Bipolar disorder is typically a chronic and debilitating condition. Thankfully, it’s also a highly treatable one. Medication is the mainstay of treatment, and psychotherapy is generally recommended as a critical complement to treatment.
Treatment for bipolar disorder can be divided into three general categories. Acute treatment focuses on suppressing current symptoms and continues until remission, which occurs when the symptoms are diminished for a period of time. Continuation treatment prevents a return of symptoms from the same manic or depressive episode. Maintenance treatment prevents a recurrence of symptoms.
In 2018, the Canadian Network for Mood and Anxiety Treatments along with the International Society for Bipolar Disorders (ISBD) published guidelines based on rigorous research and clinical experience for both pharmacological and psychosocial treatments for bipolar disorder. Consequently, most of the below recommendations and insights come from that resource.
Medication for Acute Episodes
It can take time to find the right medication or combination of medications. Your doctor will figure out what medication to prescribe based on various factors, such as: the kind of episode you’re experiencing, and the severity of that episode; how quickly you need the medication to work; whether you have any co-occurring psychiatric or medical disorders; any previous responses with medication; the safety and tolerability of the medications; and personal preference. Your doctor should thoroughly communicate the potential side effects for every medication.
To treat acute mania in bipolar I disorder, a doctor will likely start with one of these first-line medications, which include mood stabilizers and atypical antipsychotics: lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, or cariprazine.
If taking a first-line medication at an optimal dose doesn’t work or isn’t tolerable, your doctor should move on to combination therapy with first-line agents: either lithium or divalproex, and quetiapine, aripiprazole, risperidone, or asenapine.
If none of those treatments work, the next option is one of these medications (which are considered “second line” because of their safety and tolerability risks): olanzapine, carbamazepine, ziprasidone, and haloperidol. Another option is the combination therapy of olanzapine with lithium or divalproex.
Lithium and divalproex also are commonly combined in clinical practice. However, the only evidence for this combination comes from uncontrolled trials, so it’s also considered a second-line option.
Third-line medications for acute mania are chlorpromazine, clonazepam, or tamoxifen. Third-line combination therapy includes carbamazepine, oxcarbazepine, haloperidol, or tamoxifen with lithium or divalproex.
Again, your specific symptoms and history will guide your doctor’s decision. For instance, lithium or divalproex plus an atypical antipsychotic is helpful if you need a faster response, and have more severe episodes. Divalproex is recommended for people with multiple prior episodes, predominant irritable or dysphoric mood, and/or a co-occurring substance use disorder (SUD) or a history of head trauma.
For acute depression in bipolar I disorder, your doctor might prescribe any of these first-line medications: quetiapine, lithium, lamotrigine, or lurasidone. Lurasidone and lamotrigine also are recommended as first-line adjunctive treatments.
Divalproex is a second-line treatment. Another second-line option is antidepressants with lithium or divalproex, or an atypical antipsychotic. However, antidepressants should never be prescribed on their own for a depressive episode in bipolar I disorder.
Other second-line alternatives are cariprazine or a combination of olanzapine and fluoxetine. Third-line agents include carbamazepine or olanzapine; and medications that can be used adjunctively, such as aripiprazole, armodafinil, and asenapine.
Very little research has looked at effective treatments for hypomania in bipolar II disorder. Clinical experience suggests that the medications for manic episodes also are appropriate for hypomania. So, your doctor will likely prescribe a mood stabilizer—such as lithium or divalproex—and/or an atypical antipsychotic if your hypomanic episode is severe or impairs functioning.
For acute depression in bipolar II disorder, the only first-line treatment is quetiapine. Second-line treatment options are lithium, lamotrigine, or the antidepressants sertraline or venlafaxine (for people who experience a pure depressive episode, not with mixed symptoms.)
Third-line treatment includes divalproex; fluoxetine for individuals who mainly have pure depression; or ziprasidone for individuals who have depression with mixed hypomania, in addition to other medications.
Medication for Maintenance Treatment
Medication also is the foundation of maintenance treatment for bipolar disorder, which helps to prevent relapse, reduce symptoms, and improve quality of life. You’ll likely continue taking whatever medication helped you effectively treat your acute episode (with a few exceptions, such as antidepressants, because they can trigger mania in bipolar I).
Don’t abruptly stop taking your medication. Always talk to your doctor first. For instance, research shows that 50 to 90 percent of people who stopped taking lithium experienced recurrence of symptoms within 3 to 5 months. There’s also an increased risk for hospitalization and suicide.
Lithium is the gold standard for maintenance treatment for bipolar I disorder because of its ability to prevent both depressive and manic episodes and anti-suicidal effects. Lithium requires careful monitoring. For instance, you should be assessed for thyroid and renal functioning at 6 months after starting lithium, and annually after that.
Other first-line treatment includes quetiapine, divalproex, asenapine, or aripiprazole. A combination therapy of quetiapine with lithium or divalproex, or aripiprazole plus lithium or divalproex also is considered first line.
Divalproex requires monitoring, as well. This includes getting a menstrual history (because of a possible increased risk of polycystic ovarian syndrome); hematology profile; and liver function tests at 3 to 6 months in the first year of starting the medication, and then once a year.
Because of safety issues, olanzapine is considered a second-line maintenance treatment for bipolar I, as it can trigger metabolic syndrome. If you’re taking any kind of atypical antipsychotic, your blood pressure, fasting glucose, and lipid profile need to be tested at 3 months, 6 months, and then every year.
For bipolar II disorder, first-line treatment options are quetiapine, lithium, or lamotrigine. Second-line is venlafaxine, or fluoxetine. Third-line options include divalproex, carbamazepine, escitalopram, other antidepressants, or risperidone (mainly to prevent hypomania).
Lamotrigine and carbamazepine increase the risk for skin rashes, and your doctor should talk to you about Stevens-Johnson syndrome and toxic epidermal necrolysis. Asian patients should be tested for a specific allele that’s associated with a higher risk for these skin conditions (when taking carbamazepine).
Lamotrigine and carbamazepine can reduce the efficacy of oral contraceptives. Also, if you’re a woman of childbearing age, it’s important for your doctor to talk to you about the increased risk of birth defects for some medications. For instance, divalproex has an increased risk of neural tube defects and neurodevelopmental delay. Continuing to take medication is a complicated, nuanced decision, because bipolar disorder can worsen during pregnancy, and birth defects have been associated with untreated mood disorders, as well. Either way, don’t stop taking your medication until meeting with your doctor. Many women do continue to take some medication, and get regular tests to check on the health of their babies.
Most people with bipolar disorder have at least one additional psychiatric disorder. The most common disorders are SUD, anxiety disorder, personality disorder, and impulse control disorder (e.g., ADHD).
Sometimes, the medications are the same, such as quetiapine for both bipolar disorder and anxiety disorder. Other times, it’s the opposite. For instance, even though benzodiazepines rapidly alleviate anxiety, they also up the risk for abuse, dependence, and suicide.
Overall, the key in treating multiple disorders is to start with the most problematic symptoms, such as mania, psychosis, or suicidal ideation, or to treat simultaneously (as in the case of SUD). For instance, the combination of divalproex and lithium can help to concurrently treat alcohol use disorder and bipolar disorder.
There are many different types of psychotherapy. These four types have received the most research support for effectively treating bipolar disorder. However, thus far, there’s no effective psychotherapy for acute mania.
Research consistently shows that psychoeducation is highly effective for bipolar disorder, and is recommended as a first-line maintenance treatment. Psychoeducation is delivered individually or in group format, and teaches you to identify and manage depressive and manic, or hypomanic episodes; navigate stress; problem solve; and develop healthy habits. The therapist will guide you in creating personalized coping strategies to prevent relapse. These two models feature a group format, and have substantial support: Barcelona BDs Program (consists of 21 sessions over 6 months); and Life Goals Program (phase one consists of 6 weekly sessions).
Cognitive Behavioral Therapy (CBT)
CBT is recommended as a second-line treatment for acute bipolar depression, and as a maintenance treatment for individuals with fewer episodes and less severe form of bipolar disorder. It consists of 20 individual sessions over 6 months, with additional booster sessions. Specifically, CBT also includes a psychoeducation component, where you learn about your illness, and develop skills and tools to effectively manage it. In addition, therapists help you address hyper-positive thinking and impulsivity, delay gratification, and become more aware of the consequences of your actions. They help you to see the best in yourself during a depressive episode, and take action when you lack motivation, interest, and energy.
Family focused therapy (FFT)
FFT also is recommended as a second-line treatment for acute depression and maintenance. It focuses on improving communication between you and your partner and/or family. The therapist helps your family better understand how your bipolar disorder functions and manifests. FFT consists of 21 sessions over 9 months.
Interpersonal and Social Rhythm Therapy (IPSRT)
This therapy is recommended as a third-line treatment for acute depression and maintenance. IPSRT helps you manage conflict and stress, along with setting and maintaining daily routines and consistent sleep/wake cycles. It usually features 24 individual sessions over 9 months.
Research also has shown that dialectical behavior therapy (DBT) may be helpful in reducing some depressive symptoms and suicidality, and mindfulness-based cognitive therapy (MBCT) might help with reducing anxiety.
There are a number of self-help strategies a person with this condition can employ to help with the symptoms and everyday life challenges.
- Actively participate in your treatment. Ask questions, and always voice your concerns. Advocate for yourself and your needs.
- Monitor your mood, sleep, stressors, cognitive function, and overall quality of life (you can find charting tools online). This helps you identify how well your medication is actually working, and to better understand what triggers your episodes. It also helps you identify warning signs that an episode is coming on, so you can address it quickly.
- Make it easy to take your medication by having a pillbox, setting reminders on your phone, and linking it to another ritual (e.g., brushing your teeth, making coffee).
- Establish a daily routine. Create a calming evening routine. Try to go to sleep and wake up around the same time every day. (Sleep deprivation triggers mania.) Find enjoyable ways to move your body.
- Have a safety plan with warning signs, coping strategies, and support resources. Over 70 percent of suicide attempts and deaths happen during the depressive phase of bipolar disorder, so it’s imperative to know precisely what to do when you’re in that phase.
- Join an in-person or online support group. For instance, check out Psych Central’s Bipolar Support Group.
- Find healthy ways to manage stress that work for you. This might be anything from meditating to gardening to swimming to taking walks.
For further information
For more information about the treatment of this condition, please review these additional articles.