Bipolar Disorder

Understanding Bipolar Disorder

Fluctuations in mood are common in life, particularly when faced with stressful events. When those mood swings are intense and stick around for a while, leading to issues in your life, there could be an underlying bipolar disorder.

Bipolar disorder is a mental health condition where there are shifts in mood, energy, and activity levels that can affect daily functioning. People with bipolar disorder may experience episodes of depression (feeling down, low energy, loss of interest) and episodes of mania or hypomania (elevated or irritable mood, increased energy, racing thoughts). These changes go beyond the typical ups and downs of life and can impact relationships, work, school, and overall well-being.

Each person’s experience looks different. Some have long stretches of stability between episodes, while others cycle more quickly. My goal is to evaluate whether you have this condition, what type it is, and provide information on how to manage it.

Common Symptoms

Depressive episodes may include:

  • Persistent sadness or hopelessness
  • Low energy and fatigue
  • Difficulty concentrating
  • Changes in sleep and appetite
  • Thoughts of death or suicide

Manic or hypomanic episodes may include:

  • Elevated or irritable mood
  • Decreased need for sleep
  • Increased talkativeness
  • Racing thoughts or distractibility
  • Impulsive or risky behavior

The severity and timing of these episodes vary widely between individuals. Some people experience longer cycles with clear periods of stability, while others may have more rapid shifts.

Figure from The Lancet review on Bipolar Disorder by Iria Grande, MD, PhD in 2016.

Types of Bipolar Disorder

  • Bipolar I Disorder: Characterized by at least one full manic episode, often alternating with depressive episodes.
  • Bipolar II Disorder: Involves hypomanic episodes (less intense than mania) and depressive episodes.
  • Cyclothymic Disorder: Chronic fluctuations of milder depressive and hypomanic symptoms that do not meet full criteria for bipolar I or II.
  • Other specified bipolar and related disorder:
    • Bipolar-like disorders that do not meet criteria for bipolar I disorder, bipolar II disorder, or cyclothymia because of insufficient duration or severity
    • Short-duration hypomanic episodes and major depressive disorder
    • Hypomanic episodes with insufficient symptoms and major depressive disorder
    • Hypomanic episode without prior major depressive disorder
    • Short-duration cyclothymia
  • Unspecified bipolar and related disorder: Characteristic symptoms of bipolar and related disorders that do not meet full criteria for any category previously mentioned
  • Substance or drug-induced bipolar and related disorder: Certain drugs or medications can cause mania, hypomania, or depression that can mimic bipolar disorder. Each drug or medication has its own risk profile for bipolar disorder and what it means for you when you come off the drug or medication. The most common ones are stimulants, steroids, antidepressants, sedatives, and recreational substances such as alcohol and cannabis.
  • Bipolar and related disorder due to another medical condition:
    • Neurological conditions: temporal lobe epilepsy, multiple sclerosis, traumatic brain injury, brain tumors, stroke. As someone who specializes in neuropsychiatric conditions, I will evaluate for these when there is a concern for bipolar disorder.
    • Endocrine/metabolic disorders: hyperthyroidism (usually resembles mania), hypothyroidism (usually resembles depression), Cushing’s disease which is excess cortisol, Addison’s disease which is low cortisol, vitamin B12 deficiency, folate deficiency, and more.
    • Infectious/inflammatory conditions: HIV, syphilis, Lyme disease, systemic lupus erythematosus (SLE).

The Neurobiology of Bipolar Disorder

Scientists have learned a lot about the brain changes involved in bipolar disorder, though there is still much to discover. Research suggests that bipolar disorder arises from a combination of genetic vulnerability, brain circuitry differences, and disruptions in biological rhythms.

Brain Circuits and Neurotransmitters

Bipolar disorder involves imbalances in the brain’s mood-regulating systems:

  • Dopamine: Often overactive in mania (leading to heightened energy, goal-driven behavior, and risk-taking) and underactive in depression (leading to low motivation and pleasure).
  • Glutamate and GABA: Excitatory and inhibitory signals that may become dysregulated, tipping the brain into “overdrive” during mania or into slowed-down states in depression.
  • Prefrontal cortex and limbic system: Areas that regulate decision-making, impulse control, and emotion may function differently in people with bipolar disorder, leading to shifts in mood and behavior.

The Role of Circadian Rhythms and CLOCK Genes

One of the most consistent findings in bipolar research is a disturbance in the body’s biological clock or circadian rhythm. Sleep/wake cycles, energy patterns, and daily routines (sometimes called “social rhythms”) are closely tied to mood stability.

  • CLOCK genes (and related genes like ARNTL, PER, and CRY) help regulate circadian rhythms. Variations in these genes have been linked to increased risk of bipolar disorder.
  • In animal studies, mutations in CLOCK genes produce behaviors that look like mania: less sleep, more activity, and increased reward-seeking.
  • Disruptions in light exposure, sleep schedules, or jet lag can destabilize mood in people with bipolar disorder, highlighting the link between biology and environment.

Stress and Neuroplasticity

Chronic stress and repeated mood episodes can alter brain structure and connectivity. Some studies show:

  • Reduced volume in the hippocampus, a brain area important for memory and mood regulation.
  • Changes in white matter tracts that connect mood-regulating regions.
  • Inflammatory signals may also play a role, contributing to mood symptoms.

Why This Matters for Treatment

Understanding the neurobiology of bipolar disorder underscores why treatments target multiple levels:

  • Medications help balance neurotransmitters and stabilize circuits.
  • Psychotherapy helps manage stress and build healthy coping skills.
  • Lifestyle strategies like regular sleep, consistent routines, and light exposure help regulate circadian rhythms and support CLOCK gene function.

How to Diagnose Bipolar Disorder

There’s no blood test, brain scan, or genetic test that can confirm bipolar disorder. Diagnosis is made through a careful clinical evaluation: a detailed conversation about your symptoms, history, and family background. I may ask family members or loved ones about any observations they’ve made in your symptoms and personality that can offer more evidence of distinct mood episodes.

When I meet with someone, I spend time looking at:

  • Mood history: Past episodes of depression, mania, or hypomania, including how long they lasted and how severe they were.
  • Timing and patterns: Whether mood changes are episodic (lasting days to weeks) or more moment-to-moment. It would be helpful that before our first appointment to fill out a prospective mood chart, which is more accurate than any test for bipolar disorder. You can use any of the ones below that you can download:
  • Family history: Bipolar disorder and depression often run in families.
  • Medical conditions and medications: Thyroid problems, seizure disorders, vitamin deficiencies, or steroids can mimic bipolar symptoms, so it’s important to rule those out. A list of some of those is above.
  • Substance use: Alcohol, cannabis, stimulants, or certain medications can cause mood symptoms that look like bipolar disorder.

Because bipolar disorder can overlap with conditions like ADHD, borderline personality disorder, or unipolar depression, diagnosis often takes time and careful observation. Sometimes it’s only after watching how symptoms evolve, or how someone responds to treatment, that the picture becomes clear.

The goal of diagnosis is not just to put a label on symptoms, but to understand the pattern of mood shifts so we can create the right treatment plan.

Treatment Approaches

There isn’t one single treatment for bipolar disorder. Instead, we will work together to create a plan specific to your circumstances that addresses symptoms from different angles. I think of treatment as a three-legged stool: medication, therapy, and lifestyle. All three matter, and each supports the other.

1. Medication

Medication is often a cornerstone of treatment because it can help prevent mood episodes from becoming severe or recurring. Common options include:

Mood Stabilizers
  • Lithium: Remains one of the most effective treatments for mania and depression.
    • Benefits: very effective for depression and mania; prevents suicide; strengthens brain cells. Well tolerated in lower doses (for depression).
    • Risks: nausea, tremor, thirst, low thyroid, kidney problems with long term use.
  • Lamotrigine:
    • Benefits: prevents depression and mania/mixed states, almost no side effects, but does not treat active mania or mixed states. Likely treat bipolar depression.
    • Risks: severe allergic rash (Stevens-Johnson Syndrome)
  • Depakote (Valproate):
    • Benefits: treats mania and mixed states
    • Risks: stomach distress, fatigue, weight gain, hair loss, low blood count, liver problems
  • Carbamazepine:
    • Benefits: treats mania and mixed states
    • Risks: fatigue, double-vision, allergic rash, pancreatitis, low sodium. Carbamazepine can lower the levels of many other drugs including birth control.
Atypical antipsychotics

Atypical antipsychotics can treat both manic and depressive episodes.

  • Examples: Aripiprazole (Abilify), asenapine (Saphris), brexpiprazole (Rexulti), cariprazine (Vraylar), lurasidone (Latuda), olanzapine, (Zyprexa), paloperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon).
  • Benefits: all treat mania and mixed states. Some also treat depression (e.g. quetiapine, lurasidone, cariprazine, olanzapine-fluoxetine combination).
  • Risks: weight gain, drowsiness, restlessness, diabetes, high cholesterol, tardive dyskinesia (permanent muscle twitching).
Other medications and supplements
  • Calcium channel blockers such as nimodipine and amlodipine have been shown to treat mood swings that change daily or weekly but can lead to low blood pressure.
  • Allopurinol can lower uric acid levels in the blood which is typically associated with gout but has been successfully used experimentally for mania. It’s well tolerated although does carry a risk of a rare severe allergic rash (Stevens-Johnson Syndrome)
  • Probiotics reduces inflammation and can help with depression, mania, memory, and anxiety. 1 per day of probiotic with Lactobacillus mrhamnosus LG and Bifidobacterium lactis bb-12. Brands: Usana Probiotic Sticks, Culturelle Baby Grow and Thrive Liquid, and Emergen-C Drink.
  • Omega-3 Fatty Acids coats and protects brain cells and is found in fish (salmon) and green leafy vegetables. Can prevent depression, mania, and irritability. The dose is 1,000-2,500mg daily of DHA + EPA (dose must have at least 1.5 times as much EPA as DHA).

2. Psychotherapy

Talk therapies help patients recognize early warning signs, manage stress, and strengthen relationships. Here are a few types that have been shown to be helpful in bipolar disorder.

  • Interpersonal and Social Rhythm Therapy (IPSRT): Through mood charting, patients learn which daily routines help stabilize their mood. The therapist also helps client build new skills to overcome the effects of bipolar on relationships and identity.
  • Family Therapy: The therapist helps families live more effectively with mood problems in the home. Conflict resolution and specific communication skills are taught.
  • Educational Groups: In this weekly seminar a therapist teaches skills to live more effectively with bipolar. Much of the learning comes from other patients who have struggled with bipolar.

3. Lifestyle and Self-Care

Research highlights that lifestyle strategies can be as important as medication in maintaining stability. These include:

  • Sleep–Wake Regularity
    • Why it matters: Disturbed circadian rhythms and irregular sleep are both triggers and consequences of mood episodes.
    • Practical approaches:
      • Consistent bedtime and wake time daily (avoid “catching up” on weekends).
      • Avoid blue light exposure (screens, LED) 1–2 hours before sleep.
      • Use dark therapy techniques (blocking light at night, even dim light exposure can suppress melatonin).
      • Structured morning light exposure (natural sunlight or a light box cautiously, to avoid inducing mania). This can help with depression and mood stabilization if you anchor the circadian rhythm so that your daily sleep and wake schedules are more normalized. The risk of mania can be minimized by using the light box between 12:00pm and 2:30pm. Start with 15 minutes under the box and increase by 15 minutes each week toward an optimal time of 60 minutes under the box. If manic symptoms start to appear, lower the time under the box and contact your treatment team.
  • Physical Activity
    • Evidence: Regular exercise improves depressive symptoms and cognitive function in bipolar disorder (systematic reviews show moderate effect sizes).
    • Guidelines: Aim for 150 minutes/week of moderate aerobic exercise (walking, cycling, swimming) plus resistance training. This means 21 minutes every day or 30 minutes five days a week.
    • Practical strategies:
      • Routine and predictability matter more than intensity.
      • Exercise earlier in the day to avoid interfering with sleep.
      • “Behavioral activation” framing: even light activity (short walks, stretching, brisk walking but not power walking) helps disrupt depressive inertia.
  • Regular Routines
    • Sticking with a few daily routines at regular times (give or take 30 minutes) also sets the brain’s internal clock and stabilizes mood. The most important activities to do at regular times are:
      • Waking up
      • Starting work or chores
      • Starting contact with other people
      • Exercise
      • Dinner
  • Nutrition
    • Mood and metabolic health:
      • Prioritize a Mediterranean-style diet (vegetables, fruits, whole grains, lean proteins, omega-3 fatty acids).
      • Limit highly processed foods, sugars, and excessive caffeine/alcohol.
    • Specific adjuncts studied:
      • Omega-3 fatty acids (EPA > DHA formulations): modest benefit in depressive episodes, especially as adjuncts.
      • Vitamin D: correction of deficiency may improve mood, though evidence is mixed.
      • Weight management: especially critical if on atypical antipsychotics (metabolic risk).

When to Seek Help

Bipolar disorder can be challenging, especially when symptoms disrupt your daily life or relationships. It’s important to seek help for you or your child if you notice:

  • Recurrent episodes of depression (low mood, loss of interest, hopelessness) that last for weeks
  • Episodes of mania or hypomania (racing thoughts, reduced need for sleep, feeling unusually energized, impulsive spending or risky behavior)
  • Mood changes that are out of proportion to life events or that interfere with work, school, or relationships
  • Difficulty maintaining a stable daily routine or sleep pattern
  • Thoughts of self-harm, suicide, or feeling like life isn’t worth living

These are not signs of weakness. They are medical symptoms that can be treated. With treatment, stability is not only possible, it’s expected

Ready to Take the First Step?

Reaching out for help is the first step toward regaining balance. If you’re concerned about yourself or a loved one, I invite you to reach out by scheduling an appointment using the button below. Together, we’ll work toward understanding, relief, and long-term well-being.

Schedule Your Appointment