Let's Talk About Bipolar Disorder Treatment
Getting a diagnosis of bipolar disorder can be scary. But now that you’ve pinpointed the problem, you can do all the right things to treat it. Bipolar is not curable, but it is manageable.by Leslie Pepper
One of the most crucial things to know about treatment for bipolar disorder is also one of the hardest to accept: It must last a lifetime. Even when you’re feeling good, you should continue treatment to keep bipolar symptoms under control. The upside is there are many ways to help manage this condition, and once you determine your best collection of coping strategies, you’ll be much more equipped to deal with (and hopefully overcome) the hurdles you may face with this disorder.
Our Pro Panel
We went to some of the nation's top experts in bipolar disorder to bring you the most up-to-date information possible.
Po Wang, M.D.
Psychiatrist and Clinic Chief
Bipolar Disorders Clinic at Stanford University Department of Psychiatry
Linda Hubbard, L.M.F.T.
Department of Behavioral Health, Psychiatry & Psychology at the Mayo Clinic
Adam Rosenblatt, M.D.
Clinical Director of the Behavioral Health Unit and Geriatric Psychiatry
University of Maryland Upper Chesapeake Health System
No, other types of therapy can be helpful as well. Family and couples therapy can help your loved ones understand the disorder better and can help the family as a whole build healthier communication, problem-solving skills, and the necessary knowledge to be able to spot a manic episode when it’s happening. Group therapy can give you a safe place to discuss your fears, challenges, and overall feelings with others who are going through some of the same experiences.
Cognitive behavioral therapy (CBT) focuses on our thoughts and behaviors—the idea is that thoughts influence our feelings, so if we change the way we think about situations, we can also improve how we feel. Dialectical behavior therapy (DBT) focuses on developing specific skills to help you change your behavior patterns (as opposed to “thinking your way through” the issue).
Bipolar is a life-long illness. If you and those around you can get better at recognizing the signs early on, you’ll be able to head off a bout of full-blown mania—and with it, the potential for doing risky or harmful things, like blowing up your relationship or drinking too much or going on a shopping spree.
Contrary to how it may look in the movies, ECT is not painful. People are given muscle relaxants, and they’re under anesthesia, so although the procedure induces a seizure, the patient doesn’t feel anything.
First, Let's Recap the Basics of Bipolar
Low moods and high moods are part of life for everybody, but in bipolar disorder, a person experiences pronounced episodes of depression (the lows) and mania (the medical term for buoyant highs).
And those mood swings can interfere with your day-to-day—you might find it hard to do your job well, to be a good partner in your relationship, even to take care of everyday chores like laundry and grocery shopping.
But getting a diagnosis and finding the right treatment for bipolar can make a huge difference.
In order to be diagnosed with bipolar disorder, a doctor will want to be sure that you’ve had at least one episode of mania or its milder form, called hypomania. If that’s true for you, the doc can then delve deeper into your symptoms to figure out which type of bipolar you have.
Which Treatments Work Best?
There are many ways to help manage this condition. Beyond actual medication, you'll need a healthy support network you can rely on, including a psychiatrist, a therapist, and trusted family and friends.
The pros will help you create your best combination of treatments—your mental health bag of tricks, so to speak—so that you feel as stable and happy as possible.
What’s so important to remember: When treated, most people with bipolar can have full, satisfying lives.
What's the First Treatment for Bipolar?
Medication—full stop. It’s essential after a diagnosis of bipolar disorder. The immediate goal is to help stabilize mood and reduce symptoms.
Once that’s under control, continuing with drug treatment can help prevent or reduce the intensity of future episodes.
These are usually the first medications doctors prescribe for bipolar. Scientists don’t fully understand the mechanism in your brain, but what they think is happening is that mood stabilizers act on your neurotransmitters—the chemicals that let the brain’s nerve cells send signals about your mood, whether you’re anxious, depressed, or something else—to damp down those nerve signals.
Think of it as making your brain less “excitable.” It’s also thought that they might strengthen the connections between nerves that help with regulating your moods and behaviors.
Lithium. Known under the brand names Lithobid and Eskalith, lithium is the oldest of the mood stabilizers. Because of that, it is also the most studied—and has been shown to be extremely effective for bipolar disorder.
Depakote (divalproex sodium). Doctors also frequently prescribe this. It works similarly to lithium, but some patients might have fewer side effects with one drug versus another. Your doctor can help you decide which one has the best outcome for you.
Because mood stabilizers can take a while to take effect—sometimes up to three weeks—doctors usually add an antipsychotic if the person is experiencing mania.
“Antipsychotic” may sound a little scary, but it’s a common class of drug—a couple you may have heard of from medical pros, online articles, or even TV commercials are Abilify and Latuda, but there’s a large handful of options for doctors to prescribe.
Their advantage is that they act quickly as a kind of “sedative” for the brain, calming down manic episodes and preventing impulsive behavior.
Doctors aren’t exactly clear on how they work in the brain, but they do know they act quickly—some people with bipolar have their thinking return to normal within a week.
Once the mania has been reined in, the antipsychotic may be able to be phased out, though some people continue to need both meds to stay healthy.
What Are Other Treatments for Bipolar Disorder?
Medication is just one facet of treatment for bipolar. There are many different options, several of which can work well together. They include:
Electroconvulsive Therapy (ECT)
Unfortunately, ECT still brings up thoughts of One Flew Over the Cuckoo’s Nest, where Jack Nicholson’s character gets punished with the treatment.
But ECT doesn’t deserve the bad rap it gets. ECT can be a safe, rapid, and powerful option for people who have life-threatening episodes of depression or mania that hasn't responded to medications, or for those who can’t be on certain meds, such as pregnant women (odd as it seems, ECT is often the treatment of choice for them) or older adults.
It’s also used when symptoms are so severe that leaving them unchecked until the drugs take effect may be dangerous—ECT can start being effective within a week.
ECT is given in a hospital or medical center to allow the use of general anesthesia and muscle relaxants. Doctors apply an electric current through electrodes on the head that induces a short seizure in the brain (the muscle relaxants prevent a full-body convulsion). ECT may cause some confusion and limited memory loss, but that’s typically temporary.
Most patients are given three treatments a week for six to 12 treatments total. ECT can sometimes be done on an outpatient basis or started in a hospital and finished as an outpatient.
People who only respond to ECT (as opposed to medications) can do maintenance therapy every four to six weeks or they might go back to trying medications after ECT treatment.
This type of therapy helps people understand what’s going on and provides coping strategies to better handle the issues of bipolar.
Some with bipolar disorder find that therapy is an ongoing way to manage their symptoms, and they continue their sessions for years, even over their entire lives. Others end up doing well with medication but add a stint with therapy for added peace of mind and skills.
Talk therapy can happen with a psychologist or social worker, but it’s important that your therapist is trained and experienced in the particular therapies you’re exploring.
For medication, you need an M.D.—so if you don’t have a psychiatrist who can handle both talk therapy and prescriptions, your therapist can help you in conjunction with a medical doctor.
Several types of talk therapy can be beneficial:
Dialectical Behavior Therapy (DBT)
DBT helps people improve four basic skills:
Living more in the moment
Developing communication skills—this teaches those with bipolar how to tell people around them what’s happening and accept their support
Individuals learn how to do these things during one-on-one therapy sessions, then practice alongside others in a group setting. The thought behind the treatment is that some people react to emotional circumstances more extremely than others.
DBT was originally intended for people with borderline personality disorder, but research found that DBT may help regulate emotion and stabilize mood swings in people with bipolar as well.
In particular, DBT helps those with bipolar to more clearly recognize their emotions so they can actually see when they’re going into a manic phase (often, it’s hard for you to tell because mania can feel good when you’re the one with bipolar). Then they can use learned skills to stay present instead of getting panicky and deal with the intense feelings instead of letting them become overwhelming.
Cognitive Behavioral Therapy (CBT)
CBT helps you retrain how you think about a situation so that you view it in a realistic way and can behave appropriately. Research has found that CBT decreases the relapse rate and lessens the severity of depression and mania in people with bipolar.
CBT teaches patients how to calm and relax the mind and body in stressful situations—for example, if you feel a manic episode coming in and think to yourself, “This is awful. I’m out of control,” CBT helps you re-set the situation more neutrally and reframe it to yourself in less judgmental terms.
CBT also helps you find ways to become more aware of your actions and their consequences. You might even be asked to keep a journal of your daily moods and actions so you can begin to recognize your patterns.
CBT has been around a lot longer than DBT, so there’s been much more research on its effectiveness, but many doctors now believe that a combination of the therapies might be most effective.
Bipolar affects everyone differently, and of course everyone is unique to start with and has varied abilities to communicate effectively and regulate their emotions. Aspects of both types of therapy can help.
This treatment helps patients understand and accept their diagnosis by providing information about bipolar disorder and its treatment.
When people comprehend that they have a chronic condition that has a biological component and a high recurrence rate (bipolar is a lifelong diagnosis, but the frequency at which you cycle between manic and depressive episodes and back varies by person), they will be more apt to take their medication.
Psychoeducation also helps patients identify and avoid triggers, recognize the early warning signs of mania and depression, and understand the importance of maintaining routines and healthy habits (including drug and non-drug treatment). What kind of pro does this? Is this something you do for just like 6 weeks and then done?
Are There Other Lifestyle Changes That Can Help You Manage Bipolar Disorder?
Absolutely. In addition to taking medication regularly and participating in some type of therapy, getting adept at spotting what may trigger a mood swing can help you manage it, or prevent it altogether.
Chart your moods. Keep track of what’s happening with you day to day, including how much sleep you get, any big events or stressors you may face, your medication, and your mood. Sometimes specific things can spark an episode, so the goal is to see if you can spot any patterns. It may also be helpful to bring the chart to discuss with your doctor(s).
Stick to a regular routine. Disruptions (even good ones!) like vacations, a new job, or a new school schedule can lead to a bipolar episode. Changing your schedule—getting up or going to bed at different times, timing meals erratically—also makes it more difficult to stay on a regular medication regimen. If you do go on vacation or have a permanent schedule change like a new job, try to keep as many routines (time you shower, type of breakfast you eat, what kind of exercise you do, etc.) as consistent as possible.
Get a good night’s sleep. Sleep deprivation has been shown to be a potential trigger for mood swings, so stick to a regular sleep schedule as much as possible. This includes going to sleep and waking up at the same time every day, including on weekends and vacations.
Try to keep stress to a minimum. Too many deadlines, financial strains, or relationship stresses can cause moods to spiral. DBT and CBT both help teach ways of thinking and acting that can reduce reactive and negative responses to stress. Stress-management techniques, such as yoga or meditation, may also help.
Avoid drugs and alcohol. Substance abuse is common in people with bipolar disorder, and it can be dangerous. For one thing, alcohol is a known depressant (and this while you’re trying to head off depression)—and it can also potentially interact harmfully with bipolar medications. Drugs and alcohol may act on the same neurotransmitters that are involved in bipolar (though scientists aren’t absolutely sure they’re not sure it acts on the same neurotransmitters, or they’re not sure why this happens?), so using them can prompt or intensify mania or depression.
- Dialectical Behavior Therapy for Bipolar: Journal of Behavioral Therapy. (2017). “Dialectical Behavior Therapy Group Skills Training for Bipolar Disorder.” ncbi.nlm.nih.gov/pmc/articles/PMC6145450
- Dialectical Behavior Therapy for Teens with Bipolar: Journal of Child and Adolescent Psychoparmacology. (2015). “Dialectical Behavior Therapy for Adolescents with Bipolar Disorder: Results from a Pilot Randomized Trial.” ncbi.nlm.nih.gov/pmc/articles/PMC4367513/
- Cognitive Behavioral Therapy for Bipolar: PloS One. (2017). “Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials.” ncbi.nlm.nih.gov/pmc/articles/PMC5417606/
- Effectiveness of ECT: Current Neuropharmacology. (2017). “The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features.” ncbi.nlm.nih.gov/pmc/articles/PMC5405614/