Up to 5% of the population may have some form of bipolar disorder, and people with this lifelong, genetic brain disorder often suffer through many years of misdiagnosis and improper treatments. In fact, people with bipolar wait an average of nearly ten years between their first bipolar mood episode and receiving proper care specifically for the disorder.1
This ten-year gap in treatment demands that patients and their families know how to obtain the right professional team to adequately diagnose and treat bipolar disorder, while understanding what to expect through treatment.
What to Consider When First Seeking Treatment for Bipolar Disorder
In getting care for bipolar, the first thing to consider is that not all mental health providers are alike. For example, many treat depression or anxiety, but that doesn’t necessarily mean they specifically focus on the special needs of people with bipolar disorder.
About two-thirds of all bipolar patients are improperly diagnosed with some other mental disorder at some point in their lives,2 and the majority of those individuals are given a diagnosis of major depression alone (sometimes called non-bipolar or unipolar depression). Many people who don’t realize they have bipolar will seek treatment because of their episodes of depression, and frequently that becomes the exclusive focus of the initial treatment sessions.
One major problem here involves the use of certain antidepressant medications that can be effective for major depression but can also induce a manic episode in those who have unidentified bipolar disorder. Another concern is that antidepressant medications do not treat bipolar depression as well as they do major depression.
Choosing the right treatment team is essential in establishing a solid diagnosis and treatment plan when mood swings are suspected, because bipolar treatment requires a collaboration among professionals and select family members for optimal results. It’s essential to have mental health specialists who understand that both mood stabilizing medications and a comprehensive therapy approach are needed to address bipolar disorder fully.
Prepare for a Combination of Medication & Therapy
Whether you start discussions with a therapist or with a physician, know that you will ultimately need both services at the same time. If one provider offers both medications and therapy, that’s great. But these days, most providers are more specialized, with therapy and meds offered separately. So be prepared to talk with more than one provider as the bipolar treatment plan takes shape.
When you first speak with either a therapist or a doctor, always inquire about their knowledge and experience in diagnosing and treating bipolar disorder specifically. Feel free to go deeper by asking how often that professional sees actual cases of bipolar disorder in his or her practice, and how those cases are typically managed.
Look for providers who believe that bipolar is generally best approached with a combination of mood stabilizing medications and therapy, and not simply one or the other by itself. Avoid those who take extreme positions about bipolar disorder. If they either don’t believe in medications at all or believe only in medications—and not therapy—you won’t be getting the full, comprehensive approach needed for bipolar treatment success.
Also inquire about how the doctor approaches your own circumstances, knowing that some patients have different reactions to medications. It’s reasonable to ask, “How have you approached patients who haven’t responded well to bipolar meds?” Because everyone’s brain chemistry is different, some degree of trial and experimentation is a common part of psychiatry.
Sometimes, how a doctor handles your questions about your unique concerns can be as important as the information itself. It’s good to know that a provider’s experience not only involves the ordinary management of bipolar disorder, but also features working with more complex bipolar issues.
When choosing a therapist, keep in mind that he or she will likely see you more frequently than the doctor. Thus, a therapist should have adequate knowledge about the effects of bipolar medications to help watch for drug-related effects, as well as appreciate how mood stabilization can create feelings of loss and changes in personal identity through treatment. Overall, individual therapy for bipolar disorder should help patients to adapt to a healthier and more stable emotional life.
Involve Loved Ones
Because bipolar is a lifelong mental disorder, find out how select family members can be a part of treatment. At the minimum, providers should offer education on bipolar disorder and what to expect as the patient goes through the challenges of medications and stabilization.
Family members will need guidance to address denial and acceptance of bipolar in the early, or pre-stabilization, phase of treatment. And eventually, they’ll need information on how to distinguish between bipolar and the “true person” in the later, or post-stabilization, treatment phase. This empowers patients and families beyond feeling afraid or ashamed, so they can freely discuss how treatment is progressing with each other, and ultimately develop better communication about emotions and relationship issues as bipolar therapy moves forward.
Treatments for Bipolar Disorder
When people with bipolar disorder first enter treatment, they are usually in some crisis event that is either caused or worsened by the functional consequences of the disorder. Some examples include suicidal thoughts or actions, relationship conflicts, domestic violence, financial distress, or substance abuse.
Depending on the severity of the crisis and its immediate impacts, a treatment professional will typically address those issues at first, perhaps with short-term crisis intervention therapy. But moving forward, bipolar mood swings need special focus and attention, since this clinical disorder is often the direct cause for so many other problems in the lives of the people with bipolar and their loved ones.
A common course of treatment of bipolar mood swings involves a combination of psychiatric medications and psychotherapy, along with education and support for families and patients together.
Medications for Bipolar Disorder
Bipolar disorder is a genetically based condition that affects the brain’s ability to regulate mood states. Medications for bipolar disorder help a person’s brain better regulate those mood states, thereby offering the person with bipolar improved opportunities to succeed with therapy goals.
Many people are concerned about the use of medications for a variety of reasons. However, years of research and the applied use of these medications for bipolar disorder have demonstrated that they can be effective and safe when properly administered and monitored by a psychiatrist, psychiatric nurse practitioner, or other physician with proper expertise.3
The most common types of psychiatric medications used for bipolar disorder are mood stabilizing and antipsychotic medications. Also used are antidepressant and antianxiety medications, but these are generally added to an existing med plan, rather than used separately without a mood stabilizer and/or antipsychotic. There are several ways to approach initial bipolar treatment, but it is usually established based on the patient’s current or most recent mood episode.
Through the past five decades, one of the most used medications for bipolar disorder is lithium carbonate. This basic substance has been shown to reduce mood swings and help provide ongoing mood regulation when a proper therapeutic level of the drug is maintained in the body.
Blood level tests are necessary to ensure that lithium levels are neither too low (not beneficial) or too high (could become toxic). Lithium treatment can reduce and control mania, and improve depression without becoming a catalyst for mania, as some antidepressant meds can do. And lithium can also be an effective long-term medication for bipolar maintenance. Lithium has also been shown to have some protective effects on suicidality.
Other effective mood stabilizers include some drugs designed to treat and prevent seizures. Among these medications, some are better at reducing mania and others can treat bipolar depression more effectively without a risk of setting off a manic episode. It’s not uncommon for doctors to try switching among lithium and anti-seizure medications, sometimes using a combination of these drugs to effectively manage various aspects of bipolar mood swings. Not all seizure medications are used for mood disorders.
Some antipsychotic medications can be a good choice for mood stabilization, especially when psychotic features, such as delusions and hallucinations, are present during mania or depression. Like the mood stabilizers, some of these meds are better for mania while others are weighted more towards improving bipolar depression.
Combination of Medications
It’s not unusual for more than one medication to be used, or a few different meds to be tried before establishing the right course for an individual patient. Everyone’s body chemistry is different, and while doctors can start with a reasonable initial medication plan, that plan is liable to change. Thus, patience with medication trials is essential for people with bipolar as well as loved ones who eagerly await positive results.
Main Effects Vs. Side Effects
What you can expect from medications can be broken down into main effects and side effects. Generally speaking, the main effects are what we hope for in bipolar mood stabilization. The side effects involve other reactions that are not desirable. But if side effects are openly discussed before and during treatment, they can be addressed either by adapting to the effects if minimal and tolerable, or with medication changes until side effects are well-managed without reduction in the main effects.
Therapy for Bipolar Disorder
For years, many in the mental health field believed that treating bipolar disorder only came in the form of medications, thus making therapy, family support, and education about bipolar appear far less important. But here’s the truth about bipolar treatment: While mood-stabilizing medications are vital, therapy, education, and family support are also essential for lifelong success.
Therapists frequently use different approaches based on theoretical orientations and techniques they prefer. When it comes to treating bipolar disorder, however, there are certain features of the disorder that require particular attention as treatment proceeds through three distinct phases.
This phase involves assessment for bipolar symptoms, providing education and guidance for patient and family, facing the various functional consequences of bipolar, and addressing the defense of denial. Patients who present to therapy in the first phase may either be symptomatic (currently manic, hypomanic or depressed) or asymptomatic (between mood episodes, referred to as baseline).
They may have experienced mood swings from a young age, or first became manic in adult life. But whatever the initial status, they are typically in a crisis attributable to bipolar, or somehow exacerbated by the disorder.
Effective assessment is crucial for successful therapy outcomes. When assessing for bipolar, it’s generally important to compare its symptoms to other mental disorders that might have similar features in common. Mania can share some of those qualities, but its symptoms come and go in episodes that don’t stay consistent over time.
Overall, bipolar symptoms are considered episodic instead of pervasive. Euphoria and expansive mood, along with behaviors that have high-risk consequences, are typical features of mania and hypomania, but are not always present outside the mood episodes. Decreased desire for sleep and increases in energy and goal-directed behaviors are often present as well but can shift drastically as the manic episode diminishes.
On the depression side, therapists can look for a history of recurrent depressive episodes, especially if they were present in early life, or include psychotic or extreme suicidal features. Many individuals with bipolar disorder have multiple episodes of depression when younger before they experience a hypomanic or manic period.
Because family history is one of the strongest and most consistent risk factors for bipolar, obtaining as much information on the family’s psychological profile can be of great help in determining diagnosis and course of treatment. Suspicion of mood swings in the first or second generational line is critical, but any significant psychological disorder or suicidality in the family tree can be enough to bolster the bipolar evaluation.
Once the assessment objective is complete, discussions on treatment for bipolar get specific. Here we undoubtedly meet the ego defense of denial. Denial is a common feature of the pre-stabilization phase and is considered an expected issue in bipolar therapy. Instead of viewing denial as non-compliance, the individual is simply not yet ready to collaborate entirely with bipolar treatment.
Nobody wants to be told that what made them feel energetic, creative and “happy” is actually part of a “mental illness” that must be taken away. Additionally, people often have fears about psychiatric medication that originate from many different sources—some credible and realistic, some scary and erroneous.
But denial is not limited to only patients. Family members can be in denial about bipolar, as well. A spouse may say about a bipolar partner, “I don’t believe in bipolar. I think it’s just an excuse for his behavior.” Or a parent may think bipolar is simply a popular fad the kids latch onto these days. Education for patients and families create understanding through basic, reliable facts. They can learn together that bipolar is genetic and neurological in its foundations.
This awareness serves to reduce shame, stigma and blaming among family members. The therapist can then work to reduce fear in all participants, and thereby treat denial by breaking down individual symptoms that are most problematic. A symptom-focused approach in the pre-stabilization phase tends to be more effective, saving the “bigger picture” of lifelong care for the ensuing phases.
Issues related to stigma and what it means to have a mental health condition are also important to discuss and treat in therapy. It’s important to establish a sense of trust early in the overall treatment process, especially since bipolar disorder is a chronic condition requiring lifelong care.
Many people with bipolar disorder will delay accepting the diagnosis, no matter how painful or destructive the condition can be when left untreated. Identifying and addressing fears of all kinds is essential in the initial phase of therapy, and this can help patients to accept the reality of bipolar in their lives.
Facing denial and eliminating stigma begins by recognizing that having bipolar is nobody’s fault; no one caused it or ever needs to feel ashamed of it. Bipolar disorder is a genetically based condition that affects the brain’s ability to control emotions. Working to accept the diagnosis—or owning bipolar—is critical in establishing proper care.
Moving forward with treatment is best accomplished with a collaborative approach. That means, as a caregiver or family member, you can be a helpful partner in the treatment plan. It’s always good to remind each other that participation in the education and treatment of bipolar is not to gain control over the treatment plan, but to create a team approach for long-term success.
The stabilization phase of bipolar therapy occurs when medication begins. Early medication trials frequently involve more aggressive dosing to reduce mania or improve depression as efficiently as possible. As a result, patients can become discouraged, or even frightened, since such immediate changes reduce feeling “in control” of their emotions, while threatening their unique sense of self.
If meds go well right away, it certainly makes all tasks easier, but doesn’t necessarily speed up the process. That’s because stabilization is also the time for patients and families to confront more than bipolar symptoms alone.
Though medication may be initiated, the person with bipolar may not yet fully accept dealing with a lifelong mental health condition. It’s not unusual for people to get frustrated through trials of bipolar medications, and at times feel like giving up. This is natural. But it’s important for everyone to understand what the medication is expected to do and what side effects can occur to reduce any sense of mystery in the process.
As a caregiver for someone with bipolar, know that you can ask all your questions about meds and stay informed through stabilization. This improves support and guidance for the person taking the medication, but also puts you in a better position to observe how the meds are working, and thus become an important source of information for the treatment team. When this happens, better results in mood stabilization and an increased sense of empowerment for all involved are achievable. And it really helps to avoid frustration while keeping treatment on track.
Facing Grief & Loss
For patients moving towards a full acceptance of bipolar disorder, they inevitably face grief in the loss of their identity. It’s important to remember that because bipolar is a lifelong, genetic disorder, patients have always seen themselves and the world around them through the prism of extreme mood events.
Through therapy, patients can learn how mania or hypomania fueled their creative process. Once medications are manageable, therapy provides bipolar patients with alternative organizational approaches to work and create effectively. They can build new methods for inspiration through their bipolar journeys. And as they become more consistent with personal achievements, they can avoid sacrificing their health and personal relationships along the way.
Family members may be thankful for initial bipolar treatment, but often aren’t ready just to “let go and move on.” The stabilization phase gives them a chance to express how traumatic living with bipolar can be. Family empowerment strives to replace feelings of helplessness when mania and depression once ruled the home. Spouses, for example, need to know their suffering is heard and acknowledged. Parents and their children with bipolar can work together to know how bipolar disorder forced them to make impulsive decisions and destructive reactions.
Bipolar patients don’t always like participating in these exchanges because of the shame associated with the past manic behaviors. But therapists can guide the therapeutic process to remind patients and spouses that repairing relationships takes effort, patience, and the recognition that it’s the bipolar disorder that’s “bad,” not the individuals involved.
As bipolar symptoms begin to stabilize toward a more consistent baseline mood zone, therapeutic discussions begin to lace all bipolar symptoms—the desired and undesired—into one identifiable condition, moving from a symptom-based approach to acceptance of a lifelong disorder.
Treating a complete bipolar disorder means we cannot avoid or circumvent certain parts of it in favor of others. Like the requirements of sobriety, persons with bipolar must be vigilant for any threats to their newfound stability. And they especially need therapy services when life gets difficult because mania can always be alluring.
The third phase of therapy represents the rest of the bipolar person’s life. It begins as medications are set for long-term maintenance, and any other therapy objectives once delayed, can now be pursued with greater confidence.
Patients can rediscover their high level of productivity and creativity in a more reliable fashion. Overall treatment collaboration becomes more consistent as each person develops an acceptance of bipolar disorder to accommodate their own needs. Therapy is geared to treat the whole person, in every facet necessary, by whatever techniques the therapist offers.
However, despite acceptance and emphasis on whole-person therapy, one salient issue remains throughout the post-stabilization phase. Patients will eventually want to test life without meds. Not all will try, but all will consider. Some patients are able to reduce medications during a prolonged period of stable moods, but this should only be done in collaboration with your providers. Therapeutic investigation will likely show some life changes and stressors that require immediate attention.
Another prominent feature of post-stabilization in bipolar patients involves the question, “Is it me or is it bipolar?” For family members, the question is, “Is it you or is it bipolar?” In other words, patients and families require discussions on how emotional changes could either be appropriate responses to life stressors or the actual recurrence of pesky bipolar symptoms. Families struggle with balanced, equitable approaches to communication, because family relationships were always threatened by bipolar mood swings.
The Grand Bargain
One technique is called the Grand Bargain. Coming from the family member, the bargain says, “I won’t think everything about you is bipolar disorder, if I know you’re keeping your condition under good care.” Coming from the patient, the bargain says, “I will always keep you updated about my condition, as long as you don’t think everything about me is bipolar disorder.”
People with bipolar need the freedom to share emotions, challenges, and life issues honestly without worrying about feeling judged that everything about them is due to their condition. Sometimes people with bipolar disorder will say that, when they are having an emotional reaction to stress, a family member might too quickly ask, “Are you off your meds?” Through the Grand Bargain, the loved one may instead say something like, “You seem to be having a lot of stress lately. Is there something going on I can help you with?”
A healthy emotional life requires adaptation to a new identity in post-stabilization bipolar management. This includes experiencing a range of emotions over many different life events. Bipolar patients often fear becoming emotional “zombies” or believe others expect them to be.
People with bipolar disorder need the freedom to discover who they are apart from their condition, including being fun, quirky, intense, passionate or whomever they are ultimately meant to be. This may not please all family members completely. But developing a means to freely communicate these needs through therapy and education improves long-term collaboration together.
When family members support open dialogue about bipolar—along with everything else that makes the person who they truly are—fear and shame are replaced with a new sense of trust and hope for the future.