Bipolar Disorder Treatment: What Works
Bipolar disorder is a mood condition defined by episodes of mania or hypomania, usually alongside episodes of depression, in which energy, sleep need, judgement and speed of thought all move together.
Also called: Manic depression, Bipolar affective disorder, Bipolar I disorder, Bipolar II disorder.
ICD-10 F31 · ICD-11 6A60
The treatment is a plan, not a pill.
Treating an episode is only half the job. Mania is often brought under control within weeks. The harder part is the years that follow, and stopping the next episode.
No single thing does that on its own. The evidence points to a plan with several parts. You need a long-term medicine, a steady daily routine, and knowledge of your own early warning signs.
WHERE TREATMENT STARTS
Lithium first for the long term
NICE, the National Institute for Health and Care Excellence, is the body that writes the UK guidelines. It recommends lithium as the first medicine for preventing episodes. If lithium does not suit someone, the alternatives include valproate and certain antipsychotics, such as quetiapine or olanzapine.
For an episode of mania, the first choice is usually an antipsychotic. For bipolar depression, the options include quetiapine, lamotrigine, and olanzapine combined with fluoxetine.
Two warnings go with this. First, an antidepressant on its own can tip some people into mania. So it is usually given together with a mood stabiliser, if it is given at all. Second, valproate is avoided in women and girls who could become pregnant, because it can seriously harm an unborn baby.
THE PART THAT PREVENTS THE NEXT ONE
Build the plan.
The chart below shows two years in the life of one person with bipolar I. Each step across is one week. The shaded strip through the middle means well. A line rising above the strip is a high. A line dropping below it is a low.
With no treatment, this person spends about half of those two years unwell.
Each switch below adds one part of a treatment plan. Turn them on and watch the chart. The question to ask is simple. Which parts remove episodes, and which parts only make them smaller?
Tap a switch to add or remove that part of the plan. The chart redraws each time.
Weeks unwell
Weeks low
Weeks high
Episodes
104
low
4
13
0.82
none
high
25
5
0.95
sleep
low
32
11
0.74
after
high
52
4
0.62
goal
low
64
14
0.8
none
high
88
5
0.9
sleep
high
58
6
1
stop
52
Lithium, taken long term
Lithium stops some episodes from happening at all. It makes the remaining highs much smaller. It does need regular blood tests.
There is no long-term medicine. Episodes keep coming at their natural rate.
Regular sleep and daily routine
The high that began with a run of short nights never starts. The later high is smaller.
Sleep is irregular. The episodes that lost sleep sets off still happen.
An early-warning plan
Episodes are caught in their first few days and acted on. So they are shorter and less severe.
Episodes are only noticed late, once they have reached full size.
Stop lithium suddenly at month 12
lithium
A high comes back within months of stopping suddenly. Stopping slowly, with a doctor, carries far less risk.
Lithium continues as normal.
The point of this device is that no single switch does everything. Lithium does the most on its own. Routine removes the episodes that lost sleep causes. The early-warning plan does not prevent episodes, but it makes them shorter. Together they achieve more than any one of them alone. And stopping lithium suddenly undoes much of that within months.
With no plan at all, about half of the weeks in two years are spent unwell. Most of those weeks are low, not high.
Lithium on its own prevents some episodes and makes the highs much smaller.
Regular sleep and routine remove the episode that a run of short nights set off.
An early-warning plan does not stop episodes. It makes the ones that happen shorter.
Stopping lithium suddenly brings a high back within months.
These two years are an illustration. They are built from the shape of the research, not from one real person, and they do not predict what will happen to anyone. Real plans are made with a psychiatrist, and they change over time.
NOT ONLY MEDICATION
What else has evidence
In bipolar disorder, talking treatments do not replace medication. They make the medication work better, and they cut the number of relapses.
Group psychoeducation
You learn how the condition works, what your own early signs are, and what to do about them. In trials this cut relapses, and the benefit lasted for years.
Social rhythm therapy
This builds steady times for sleeping, waking, eating and seeing people. It also repairs the relationship problems that often come with episodes.
Family-focused therapy
This brings the family in. They learn about the condition, practise talking with less conflict, and learn to spot warning signs together.
Why the plan beats the pill
Medication lowers the risk of an episode starting. Knowing your signs, and having a plan ready, means the episodes that do start get caught while they are still small. Each one covers a gap the other leaves.
IF LITHIUM IS THE ROUTE
What actually happens, in order
Lithium needs more monitoring than most medicines, and there is a good reason for that.
Before starting, the doctor checks your blood, your kidneys, your thyroid and your weight.
The dose is then raised slowly until the level in your blood is right. That is usually between 0.6 and 0.8 mmol/L. Below that range it does not protect you. Above it, lithium becomes toxic.
Blood levels are checked weekly at first. Then every three months during the first year. Then less often, once the level is steady.
Some things push the level up. Vomiting, diarrhoea and some common painkillers all do it. So people learn the warning signs of too much lithium. Those are shaking hands, feeling sick, and confusion.
The full protective effect can take months to arrive.
OVER YEARS
What the long-term data shows
Lithium has the longest record of any medicine in psychiatry.
One large trial compared long-term treatments directly. Lithium prevented more episodes than valproate did.
Large studies also link lithium with fewer suicides. A 2022 trial in US veterans did not find that result, so the question is still being argued about.
Over many years, lithium can affect the kidneys and the thyroid. That is why both are checked regularly. For most people the protection is worth the risk.
In trials, group psychoeducation kept relapses down for up to five years.
COMING OFF
Slowly, and never suddenly
How lithium is stopped matters as much as whether it is stopped.
Stopping lithium suddenly brings a high risk of relapse over the following months. Mania is the most likely form it takes.
NICE advises reducing the dose gradually, over at least four weeks, with a doctor. It also advises watching closely for early signs of mania and depression afterwards.
Many people feel well for so long that they start to wonder whether they still need it. That feeling is usually a sign that the medicine is doing its job.