The depressive phase of bipolar disorder affects thinking distinctly from mania. Mental energy plummets, and simple tasks and decisions feel exhausting. Concentration becomes difficult, “brain fog” often makes otherwise simple tasks monumental. You might read the same paragraph multiple times without retaining anything. Memory feels unreliable. Processing speed slows down. What once took minutes now takes hours [5].

Beyond these cognitive difficulties, depression often introduces cognitive distortions. These are patterns of thinking that distort reality in ways that reinforce hopelessness and worthlessness. These aren’t conscious choices, but rather symptoms of how depression alters thought processing [6].

Common Cognitive Distortions in Bipolar Depression

It’s crucial to understand that while the feelings associated with these thought patterns are intensely real, the content is often distorted by the illness itself. This is where talk therapy can be invaluable. Therapists who specialize in modalities like cognitive behavioral therapy (CBT) can help identify these distortions [6]. They develop strategies to challenge them, and research suggests that this type of therapy in the days following IV ketamine treatment can enhance and extend the positive results of psychotherapy [7] by leveraging the window of neuroplasticity that ketamine creates.

Memory Impairment: How Bipolar Disorder Affects Recall and Focus

Beyond mood symptoms, bipolar disorder significantly affects memory and concentration. Research shows that these cognitive effects occur during mood episodes [3]. They also persist even during periods of remission. However, they typically worsen during active depression or mania [3].

Cognitive Symptoms Across Mood States

Note: Individual experiences vary and are unique to each person affected. This table represents common patterns observed in research and clinical practice.

Several types of memory are particularly affected:

Delayed memory: The ability to recall information after a period of time passes. Studies show impairments in delayed memory can occur during manic episodes and continue between mood episodes [9].

Working memory: The capacity to hold and manipulate information temporarily while performing tasks. This affects everything from following multi-step instructions to maintaining focus during conversations [9].

Verbal memory: Remembering words and language-based information. This can make it difficult to recall names, follow complex discussions, or remember what you read [9].

Prospective memory: Remembering to perform planned actions at the right time. Research indicates prospective memory can be impaired in bipolar disorder [10]. It affects everything from taking medications on schedule to remembering appointments.

For individuals who experience psychosis during mood episodes, memory and reasoning can be further compromised. Studies show that people with bipolar disorder who experience psychotic symptoms are more likely to have problems with verbal-declarative memory and spatial working memory [11]. This is compared to those without psychosis.

These memory difficulties aren’t “all in your head.” Brain imaging studies have identified structural changes associated with bipolar disorder [12]. These include thinning of cortical gray matter in regions responsible for memory and executive function. Understanding that these are neurobiological symptoms, not personal failures, is essential. This understanding supports both self-compassion and effective treatment planning.

How We Treat Bipolar Depression at Ember Health

IV Ketamine for Bipolar Depression

Research demonstrates that IV ketamine is an effective treatment for the depressive state of both Bipolar I and Bipolar II Disorders, and that it does not protect or prevent manic episodes. Studies have also clarified that ketamine does not appear to cause manic/hypomanic switching, meaning it doesn’t appear to trigger manic symptoms in susceptible individuals.[16, 17] At Ember Health, 10% of our patients are dealing with bipolar disorder, and we see 84% of them improve or resolve their depressive symptoms, which is identical to our success rates for Major Depressive Disorder (MDD).

IV ketamine works differently than traditional antidepressants, with many people experiencing relief within hours to days [14] rather than weeks to months. Care starts with an initial foundation of four treatments over two weeks, followed by maintenance treatments approximately once every 6 weeks [15]. Individual outcomes are highly individual, and care is always coordinated with your existing care team to ensure a comprehensive plan is in place for your wellbeing.

Safety Protocols for Bipolar Depression

At Ember Health, patient safety is our highest priority. We require all patients to work with a licensed mental health provider who manages other medications, including mood stabilizers, throughout treatment. Our safety protocols for people managing bipolar disorder include:

• Licensed Mental Health Provider Care Team – Comprehensive mood management and coordination
• Mood Stabilizers as necessary – If your bipolar type involves manic episodes, a prescribing provider will likely recommend mood stabilizers for mania prevention which must be taken in addition to the ketamine treatments
• 1:1 Medical Supervision – Board-certified emergency medicine physician present throughout every ketamine treatment

Partnership Approach to Maximizing Outcomes

IV ketamine creates a window of enhanced neuroplasticity when the brain is particularly receptive to forming new connections [7]. The mental health professionals we partner with leverage this opportunity through psychotherapy using techniques like CBT [6], behavioral changes for sleep and stress management, and addressing environmental factors that contribute to mood instability. This integrated approach, combining ketamine’s rapid effects with comprehensive psychiatric care, offers the best outcomes for bipolar depression.

Final Insights: Finding Stability and Clarity with IV Ketamine for Bipolar Depression

Bipolar disorder profoundly affects not just mood, but the very architecture of thought, from racing ideas during mania to slowed processing and memory difficulties during depression. Understanding these cognitive symptoms helps explain why managing bipolar disorder requires comprehensive treatment addressing multiple dimensions of the illness. While traditional treatments like mood stabilizers and therapy can help, research continues to demonstrate that IV ketamine offers a valuable option for the depressive state of bipolar disorder, particularly when other treatments haven’t provided adequate relief [1,13,14].

If you’re managing bipolar depression and haven’t found relief with conventional treatments, we encourage you to explore whether IV ketamine therapy might be appropriate for your situation. The key is approaching treatment collaboratively, with coordination among all members of your mental health team. Treatment decisions should always be made in consultation with your mental health providers to ensure ketamine integrates seamlessly with your existing care plan.

‍

‍

Frequently Asked Questions

Q: Are the thoughts a person with bipolar has “real” or just part of the illness?

The feelings are intensely real and valid, but the content of those thoughts is often distorted by the illness. For example, during a depressive episode, you might feel deeply convinced that you’re worthless or situations are hopeless. These feelings are genuine, you’re not making them up or being dramatic.

However, the conclusions you’re drawing are often influenced by cognitive distortions [6] like catastrophizing (assuming the worst will happen) or overgeneralization (one negative event means everything is negative). These are symptoms of depression rather than accurate reflections of reality. This is precisely why talk therapy can be so helpful. It assists in identifying and addressing these cognitive distortions, helping you separate the emotional experience from distorted interpretations.

Q: How is Bipolar I thinking different from Bipolar II thinking?

The primary difference lies in the mood state severity. Bipolar I involves full manic episodes, while Bipolar II involves less severe and shorter hypomanic episodes. The thinking patterns, racing thoughts, impulsivity, and difficulty concentrating, are similar in both conditions, but less intense during hypomania.

Individual experiences vary, but generally someone with Bipolar I might experience such severe racing thoughts during mania that they cannot complete sentences or sleep for days. In Bipolar II, the racing thoughts during hypomania are present but typically don’t reach this level of severity or duration. Hypomania can even be perceived positively as it can come with periods of extreme productivity and accomplishment. Both can involve cognitive distortions during depressive phases, but the intensity of manic versus hypomanic thinking differs significantly.

Medical Disclaimer

This information is for educational purposes and does not replace medical advice. IV ketamine for depression is an off-label use of an FDA-approved anesthetic medication. Ember Health requires patients to work with a licensed mental health provider to ensure collaborative, comprehensive care. Treatment outcomes vary by individual, though 84% of our patients at Ember Health experience meaningful relief from depression. All treatments are administered in medically supervised settings with 1:1 patient-to-clinician ratios by board-certified emergency medicine physicians.

References

[1] Fancy F, Haikazian S, Johnson DE, et al. Ketamine for bipolar depression: an updated systematic review. Ther Adv Psychopharmacol. 2023;13:20451253231202723. https://pubmed.ncbi.nlm.nih.gov/37771417/

[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Publishing. 2013. https://www.psychiatry.org/psychiatrists/practice/dsm

[3] Bourne C, Aydemir Ö, Balanzá-Martínez V, et al. Neuropsychological testing of cognitive impairment in euthymic bipolar disorder: an individual patient data meta-analysis. Acta Psychiatr Scand. 2013;128(3):149-162. https://pubmed.ncbi.nlm.nih.gov/23617548/

[4] Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Moeller FG. Impulsivity: a link between bipolar disorder and substance abuse. Bipolar Disord. 2004;6(3):204-212. https://pubmed.ncbi.nlm.nih.gov/15117399/

[5] Arts B, Jabben N, Krabbendam L, van Os J. Meta-analyses of cognitive functioning in euthymic bipolar patients and their first-degree relatives. Psychol Med. 2008;38(6):771-785. https://pubmed.ncbi.nlm.nih.gov/17922938/

[6] Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford Press. 1979.

[7] Wilkinson ST, Rhee TG, Joormann J, et al. Cognitive behavioral therapy to sustain the antidepressant effects of ketamine in treatment-resistant depression: a randomized clinical trial. Psychother Psychosom. 2021;90(5):318-327. https://pubmed.ncbi.nlm.nih.gov/34186531/

[8] Moore TM, Walker K, Tung E, et al. Combined ketamine and psychotherapy provide no additional benefit beyond ketamine alone in treating depression or PTSD: Evidence from a help-seeking sample. J Affect Disord. 2025;381:233-241. https://pubmed.ncbi.nlm.nih.gov/40203964/

[9] Robinson LJ, Thompson JM, Gallagher P, et al. A meta-analysis of cognitive deficits in euthymic patients with bipolar disorder. J Affect Disord. 2006;93(1-3):105-115. https://pubmed.ncbi.nlm.nih.gov/16677713/

[10] Wang, Y., Liu, W., Tan, Y., & Ma, Y. (2018). Prospective memory in bipolar disorder: A meta-analysis. Psychiatry Research, 264, 247–255. https://doi.org/10.1016/j.psychres.2017.05.072​

[11] Simonsen C, Sundet K, Vaskinn A, et al. Neurocognitive dysfunction in bipolar and schizophrenia spectrum disorders depends on history of psychosis rather than diagnostic group. Schizophr Bull. 2011;37(1):73-83. https://pubmed.ncbi.nlm.nih.gov/19443616/

[12] Hibar DP, Westlye LT, Doan NT, et al. Cortical abnormalities in bipolar disorder: an MRI analysis of 6503 individuals from the ENIGMA Bipolar Disorder Working Group. Mol Psychiatry. 2018;23(4):932-942. https://pubmed.ncbi.nlm.nih.gov/28461699/

[13] McIntyre RS, Rosenblat JD, Nemeroff CB, et al. Synthesizing the evidence for ketamine and esketamine in treatment-resistant depression: an international expert opinion on the available evidence and implementation. Am J Psychiatry. 2021;178(5):383-399. https://pubmed.ncbi.nlm.nih.gov/33726522/

[14] Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006;63(8):856-864. https://pubmed.ncbi.nlm.nih.gov/16894061/

[15] Singh B, Vande Voort JL, Frye MA, et al. Ketamine treatment for bipolar disorder. Bipolar Disord. 2023;25(5):373-383. https://pubmed.ncbi.nlm.nih.gov/36978284/

[16] Jawad, M. Y., Qasim, S., Ni, M., Guo, Z., Di Vincenzo, J. D., d’Andrea, G., Tabassum, A., Mckenzie, A., Badulescu, S., Grande, I., & McIntyre, R. S. (2023). The Role of Ketamine in the Treatment of Bipolar Depression: A Scoping Review. Brain sciences, 13(6), 909. https://doi.org/10.3390/brainsci13060909

[17] Santucci, M. C., Ansari, M., Nikayin, S., Radhakrishnan, R., Rhee, T. G., & Wilkinson, S. T. (2024). Efficacy and safety of ketamine/esketamine in bipolar depression in a clinical setting. Journal of Clinical Psychiatry, 85(4), 24m15376. https://www.psychiatrist.com/jcp/efficacy-safety-ketamine-esketamine-bipolar-depression-clinical-setting/

‍