Bipolar Disorders: Basic Concepts and Management Principles in the Pursuit of Individualized Care

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As providers, diagnosing and treating bipolar I disorder (BD-I) may involve unique challenges due to uncertainty as to what causes the condition, overlapping symptoms with other psychiatric disorders, complex medication needs, and significant stigma.

In addition, an initial BD-I diagnosis can feel overwhelming, disorienting, and isolating to patients. However, an accurate mental health assessment is the first step toward helping patients receive individualized care to support long-term condition management. With a broad range of available treatment options, along with psychosocial support and self-care, patients with BD-I can live healthy, fulfilling lives.

Understanding Bipolar I Disorder

Presentation of BD-I typically alternates between euphoric, high-energy manic periods and debilitating depressive periods. According to the DSM-5, a diagnosis of BD-I requires at least 1 manic episode lasting at least 7 days (or requiring hospitalization), which may be preceded or followed by hypomanic or depressive episodes. Manic episodes may include symptoms such as inflated self-esteem, decreased need for sleep, rapid speech, racing thoughts, and risky behavior.¹ Symptoms of BD-I may vary widely, with some patients experiencing chronic recurrence and others episodic, irregular episodes. A severe manic or depressive episode may trigger psychotic symptoms, such as delusions or hallucinations, further complicating the clinical picture. Research suggests that approximately 4.4% of US adults experience bipolar spectrum disorders in their lifetime, with BD-I comprising about 0.6% of the population annually. The variability in presentation emphasizes the importance of accurate diagnosis and personalized treatment approaches.²

The 3 primary types of bipolar disorder—BD-I, bipolar II disorder (BD-II), and cyclothymic disorder—are similar in that each manifests mood instability involving manic or hypomanic and depressive periods. BD-II involves episodes of hypomania—less intense than full-blown mania—and major depressive episodes. The major depressive episodes that occur in bipolar disorder (I or II) are indistinguishable from the ones that occur as part of a major depressive disorder. A major depressive episode is characterized by persistent depressed mood for most of the day, nearly every day, along with persistent lack of motivation that significantly impairs daily functioning. Cyclothymic disorder represents a milder but chronic form of mood instability.¹

Challenges With Diagnosis
Although symptoms can occur at any age, most diagnoses of bipolar disorder occur in late adolescence or early adulthood, with the average age of onset around 25 years. A smaller percentage of cases, approximately 5% to 10% of individuals, experience their first episode after age 50.⁴ One of the challenges of treatment is that bipolar disorder is often misdiagnosed in itsearly phases. In fact, it may take from 5 to 10 years between the onset of symptoms and confirmation of an accurate diagnosis.⁵

The diagnostic process is layered with complexity. Conditions such as posttraumatic stress disorder (PTSD), anxiety, or attention-deficit/hyperactivity disorder (ADHD) may have similarities with bipolar disorder, leading to an inaccurate diagnosis.⁶ Moreover, these instances of misdiagnosis may be bidirectional, and further complicated by a high prevalence of psychiatric comorbidities that can present in a person living with BD-I, such as anxiety disorders, ADHD, or substance use disorders.²

With no definitive biological markers to guide diagnosis, thorough interviews and record reviews are crucial. When considering a diagnosis of BD-I, I rely heavily on medical records, clinical observation, validated tools, and direct patient interviews. I also value the collaboration of family members, as they can provide a more complete and chronologically cumulative picture. This is especially important as patients may lack insight during manic phases or struggle to recount depressive symptoms accurately. Often, the patient is unsure when the episodes of mania or depression began; sometimes, even family members don't remember. As a result, we as clinicians bear a responsibility to be as comprehensive as possible in our assessments.

For example, consider a composite case: a 24-year-old male patient, “John Doe,” comes in with severe depressive symptoms like fatigue, feelings of worthlessness, and social withdrawal. When asked, he mentions a period a few months ago when he felt “on top of the world,” started ambitious projects, spent impulsively, and barely slept. His parents thought he was just being productive. A review of his records reveals a previous visit for agitation and irritability, which had not been recognized as mania. Together, these pieces point to a diagnosis of BD-I, illustrating the challenges of making an accurate diagnosis.

Treatment Options for Bipolar-I Disorder

We still do not know the exact cause of BD-I. While genetic predispositions are associated with increased risk, researchers continue to study specific biological markers. Dysregulation of neurotransmitters like dopamine, serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) play a key role in mood regulation.²

Recognizing the range of treatment options for BD-I is essential. Treatment is guided by goals like acute symptom control and relapse prevention while balancing benefits, side effects, and patient factors, such as comorbidities and adherence. A personalized approach is key to optimizing outcomes and achieving long-term stability.

According to the American Psychiatric Association (APA) guidelines, first-line pharmacologic treatments for BD-I include mood stabilizers, such as lithium and valproate, as well as second-generation antipsychotics, like olanzapine, quetiapine, and aripiprazole.⁷ Although efficacious, these therapies must be closely monitored for adverse events. For example, use of unopposed antidepressants must be avoided to prevent triggering mania. Lithium effectively prevents relapse, but requires monitoring for renal or thyroid function impairment, while antipsychotics like olanzapine tame acute mania and prevent relapse, but may cause metabolic side effects.⁷ Moreover, the simultaneous use of these drugs (polypharmacy) is often required in bipolar disorder, with studies indicating that up to 50% of patients may require 2 or more medications to manage their symptoms.⁸ This approach is needed to target the varied symptoms of the disease, such as mood fluctuations, psychotic symptoms, or insomnia. Individuals with bipolar disorder in the US may take up to 5 medications simultaneously to manage their symptoms and alleviate common side effects such as weight gain, sedation, and movement disorders.⁸

Managing multiple drugs increases risks like drug interactions and can complicate medication adherence. Rather than layering multiple medications, clinicians may consider discussing alternative medication options with patients to find a treatment regimen that may work best for a patient.

Finding the right treatment for BD-I is a complex process that often requires time, trial and error, and a collaborative partnership between patients and providers to ensure a course of care that effectively manages symptoms while supporting overall well-being.

Formulating a Personalized Treatment Plan

Social and cultural stigma remains a barrier to both diagnosis and treatment of BD-I. In my practice, I observe the effects of persistent stigma around mental illness daily. Additionally, I have seen how stigma can originate with an individual person, including those living with the condition, in families and communities, and even within the medical community. For instance, patients often delay seeking treatment for fear of being judged by their peers or labeled as “unstable.” Families may dismiss early symptoms as temporary stress, while communities with limited access to mental health education may attribute these symptoms to external factors, such as poor lifestyle choices or lack of discipline.In my opinion, we must promote efforts to normalize mental health conversations and educate families and communities as a pathway to promoting access to treatment.

An integrated treatment plan—one that combines psychopharmacological agents, therapy, family support, and psychoeducation—is essential to improving the management of BD-I. Different types of therapy play distinct roles in the treatment paradigm. Cognitive-behavioral therapy (CBT) helps patients identify and manage mood triggers, develop coping strategies, and adhere to treatment plans. Interpersonal and social rhythm therapy (IPSRT) focuses on stabilizing daily routines, such as sleep and activity patterns, to reduce mood episode recurrence.⁹ Regular therapy sessions aid patients in recognizing symptoms early, adhering to treatment recommendations, and managing interpersonal relationships. In my practice, collaboration with therapists is integral to creating a cohesive treatment plan. I maintain open communication with therapists to ensure alignment in treatment goals and to address specific challenges patients face, such as medication adherence or lifestyle adjustments.

Personalized care plans that include strategies to manage stress or ensure good sleep hygiene are also critical. Research has demonstrated that poor sleep is a significant trigger for mood episodes in individuals with bipolar disorder.¹⁰ I incorporate the latest science and emerging protocols that I believe can help patients regulate their moods. This may include using natural supplements like melatonin for sleep and omega-3 acids or neurostimulation to reduce the severity of symptoms. For instance, neurostimulation therapies, such as transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), are supported by guidelines for treatment-resistant cases, with evidence pointing to their ability to reduce symptom severity and improve overall functioning.¹¹ These approaches are grounded in scientific evidence and clinical guidelines, emphasizing their safety and efficacy when integrated into comprehensive treatment plans.

It is important for patients and their families to understand that BD-I requires treatment throughout the patient’s life. Psychoeducation is a valuable approach that I utilize in my practice on a daily basis. It is essential for the patients and their support systems to understand that BD-I is a chronic condition that requires specialized care and regular clinical monitoring. It improves medication adherence, reduces relapse rates, and enhances quality of life. Family programs also foster communication, ease caregiver burden, and boost treatment engagement.¹² In my practice, sessions respect privacy while promoting collaboration between patients and families. Incorporating this multi-disciplinary approach encourages long-term commitment to treatment plans, helping patients lead fulfilling lives despite challenges faced.

Dr Medina is a psychiatrist in Orlando, Florida.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association. 2013.

2. Bipolar disorder. National Institute of Mental Health. Revised 2022. Accessed January 3, 2025. https://www.nimh.nih.gov/health/publications/bipolar-disorder

3. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64(5):543-552.

4.Bipolar disorder. National Alliance on Mental Illness. August 2017. Accessed December 5, 2025. https://www.nami.org/about-mental-illness/mental-health-conditions/bipolar-disorder/

5. Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: challenges and future directions. Lancet. 2013;381(9878):1663-1671.

6. Comparelli A, Polidori L, Sarli G, et al. Differentiation and comorbidity of bipolar disorder and attention deficit and hyperactivity disorder in children, adolescents, and adults: a clinical and nosological perspective. Front Psychiatry. 2022;13:949375.

7. Practice guideline for the treatment of patients with bipolar disorder. American Psychiatric Association. Am J Psychiatry. 1994;151(12):1-36.

8. Goodwin G, Haddad P, Ferrier I, et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30(6):495-553.

9. Miklowitz DJ, Scott J. Psychosocial treatments for bipolar disorder: Cost-effectiveness, mediating mechanisms, and future directions. Bipolar Disord. 2009;11(Suppl 2):110-122.

10. Harvey AG. Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony, and regulation. Am J Psychiatry. 2008;165(7):820-829.

11. Perugi G, Medda P, Toni C, et al. The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Curr Neuropharmacol. 2017;15(3):359-179.

12. Jones BDM, Umer M, Kittur ME, et al. A systematic review on the effectiveness of dialectical behavior therapy for improving mood symptoms in bipolar disorders. Int J Bipolar Disord. 2023;11(1):6.