Bipolar disorder treatment

Bipolar disorder causes distinct episodes of unusual mood, energy and activity that are clearly different from a person's usual self. According to the National Institute of Mental Health, the main types are bipolar I (at least one full manic episode, often with depressive episodes too), bipolar II (depressive episodes alternating with hypomania, a milder form of mania) and cyclothymic disorder (long-running mood swings that don't reach full episodes).

During a manic or hypomanic episode, NIMH lists signs such as:

• Feeling very up, elated, or unusually irritable and touchy
• Needing far less sleep without feeling tired
• Talking fast, jumping between ideas, feeling that thoughts are racing
• Taking on many projects at once or feeling unusually important or powerful
• Risky choices: spending sprees, reckless driving, impulsive sex or business decisions

During a depressive episode, the picture can look like severe depression:

• Feeling sad, empty or hopeless; losing interest in almost everything
• Very low energy, sleeping too much or too little, trouble concentrating
• Thoughts of death or suicide

Many people with bipolar II spend far more time depressed than hypomanic, and hypomania can feel like simply having a productive week. That is a big reason bipolar disorder is often first treated as ordinary depression, sometimes for years.

There is no lab test that confirms bipolar disorder, so diagnosis rests on a detailed history. In your psychiatric evaluation, we ask about the full timeline of your moods, not just how you feel today: periods of unusually little sleep, bursts of energy or spending, how past antidepressants affected you, and whether parents, siblings or children have had mood disorders, since bipolar disorder tends to run in families.

With your permission, it often helps to hear from a spouse, parent or close friend, because people don't always notice their own hypomania. We may order blood work to rule out thyroid disease or other medical causes, ask about alcohol and drug use, and screen for conditions that commonly occur alongside bipolar disorder, such as anxiety and ADHD. A mood chart kept over a few weeks can also sharpen the picture.

Bipolar disorder is a lifelong condition, but NIMH notes that an effective treatment plan, usually medication plus psychotherapy, helps many people manage their symptoms and live well. The aim is not only to end the current episode but to prevent the next one.

Mood stabilizers. Lithium is one of the oldest and best-studied treatments for bipolar disorder and is used both for acute mania and for long-term prevention. Valproate (divalproex), lamotrigine and carbamazepine are other options; each has a different profile. Lamotrigine, for example, is used mainly to prevent depressive episodes, while valproate is generally avoided in people who could become pregnant because of risks to a developing baby.

Second-generation (atypical) antipsychotics. Several of these medicines are FDA-approved for mania, for bipolar depression, or for maintenance, and they are often combined with a mood stabilizer. We monitor weight, blood sugar and cholesterol while you take them.

Psychotherapy and routines. Psychoeducation, cognitive behavioral therapy, family-focused therapy and interpersonal and social rhythm therapy help people recognize early warning signs, protect sleep and keep daily routines regular. Our therapists can work alongside your prescriber.

Lithium works well for many people but has a narrow range between an effective level and a toxic one, so regular blood work is part of taking it safely. Before starting, we typically check kidney function, thyroid function and calcium, and an ECG may be recommended for some patients. After starting or changing the dose, lithium blood levels are checked about 12 hours after the last dose until a stable level is reached, then every few months, along with periodic kidney and thyroid tests.

Dehydration, a stomach bug and some common medicines (including certain anti-inflammatory pain relievers and blood pressure medications) can raise lithium levels. Call us if you develop vomiting, diarrhea, new shakiness, confusion or unsteadiness while taking lithium.

It seems logical to treat bipolar depression with an antidepressant, but in people with bipolar disorder, an antidepressant taken without a mood stabilizer can trigger a manic or hypomanic episode or speed up mood cycling. NIMH and American Psychiatric Association guidance both caution against antidepressant monotherapy in bipolar disorder. If an antidepressant is used at all, it is usually paired with a mood stabilizer and watched closely.

This is also why we ask about your full history before treating depression: if you have ever felt "wired" or unusually energized on an antidepressant, tell us. That detail can change the plan.

Our New City office offers TMS therapy, and patients sometimes ask whether it can help bipolar disorder. TMS is FDA-cleared for major depressive disorder, not for bipolar disorder. It has been studied for bipolar depression with mixed results and a possible risk of triggering mania, so it is not a first-line bipolar treatment. In selected cases, a psychiatrist may discuss it as an add-on when depression persists despite a stable mood-stabilizer regimen, but medication and therapy come first.

• Weeks 0–2: Evaluation, baseline labs, a safety plan and a first medication choice. If an antidepressant is making things worse, we adjust it. You begin a simple daily mood and sleep chart.
• Weeks 2–6: Frequent check-ins while doses are adjusted, with lithium or other blood levels drawn as needed. Therapy starts on sleep routines and early warning signs.
• Weeks 6–12: Reviewing how mood, sleep and daily functioning have changed, managing side effects, and building a relapse-prevention plan you can share with family. Once stable, visits space out to every one to three months, many of them by video.