Bipolar Disorder Treatment

Bipolar disorder, previously called Manic-Depressive Disorder, is currently understood through a biological lens, considered to be a circadian rhythm disorder. You may have seen my blog on other uses for the term, but here are three specific diagnoses:

Diagnosis	Manic Symptoms	Depressive Symptoms
Bipolar I Disorder	At least 1 Manic Episode	Not required, but often involves severe, deep depressions
Bipolar II Disorder	At least 1 Hypomanic Episode	At least 1 Depressive Episode
Cyclothymic Disorder	Subsyndromal, persistent Hypomanic Symptoms	Subsyndromal, persistent Depressive Symptoms

Bipolar Disorder tends to present or become florid enough for diagnosis (it's often 5+ years before diagnosis) during early adulthood when people are transitioning from a period of life in which severe mood episodes are low risk - during education - to high risk, such as losing or leaving their job and not returning, most frequently due to shame, unlike Major Depression (MDD), in which people frequently take Family Medical Leave of Absence (FMLA). Additionally, the severity of depressive episodes is often markedly worse in Bipolar Disorder. Consequently, the condition is much more life-disrupting. Symptom management is vital in order for individuals to maintain meaningful jobs that match their aptitude and, consequently, are rewarding, and psychoeducation to reduce stigma is important in order to help people from abandoning jobs due to shame after a mood episode.

[Note: Bipolar Disorder can present in childhood, but often presents differently, and is beyond the scope of this article].

Treatment

As a circadian rhythm disorder, lifestyle change is frequently the major psychotherapeutic intervention. However, these lifestyle changes are often resisted. A consistent wake up time - ideally +/- 15 minutes (30 for people who are more stable) including weekends is arguably the most important intervention. This wake up time will influence and help dictate the sleep time, but the client must also maintain this consistent sleep time regardless of life events: if there is a wedding, night out on weekends, or travel. Traveling across time-zones can be a major trigger and should not be done without preparation and a period of mood stability, circadian rhythm coping skills, and adequate antimanic medications.

Note: see these interventions resources below. If your a therapist, consider using with your clients. If you have bipolar (or unipolar) disorder, consider using for yourself or asking for support with it from your therapist. We are happy to provide brief skills training to individuals with bipolar disorder, or clinical supervision to therapists.

Bipolar Social Rhythm Metric

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Bipolar Mood Tracker

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Devices like the Oura ring can help track circadian rhythms and may even help predict mood changes before full-blown mood episodes occur. We may be able to implement interventions to avoid full-blown episodes ahead of time. If we see early signs of mania, we may avoid exposure to bright sunlight in the morning and dim internal lights, engage in calming/soothing activities, avoid excessive interpersonal stimulation and emotional activation, get plenty of sleep, and consult psychiatry to determine if antidepressant dosage is too high or antimanic is too low. When there are early signs of depression, we do the opposite: get outside in the morning to access sunlight (and/or use bright light therapy), increase activity levels and social interaction, avoid oversleeping (in fact, reduced sleep can have an antidepressant effect), and consult psychiatry to ensure adequate antidepressant dosing (though arguably less imperative than when we see manic episodes).

You can imagine that some young adults, in that transitional stage from college or graduate school into their career, are resistant to strict sleep and wake times, as well as reducing or eliminating recreational drugs (which significantly alter sleep architecture among other risk factors). Consequently, a lot of my work in the outpatient setting hasn't been with the person who has bipolar disorder, but with the mother of late 20's to early 30 year old men who have been resistant to treatment. Discussing not only the skills, how the parent can support their adult child, but also boundary setting becomes the focus on therapy. We often do family sessions as well.

These parents are often at wits' end, ambivalently split between empathy for their child and needing to set limits. The behavior during mania might be running family bank account's dry, causing legal ramifications, or disrupting home and family life including leading in the direction of divorce. There is frequently discussion that the adult child cannot live under the same roof (either they are because of transition to their career or because of consequence of mania), but this can be a gut-wrenching decision for a loving parent. Validating this need for boundary setting is important. Boundary setting typically involves pointing out the responsibilities for each parties roles, and expectations of carrying it out: most parents agree that they'd continue to do or give anything so long as their adult-child is engaging in and taking seriously treatment including medication and lifestyle management. We discuss an intervention that I call a double bind statement: "I want to do everything I can to help you, but I can't keep giving if you aren't also meeting me in the middle." We might use the DEAR-MAN Interpersonal Effectiveness Skills from DBT:

• Describe the situation: "You didn't take your medication, became manic, left your job and destroyed a brand new iPhone."

• Express: "This makes me sad about what your going through, but also frustrated that you won't help yourself and expect me to pick up the costs and pieces."

• Assert: "I want to keep helping and supporting you, but I need you to do the same for yourself and engage in treatment. I can only do so if you are in treatment."

• Reinforce: "I know you can do this and I will be with you every step of the way. I will always love you."

• Mindful: Repeat as necessary, reiterate treatment is non-negotiable.

• Appear Confident

• Negotiate: While treatment is non-negotiable, the care provider or other aspects of how to proceed may (and should) be.

Diagnostic Considerations

Bipolar is often misdiagnosed. It is often missed for many years for various reasons. People with bipolar disorder are often poor historians at least in part due to loss of insight during manic episodes. Hypomanic episodes are often misinterpreted as "doing well" or being euthymic. People often don't know what feeling normal, in terms of mood, is, but regularly rating mood and reviewing symptoms (daily early in treatment) helps, on a scale of -5 (too depressed to get out of bed) to +5 (requires hospitalization for mania). +/-2 is rounding the corner to concern and needing lifestyle behavior change, +/-3 would be clinically significant but not severe mood episode.

Bipolar disorder is more likely to involve both insomnia and hypersomnia compared to MDD, and the Hallmark of (hypo)mania is reduced need for sleep. Other conditions can result in impulsivity or increased mood and energy, but if the client is sleeping 5 or less hours for several days and not feeling fatigued (until they start to crash from the hypomania), this is likely a manic episode if not caused by medical or medication changes. Blood work is usually a good consideration to rule out things like thyroid disorder.

Conclussion

While I discussed working with parents of adult-offspring with bipolar disorder, I work with numerous individual therapy clients with bipolar disorder who have been very well managed and even reduced their antimanic drug use via lifestyle change. While antimanics are still recommended as a safety net regardless of stability (consult a psychiatric medication manager) and are life saving / changing medications, they also have health concerns that can increase over time. Some of my clients, it took several years to confirm bipolarity, understand their patterns, and implement coping-ahead skills such as knowing when mood episodes tend to occur and altering behaviors (and sometimes medication) based upon season and early symptoms. We get very good at recognize each individual's early symptoms, and these clients without even thinking about it review their early warning signs at the start of session.

Bipolar disorder is one that often worsens with time when left untreated - like most mental health episodes, bipolar mood episodes predict future ones. In other words, the illness worsens - frequency and intensity of episodes - with each episode that occurs. Consequently, early treatment is not only vital to prevent psychosocial consequences of episodes in the here-and-now but to protect future wellness.

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Academic Bibliography and Reference List

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR). American Psychiatric Association Publishing.

• Application: Outlines the core diagnostic classifications and longitudinal timeline thresholds for Bipolar I, Bipolar II, and Cyclothymic Disorders. It formalizes the objective distinctions between full mania, hypomania, and subsyndromal mood polarities while highlighting the diagnostic complexity caused by patient loss of insight.

Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A., ... & Monk, T. H. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62(9), 996–1004.

• Application: Serves as the primary evidence-based backing for treating bipolar disorder via a circadian rhythm lens. It validates the use of Interpersonal and Social Rhythm Therapy (IPSRT) principles, proving that stabilizing daily routines, tracking sleep-wake metrics, and protecting biological clocks against time-zone shifts reduces episode frequency.

Harvey, A. G. (2008). Sleep and circadian rhythms in bipolar disorder: Seeking synchrony, building stability. The American Journal of Psychiatry, 165(7), 820–829.

• Application: Documents the pathophysiological mechanics linking sleep architecture, biological vulnerabilities, and episode onset. It substantiates the blog's practical warning signs checklist, showing how reduced need for sleep initiates manic pathology while hyper-somnolence predicts a recursive depressive collapse.

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

• Application: Establishes the clinical behavioral script for the DEAR MAN assertiveness protocol referenced by the author. It supports the structural adaptation of interpersonal effectiveness skills to family-focused boundary setting and limit-enforcement dynamics.

Miklowitz, D. J., & Chung, B. (2016). Family-focused therapy for bipolar disorder: Reflections on 30 years of research. Family Process, 55(3), 483–499.

• Application: Validates the clinic's therapeutic emphasis on family session frameworks for young adults experiencing vocational disruption and treatment resistance. It details how resolving familial ambivalence and implementing boundary-setting loops directly improves medication compliance and reduces household stress.