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Summary: The best treatment for bipolar disorder includes a combination of medication, psychotherapy, patient and family education, and lifestyle changes.

Key Points:

  • Early, accurate diagnosis of bipolar disorder significantly improves long-term outcomes.
  • Research shows the best treatment for bipolar disorder occurs in three stages.
  • Acute, or stage one, focuses on stabilizing behavior, thought, and mood
  • Continuation, or stage two, focuses on allowing patients to experience life without disruptive, distressing symptoms
  • Maintenance, or stage 3, focuses on monitoring symptoms, medication adherence, and relapse prevention
  • Adherence to medication is the most important component associated with long-term treatment success.

The Importance of Accurate Diagnosis in Treatment for Bipolar Disorder

The paper “Bipolar Disorder Diagnosis: Challenges and Future Directions” indicates that the name bipolar disorder was adopted in 1980 to replace the previous name of the disorder, manic depression. There are five subtypes of bipolar disorder, each with a different symptom profile:

  1. Bipolar I disorder (BD-I):
    • Patients report a history of recurring manic, depressive, and hypomanic episodes.
  1. Bipolar II disorder (BD-II):
    • Patients report/show at least one hypomanic and one major depressive episode
    • Differentiated by absence of full manic episode/episodes
  2. Cyclothymic disorder:
    • Patients report/show both hypomanic and depressive symptoms
    • Symptoms are less severe than those associated with BD-I and BD-II.
  3. Other specified bipolar disorders:
    • Patients report/show bipolar symptoms less severe than BD-I, BD-II, or cyclothymic disorder.
  4. Unspecified bipolar disorders:
    • Patients report/show bipolar-like symptoms that don’t meet criteria for diagnosis of BD-I/BD-II
    • Symptoms don’t cause significant disruption

When we say manic or mania in the context of bipolar disorder, here’s what we mean:

“A manic episode is a period of at least one week when an individua experiences elated mood and/or irritable mood most of the day for most days and possesses more energy than usual.”

Symptoms of a manic episode include:

  • Sleeping less
  • Increase in activity/energy
  • Difficulty staying focused
  • Racing thoughts/uncontrollable thoughts
  • Increase in risky behavior, i.e. alcohol drug use, unsafe driving
  • Inflated sense of self-importance/grandiose sense of self.
A hypomanic episode is like a manic episode, but the symptoms are less severe, less intense, and last for 3-4 days only.

When we say depressive episode in the context of bipolar disorder, here’s what we mean:

A depressive episode is a period of at least two weeks in which an individual experiences at least five of the following symptoms and must experience at least one of the first two:

  • Sadness/hopelessness/despair
  • Loss of interest/declining interest in favorite activities
  • Feelings of worthlessness or guilt
  • Fatigue/tiredness
  • Changes in sleep: too much or too little
  • Changes in eating and appetite: significant increase or decrease
  • Restlessness
  • Problems with concentration/focus
  • Suicidal ideation: thinking about, talking about, and/or planning suicide

When we read these symptoms, we see significant overlap with other mental health disorders:

Symptom overlap leading to misdiagnosis can result in delayed treatment and a gradual increase in symptom frequency and severity. The study “Exploring Factors of Diagnostic Delay for Patients With Bipolar Disorder: A Population-Based Cohort Study” indicates the following:

“Bipolar disorder if untreated, has severe consequences: severe role impairment, higher health care costs, mortality and morbidity. Although effective treatment is available, the delay in diagnosis might be as long as 10–15 years.”

The average delay between first symptoms and accurate diagnosis and appropriate treatment is between 5 and 10 years. Evidence shows that as recently as the year 2000, misdiagnosis of bipolar disorder was more common than accurate diagnosis:

  • One-third of individuals with BD reported a 10-year delay between onset of symptoms and accurate diagnosis
  • 69% reported initial misdiagnosis:
    • 60% misdiagnosed with depression (MDD)
    • 26% misdiagnosed with an anxiety disorder
    • 18% misdiagnosed with schizophrenia
    • 17% misdiagnosed with personality disorder
    • 14% misdiagnosed with substance use disorder (SUD)

Everything we’ve mentioned up to this point implies that in order to find and receive the best treatment for bipolar disorder, there’s something that needs to happen first: patients need an accurate diagnosis from an experienced mental health professional with significant experience supporting patients with bipolar disorder.

The Best Treatment for Bipolar Disorder: Integrated, Multimodal, Collaborative

There are at least four essential components of effective treatment for bipolar disorder, not counting an accurate diagnosis. The components include:

1. Medication.

Effective medication for bipolar disorder includes:

  • Mood stabilizers
  • Antidepressants
  • Antipsychotics
  • Anti-seizure medications

Medication helps reduce the frequency and intensity of manic episodes in bipolar disorder, which is associated with a significant decrease in emotional distress and other problems associated with bipolar disorder. Medications for bipolar disorder also help reduce the frequency and intensity of depressive episodes associated with bipolar disorder, which helps patients improve mood, wellbeing, and overall quality of life.

2. Psychotherapy:

Psychotherapy can give people with bipolar disorder practical tools and skills to manage symptoms and reduce the amount of disruption they cause. While therapy alone is not effective for bipolar disorder, a skilled therapist can help a person with bipolar disorder consolidate the gains achieved by adherence to medication. A skilled therapist will collaborate with a person with bipolar disorder to identify treatment goals, give them agency in the treatment plan, and help them face and overcome the daily challenges associated with bipolar disorder.

3. Education:

  • Psychoeducation for people with bipolar disorder
  • Psychoeducation for families of people with bipolar disorder

Education for an individual with bipolar disorder and their families improved long-term outcomes. For the person with BD, education can empower them to understand how BD affects their lives, realize the importance of adherence to medication, and develop the skills they need to manage stress and powerful emotions. For families, education helps parents, spouses, siblings, and others understand and recognize the symptoms of bipolar disorder, as well as triggers associated with manic, hypomanic, and depressive episodes.

The best treatment for bipolar disorder happens when the patient, provider, and family all understand the goals of treatment, and what the individual with bipolar disorder needs to achieve those goals.

4. Lifestyle changes:

  • Healthy diet
  • Sleep hygiene
  • Daily exercise/activity

The goal of lifestyle changes in bipolar disorder treatment is to create a default condition of optimal health that supports the overall goals of therapy and medication, e.g. symptom reduction, improved quality of life, and effective daily functioning. Studies show lifestyle changes associated with diet, sleep, and exercise help improve depressive mood and daily functioning for people with bipolar disorder.

Best Results Come From Sticking to the Right Plan

The best treatment plan for a person with bipolar disorder is one the person with the disorder believes in and will follow through on. That’s what we mean when we say treatment adherence.

And when we say the right plan, what we mean is a plan developed through a collaborative process involving the patient, a provider/therapist they have a good rapport with, and family members (if appropriate).

When a person with bipolar disorder understands why they need to take medication, knows how therapy and lifestyle changes help them, and has the support of a skilled therapist and compassionate peers and family members, they can achieve balance in their lives, restore harmony in relationships, and live life on their own terms.