Bipolar disorder causes episodes of mania or hypomania and depression. It is treated with mood stabilizers (lithium, lamotrigine, valproate) and certain atypical antipsychotics (quetiapine, lurasidone, cariprazine), combined with psychotherapy and attention to sleep. Antidepressants alone are avoided. With consistent treatment most people achieve long stretches of stability.
Stedfast Psychiatry treats bipolar disorder with the medications that have the best long-term evidence, careful monitoring, and psychotherapy that helps you recognize early warning signs. Getting the diagnosis right is the first and most important step, because the standard treatment for depression (an antidepressant alone) can make bipolar disorder worse.
Symptoms of bipolar
- Periods of unusually elevated, expansive or irritable mood lasting days to weeks
- Needing much less sleep without feeling tired
- Racing thoughts and rapid, pressured speech
- Grandiose ideas or inflated confidence
- Impulsive spending, sexual behavior, driving or business decisions
- Increased activity, starting many projects at once
- Episodes of deep depression with low energy and hopelessness
- Depressive episodes that start early in life and recur often
- Antidepressants that caused agitation, insomnia or a sudden mood lift
Causes and risk factors
Bipolar disorder is strongly genetic; heritability is estimated at 60 to 85 percent, and having a first-degree relative with the condition raises risk roughly tenfold. Environmental factors shape when and how it appears: sleep disruption, stimulant and cannabis use, major stress, childbirth and antidepressant exposure can trigger episodes in vulnerable people. The biology involves instability in circadian rhythm regulation, dopamine signaling and intracellular signaling pathways that lithium and other mood stabilizers act on. Onset is usually in the late teens or early twenties.
An estimated 2.8 percent of US adults had bipolar disorder in the past year, and 4.4 percent will have it at some point in their lives.
Source: NIMH, National Comorbidity Survey Replication
About 83 percent of people with bipolar disorder have serious impairment, the highest rate of any mood disorder.
Source: NIMH
People with bipolar disorder spend roughly three times as many weeks depressed as manic or hypomanic.
Source: NIMH Collaborative Depression Study (Judd et al., 2002)
Long-term lithium treatment is associated with a significantly reduced risk of suicide in people with mood disorders.
Source: Meta-analysis, BMJ 2013 (Cipriani et al.)
How we diagnose it at Stedfast Psychiatry
Diagnosing bipolar disorder requires a careful history of mood episodes over the whole lifespan, not just the current symptoms. We ask in detail about any period of decreased need for sleep with increased energy, because that is the most reliable marker of past hypomania or mania. We use the Mood Disorder Questionnaire as a screen and the PHQ-9 and Young Mania Rating Scale to track severity. Family history, age of onset, number of past depressive episodes, response to prior antidepressants and substance use all inform the diagnosis. Input from a family member is valuable because people rarely recognize their own hypomania. Before starting medication we order baseline labs: a metabolic panel, thyroid function, kidney function, complete blood count, and for some medications a pregnancy test and lipid panel. Medical mimics such as hyperthyroidism, steroid use and stimulant intoxication are ruled out.
Treatment options
Medication management
Mood stabilizers are the foundation. Lithium remains the best-studied medication for bipolar I, reduces suicide risk, and requires blood level monitoring (every one to two weeks at the start, then every three to six months) along with kidney and thyroid checks. Lamotrigine is effective for preventing bipolar depression and has few metabolic side effects, but must be started slowly over six weeks to reduce the risk of a serious rash. Valproate works well for acute mania and mixed states. Atypical antipsychotics with evidence for bipolar depression include quetiapine, lurasidone, cariprazine and lumateperone; for mania, aripiprazole, risperidone, olanzapine and others are used. We monitor weight, glucose, lipids and movement side effects on antipsychotics. Antidepressants are used cautiously, if at all, and only in combination with a mood stabilizer. Acute episodes typically settle in two to six weeks; maintenance treatment continues long term because relapse without medication is very likely.
Psychotherapy
Psychoeducation about the illness, early warning signs and the role of sleep is the most protective thing we can offer after medication. Interpersonal and social rhythm therapy stabilizes daily routines, which stabilizes mood. CBT and family-focused therapy reduce relapse and help with the depressive side. Therapy also addresses the common companions of bipolar disorder: anxiety, substance use and the damage past episodes may have done to relationships, finances and work.
Interventional options
Deep TMS is FDA-cleared for major depressive disorder, OCD, anxious depression and smoking cessation; it is not FDA-cleared for bipolar depression, and we discuss it only as an off-label consideration in specific cases with the risk of switching to mania in mind. Spravato is FDA-approved for treatment-resistant depression and MDD with suicidal ideation in adults, not for bipolar disorder, and its trials excluded bipolar patients. For severe or treatment-resistant bipolar depression and for severe mania, electroconvulsive therapy remains the most effective option and we coordinate referrals when it is needed.
What to expect
Your first visit is a thorough 60-minute evaluation, in person or by video, often with a family member if you agree. If the diagnosis is bipolar disorder, you leave with a medication plan, lab orders and a safety plan. Follow-ups are at one to two weeks early on, especially when lithium or lamotrigine is being titrated, then monthly, then every two to three months once stable. Telehealth follow-ups are available in Florida and South Carolina; lab draws can be done at a local lab near you.
When to seek help
Seek evaluation if you have had depressive episodes plus any period of unusually high energy with little need for sleep, if antidepressants have made you worse or caused a sudden switch to feeling wired, or if a close relative has bipolar disorder and you are struggling with mood. Mania can be a medical emergency: if someone is not sleeping for days, is behaving dangerously or has lost touch with reality, go to the emergency room or call 911. If you have thoughts of suicide, call or text 988. Suicide risk in bipolar disorder is high, particularly during depressive and mixed episodes, and effective treatment lowers it substantially.
Subtypes and specifiers
Beyond bipolar I and II, cyclothymic disorder involves two or more years of fluctuating hypomanic and depressive symptoms that never meet full episode criteria. Rapid cycling means four or more mood episodes in a year and tends to respond better to lamotrigine, valproate or atypical antipsychotics than to lithium. Mixed features, where symptoms of depression and mania occur together (for example, depressed mood with racing thoughts and agitation), carry a higher suicide risk and call for mood stabilizers rather than antidepressants. Bipolar disorder with psychotic features during mania or depression is treated with an antipsychotic alongside the mood stabilizer. Seasonal patterns and postpartum onset are also recognized.
Differential diagnosis
Several conditions overlap with bipolar disorder. Unipolar depression is the most common misdiagnosis in the other direction. Borderline personality disorder involves rapid mood shifts within a day, usually in reaction to relationships, rather than sustained episodes lasting days or weeks. ADHD shares distractibility, impulsivity and talkativeness but lacks the episodic change from baseline. Substance-induced mood changes, particularly from stimulants, steroids and cannabis, can look like mania. Schizoaffective disorder involves psychosis that persists outside of mood episodes. Thyroid disease and, in older adults, neurological conditions can also cause mood instability. We sort these out through the pattern over time, not a single snapshot.
Sleep and routine
Sleep is both a symptom and a trigger. Losing even one or two nights of sleep can tip a vulnerable person into hypomania, and a regular sleep and wake time is one of the most effective relapse-prevention tools available. We treat insomnia aggressively in bipolar disorder, discourage shift work when possible, and plan ahead for travel across time zones and for high-risk periods such as the postpartum months. Limiting alcohol and avoiding cannabis and stimulants reduces episodes. A written relapse plan that lists your personal early warning signs and what to do when they appear gives you and your family a way to act before an episode takes hold.
Prognosis
Bipolar disorder is a serious illness, but it is one of the more treatable ones in psychiatry when the diagnosis is correct and treatment is consistent. Many people go years without a major episode, work full time and raise families. The factors that predict a good course are early accurate diagnosis, adherence to maintenance medication, stable sleep, avoiding substances, and a therapeutic relationship that allows quick adjustment when symptoms shift. The factors that predict a poor course are the mirror image. Our job is to make the good course the easy one to follow.
Frequently asked questions
What is the difference between bipolar I and bipolar II?
Bipolar I requires at least one full manic episode: a week or more of elevated or irritable mood with marked impairment, often requiring hospitalization, sometimes with psychosis. Bipolar II involves hypomania, which is shorter and less severe and does not cause major impairment, plus at least one major depressive episode. Bipolar II is not milder overall; the depressions are often longer and more disabling, and the risk of misdiagnosis as unipolar depression is higher.
Why can antidepressants be a problem in bipolar disorder?
An antidepressant taken without a mood stabilizer can trigger mania or hypomania, speed up cycling, or produce an agitated mixed state in someone with bipolar disorder. It can also simply fail to work. That is why we screen every depressed patient for past hypomania before prescribing. When an antidepressant is used in bipolar disorder, it is added to a mood stabilizer and watched closely.
Will I need to take medication forever?
Bipolar disorder is a lifelong condition and most people do best on maintenance medication. Stopping treatment, even after years of stability, carries a high risk of relapse, and each episode can make the next one more likely. That said, the regimen often simplifies over time, side effects can be managed, and the goal is a medication plan you can live with comfortably for the long term.
Is lithium safe?
Lithium has been used since the 1950s and remains one of the most effective treatments for bipolar disorder. It requires blood level checks because the therapeutic range is narrow, and it can affect the kidneys and thyroid over many years, which is why we monitor both. Common early side effects include thirst, tremor and nausea, which usually settle. For many patients the benefits, including a lower suicide risk, outweigh the monitoring burden.
Can bipolar disorder be treated through telehealth?
Yes, for most of the care. Evaluation, medication management, therapy and follow-up visits work well by video across Florida and South Carolina, and the convenience helps patients keep the regular contact that long-term stability depends on. You will need periodic lab draws at a local lab for medications such as lithium and valproate, and we send the orders electronically. If you are acutely manic, mixed or in crisis, in-person or emergency care is appropriate.
Is bipolar treatment covered by insurance?
Yes. We accept most major insurance plans and Medicare, and visits are billed as specialist office visits with your usual copay. Most mood stabilizers and generic antipsychotics are inexpensive, and newer brand-name agents usually require prior authorization, which our staff handles. Our self-pay rate for a new-patient evaluation is $185, and lab costs vary by your plan and the lab you use. We verify benefits before your first appointment.
Can TMS or Spravato treat bipolar depression?
Neither is FDA-cleared or approved for bipolar disorder. Deep TMS is cleared for major depressive disorder, OCD, anxious depression and smoking cessation; Spravato is approved for treatment-resistant depression and MDD with suicidal ideation in adults. Both have been studied in bipolar depression with mixed results, and there is a risk of switching to mania. We may discuss TMS off-label in select cases, but for severe treatment-resistant bipolar depression, ECT has the strongest evidence.
Can teenagers have bipolar disorder?
Yes. Onset is often in the mid to late teens, although diagnosis in adolescents is difficult because irritability, mood swings and risk-taking overlap with normal development, ADHD and depression. Our child and adolescent providers take a careful longitudinal approach, involve the family, and use medications with pediatric evidence such as lithium, lurasidone and aripiprazole when the diagnosis is clear.
Where to get treatment for bipolar disorder
Evaluation and treatment for bipolar disorder is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.