When Natasha Tracy was 19, a psychiatrist diagnosed her with minor depression.
“I knew this was wrong,” Tracy says. “He hadn’t listened to me. I was suffering from severe, suicidal depression.”
In addition, she experienced hypomania — a condition marked by elevated mood, increased energy and activity — and suspected she had bipolar disorder.
Tracy’s self-diagnosis was correct: A year later, she was properly diagnosed with bipolar II disorder, a type of bipolar disorder characterized by fluctuating episodes of mild highs and severe lows.
But her experience trying different medications proved to be just as frustrating as trying to get an accurate diagnosis. She had tried many antidepressants but couldn’t get on the right dose due to the horrible side effects she experienced, such as hair loss, high and low blood pressure, nausea, vomiting, weight gain and more.
It took her two years to find a medication she could tolerate and that worked.
“When that happened, it felt like a literal miracle. I could smile again for the first time in years,” says Tracy, who is now a mental health speaker and author of “Lost Marbles: Insights Into My Life With Depression and Bipolar.”
As Tracy experienced, treating bipolar disorder often involves trying out different medications to see which is best for you.
“It can be a challenge to find the right combination of medications for a patient because we can’t predict which one will work for which patient or which might lead to greater side effects,” says Dr. Kristin Raj, a clinical associate professor of psychiatry and behavioral sciences at Stanford University. “It often takes some time and trials to sort this out.”
Here’s what to know about the disorder, how it’s diagnosed and how it’s treated.
[READ: What to Do During a Mental Health Crisis]
What Is Bipolar Disorder?
Bipolar disorder is a mental health condition marked by extreme mood episodes, including highs (mania or hypomania) and lows (depression).
During manic episodes, people with bipolar disorder often experience euphoria, high energy or irritability. In contrast, during depressive episodes, people often feel extreme sadness, hopelessness or become uninterested in activities.
These mood swings not only affect people’s mental well-being, behaviors and judgments, but they can also impact physical health, including sleep and energy.
These swings between mania and depression aren’t rapid, as often portrayed in movies. Instead, the shifts in mood may occur periodically throughout the year over the course of a few days. In between episodes, people can either experience emotional stability or mood swings.
[READ: What’s the Difference Between Bipolar Disorder and Borderline Personality Disorder?]
Signs and Symptoms of Bipolar Disorder
Mania and depression tend to manifest much differently, though people with bipolar disorder may experience symptoms of both simultaneously. Generally, depending on the type of episode, they will have at least some of these symptoms.
Mania symptoms
— Hyperactivity, excitability and irritability
— Boundless energy
— Significantly less sleep
— Racing thoughts
— Uncharacteristically rapid speech
— Decreased tolerance for frustration
— Impulsiveness and reckless behavior
— A notable increase in goal-directed activity (socially, at work, school or sexually)
— Grandiosity or inflated self-esteem
— Hallucinations and delusions
To meet the medical criteria for bipolar disorder, people must have a history of one or more episodes of mania or hypomania (a milder form of mania).
Mania may not involve elevated mood and is not generally a happy time for people who experience it. Instead, it’s a period of intense agitation and arousal that curtails their ability to sleep and manage other daily tasks.
These episodes can be extremely distressing for the person with bipolar disorder as well as family and friends around them. Patients may end up hospitalized during episodes of mania.
Depressive symptoms
— Prolonged lethargy and loss of energy
— Feelings of guilt, despair and worthlessness
— Sadness and hopelessness
— Unwanted weight loss or weight gain
— Sleep difficulties, from excessive sleeping to insomnia
— Decrease in performing daily activities, such as bathing
— Suicidal thoughts
Depressive episodes are typically severe, leaving people unable to get out of bed or engage with work, school or family duties.
Early onset of symptoms
Symptoms of bipolar disorder often develop at a young age.
Similar to adults, children and teens with bipolar disorder go through unusual mood changes. As a parent, you may notice or hear from other family members or teachers about certain symptoms that could suggest bipolar disorder:
— Exceptional moodiness or excitability
— Notable highs and lows occurring more frequently than in other children
— Extreme behavior changes
— Bouts of significant irritability, frustration or aggression
— Inability to sleep
— Clouded thinking and a decline in academic performance
— Disrupted friendships and high drama with peers
— Episodes of self-harm or suicidality
[Read: Low-Cost Therapy Options for Every Budget.]
Types of Bipolar Disorder
Not all cases of bipolar are the same. There are a few distinct types:
— Bipolar I disorder. Bipolar I is the most severe type. People with bipolar I disorder have had a manic episode lasting at least a week or have been hospitalized with severe mania. They may have had major depression lasting 14 days or more. Major depressive episodes are not required for this diagnosis, but most individuals do experience major depressive disorder.
— Bipolar II disorder. This less severe form of bipolar disorder is characterized by at least one episode of hypomania and a major depressive episode.
— Cyclothymia. A related condition called cyclothymia (also known as cyclothymic disorder) involves recurring episodes of hypomania and depression. These are less severe but persistent and occur over the span of at least two years in adults.
— Unspecified. When symptoms don’t quite fit any of these categories, the illness may be classified as unspecified bipolar disorder.
Causes of Bipolar Disorder
Exactly why bipolar disorder impacts some people and not others isn’t entirely understood, but there are several factors that can elevate risk.
— Genetics. Multiple genes raise your odds. Having a first-degree relative, such as a parent, brother or sister with the condition, puts you at higher risk.
— Childhood trauma. Childhood trauma, neglect and abuse have been found to contribute to the severity of bipolar disorder symptoms. Adverse childhood events, such as emotional or sexual abuse, can create worse outcomes for bipolar disorder later in life.
— Lifestyle factors. Substance use can be a contributing factor to developing bipolar disorder, but it can also be a symptom of the disease.
— Other environmental factors. Brain injuries, living situations, certain viral infections and obstetric complications, such as maternal influenza during pregnancy, have all been associated with a higher risk of developing bipolar disorder.
Bipolar Disorder Diagnosis
For adults and adolescents alike, a bipolar diagnosis can be a difficult, lengthy process.
— Medical history. During an evaluation, the provider conducts a comprehensive assessment of your medical history, along with the symptoms you’re experiencing.
— Physical exam. Your health care provider may conduct a physical exam to rule out any other potential medical conditions that may mimic symptoms of bipolar disorder.
— Mental health assessment. Health care professionals will review your mental health history and symptoms, including behavior patterns. While manic behaviors are a key defining feature of bipolar disorder, it’s often the depressive symptoms that initially drive someone to seek help. It’s not uncommon for someone who’s been treated for depression to actually have bipolar disorder.
Bipolar Disorder Treatments
In both bipolar I and II disorders, the goal is to prolong the “maintenance” phase, when the person feels stable, but there are differences in how they are each treated.
“In bipolar I, we tend to maintain a strong focus on trying to prevent the highs, or mania, as they are more disabling for patients than the highs that come with bipolar II,” Raj says.
However, there are more treatment options approved for bipolar I disorder, as there has been more research conducted on it than bipolar II disorder. This is partly because bipolar II disorder was only recognized as a separate disorder in 1994 and presents symptoms that are harder to spot than the very obvious manic episodes of bipolar I disorder.
“Less information is available about evidence-based treatments for bipolar II disorder, and therefore, psychiatrists often ‘borrow’ from the bipolar I disorder evidence-based medications to treat bipolar II disorder,” says Dr. Holly Swartz, a professor of psychiatry at the University of Pittsburgh.
Medications
There are several types of medications for bipolar disorder that treat the neurochemistry and symptoms of mania, hypomania and depression involved in the condition.
These medications include:
— Mood stabilizers: These medications, which reduce episodes of mania or hypomania, are mainstay treatments for both types of bipolar disorders. The gold standard mood stabilizer drug is lithium (Lithobid, Eskalith). Other mood stabilizers include anticonvulsants, such as divalproex sodium (Depakote, Depakote ER), carbamazepine (Tegretol, Tegretol XR and Equetro) and lamotrigine (Lamictal).
— Antipsychotics: These medications treat psychosis-related symptoms, such as hallucinations and delusions, and include olanzapine, risperidone and quetiapine.
— Antidepressants: These medications treat depressive symptoms and include selective serotonin reuptake inhibitors (SSRIs). They are used cautiously only in bipolar II disorder and only with a mood stabilizer so they don’t cause hypomania. Antidepressants are often avoided in bipolar I disorder because of the risk of inducing mania.
“Your mental health specialist will address your unique symptom presentations and prescribe medications that best address your mood disorder experiences,” says psychologist Deborah Serani, a professor at Adelphi University and author of “Living with Depression.”
Many patients — such as Tracy — may need additional medications to manage their condition.
“Some individuals are excellent lithium responders and require no further medications. However, a large percentage of individuals with either bipolar I or II disorder do not respond to a single medication — lithium or otherwise — and require multiple medications with different mechanisms of action to achieve stability,” Swartz says.
This trial and error to find the best combination of meds for each patient can take a long time, which is something Tracy experienced.
“Throughout the years, I have had to switch or augment medications many times because of either intolerable side effects, such as continuous weight gain, or because the existing treatment stopped being effective,” she says.
According to a recent Harris Poll survey, patients with bipolar I change medications an average of seven times over the course of their treatment journey.
“This underscores just how complex and individualized care needs to be. Everyone responds differently based on their biology, symptoms and side effect tolerance,” says Dr. David Medina, medical director of Nova Psychiatry in Orlando, Florida.
Psychotherapy
While medications can help manage bipolar episodes, they are not the be-all and end-all solution. It’s common for people to experience bipolar episodes while being treated with drugs. In fact, as many as 60% of bipolar disorder patients experience a mood episode even while medicated, according to Swartz.
“Medications are important, but they’re not the whole answer,” Medina says. “The goal of therapy and other nonmedication treatments is to give patients tools to manage their condition day to day.”
The two treatment approaches target different things: While medication helps modulate mood swings, psychotherapy works to build life management skills for living with a chronic mood disorder.
As with medications, there are different types of therapy that have been proven to treat bipolar disorder:
— Psychoeducation: Understanding the disorder through education about it gives patients insight into triggers, decision-making, risk-taking behaviors and problem-solving.
— Cognitive behavior therapy (CBT): This form of therapy focuses on changing thought patterns to lead to healthier behavior. “It reframes how you think into adaptive, instead of maladaptive, approaches,” Serani says.
— Dialectical behavior therapy (DBT): This approach teaches people with bipolar disorder skills to manage difficult and intense emotions, situations and relationships.
— Family-focused therapy: This type helps family members better support the person with bipolar disorder to decrease their stress levels.
— Interpersonal and social rhythm therapy: This strategy focuses on improving daily routines, circadian rhythms and relationships.
“Many psychosocial factors can impact mood. The goal of therapy is both to identify which of these factors are leading in an individual’s life and how those can be modified to help someone optimize their mood,” Raj says.
Therapy helps patients:
— Understand their diagnosis
— Recognize early warning signs of manic or depressive episodes
— Prevent recurrence of episodes
— Build routines and time management
— Develop coping strategies
— Improve symptoms
— Adhere to medications
— Enhance functioning
“It’s also where they get validation, as someone is listening and helping them process what they’re going through. That support can make all the difference,” Medina says.
People with bipolar disorder may see a psychologist or social worker for therapy, but only a psychiatrist, psychiatric nurse practitioner or another medical specialist can prescribe medications. However, the two should work closely together.
Lifestyle Changes for Bipolar Disorder
Therapy may also help guide people with bipolar disorder to lifestyle modifications that can directly impact mood stability and, as a result, help manage their condition more effectively.
Lifestyle modifications to manage bipolar disorder include:
— Sleep: Stable sleep can be key to maintaining a stable mood for patients with bipolar disorder. Insomnia is a common symptom of bipolar because of a dysregulation in circadian rhythms and sleep/wake cycles in people with the disorder. Poor sleep can also make mood episodes more likely. Conversely, getting good quality sleep can help regulate moods.
— Nutrition: Eating a wide variety of healthy foods, including whole grains, vegetables, fruit and oily fish such as salmon, give your brain more nutrients to help it function properly. These foods also keep your gut microbiome, the good bacteria in your gastrointestinal system, balanced, which has been shown to impact mood as well.
— Avoiding drugs and alcohol: Even moderate amounts of alcohol consumption has been shown in studies to increase episodes of mania, hypomania or depression in people with bipolar disorder. People with bipolar disorder are also more likely to have alcohol use disorder. Drugs, except the ones prescribed by your doctor, can also alter mood and have negative effects on your overall health
— Structure and routine: People with bipolar disorder often have dysregulated circadian rhythms, which are the body’s natural cycles of physical, mental and behavioral changes over 24 hours. Keeping a stable routine and structure to the day works to balance these rhythms, helping people with bipolar disorder feel steady, secure and in control.
While these self-care aspects can be hard to stick to and take practice, they are vital to the well-being of people with bipolar disorder.
Holistic Treatments for Bipolar Disorder
Complementary alternative medicine (CAM) may help in treating bipolar disorder by focusing on the mind-body connection and decreasing stress, but they do not replace medication or psychotherapy.
“CAM therapies are well-researched and can offer supplemental support alongside traditional treatments. They bring comfort, ease and relaxation,” Serani says.
These include:
— Acupuncture, reflexology or massage
— Art or music therapy
— Biofeedback (awareness of the functions of your body)
— Chiropractic care
— Exercise, including dance or movement therapy and tai chi
— Herbal and dietary supplements, such as ashwagandha, fish oil and vitamin B complex (always check with your doctor first)
— Hypnosis
— Meditation and breathing techniques
— Reiki
— Zen gardening (horticultural therapy)
New Treatments for Bipolar Disorder
Research into new treatments is yielding some encouraging results.
“Neuromodulation therapies are a really promising space,” Medina says.
These treatments use electrical impulses and medication to alter how nerve cells carry information to and from the brain to impact mood.
Vagus nerve stimulation (VNS)
VNS is currently being studied for treatment-resistant depression. With this treatment, which Tracy has tried, electrical signals are sent through the vagus nerve to stimulate areas of the brain involved in mood regulation.
“It’s exciting because it offers a nonmedication option that could provide long-term relief, especially for patients who haven’t responded to other treatments,” Medina says.
Transcranial magnetic stimulation (TMS)
TMS is a noninvasive neuromodulation treatment that uses magnetic fields to stimulate nerve cells in the brain.
“This treatment carries fewer side effects than medications and can be very effective for depressed mood in bipolar,” Raj explains.
Electroconvulsive therapy (ECT)
ECT is another type of neurostimulation for severe and treatment-resistant bipolar disorder. Usually done under anesthesia, ECT acts on the brain’s chemistry through an electric current.
Ketamine
On the medication side, studies on ketamine have shown positive results for treating the depressive aspects of bipolar disorder in the short-term, without risk of inducing manic episodes.
Challenges in Treating Bipolar Disorder
Although bipolar disorder has many effective treatments that make it possible to live with the condition, there are still some difficulties in getting patients to adhere to them.
About half of bipolar disorder patients stop going to therapy or taking their medication.
“For chronic mood disorders, the mindset of knowing one has to live with it, manage it and have professional treatment for it long-term may not be easy to accept,” Serani says.
Once patients report feeling better, they may not see the need for continued care. However, experts caution against this. Without continued treatment, the cycle of elevated and depressed moods continues.
Other reasons for dropping treatment might include:
— When in a manic state, patients might not think they need help
— Patients don’t like the side effects, such as weight gain, or feeling sedated or emotionally flat
— Cost of medications or therapy
Medina encourages patients to stick with their treatment through education, support and honesty about what to expect.
“I try to explain the condition so they can really understand what bipolar is, why treatment matters and what their options are. I validate their symptoms, talk through the side effects of medication and let them know they’re not alone,” he says.
Bottom Line
Although there is no cure for bipolar I or II disorder, individualized treatment plans can help patients manage the condition throughout their life.
“Each individual will bring a singular, personal experience of how this mood disorder affects their life, so in that regard, treatment will be different for each person,” Serani says.
Tracy has finally figured out how to manage her condition with the help of her doctors and support system, which she refers to as Team Natasha.
“The most useful treatment for me involves a combination of lifestyle changes — such as routine and good sleep hygiene — psychotherapy and a medication cocktail,” she says. “It’s all three that are needed to keep my bipolar disorder under control.”
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A Patient’s Guide to Bipolar Disorder originally appeared on usnews.com
Update 04/10/25: This story was previously published at an earlier date and has been updated with new information.
