Bipolar Disorders

Bipolar I is defined by at least one manic episode: a sustained period of elevated or irritable mood, dramatically increased energy and activity, decreased need for sleep, and impaired judgment, often severe enough to require hospitalization. Bipolar II is defined by at least one hypomanic episode (a milder, shorter elevated state without psychosis or severe impairment) and at least one major depressive episode; the depression usually dominates the lived experience. Cyclothymia is a chronic, lower-amplitude pattern of mood ups and downs that does not reach the threshold for full hypomania or major depression but is still distressing and impairing.

Many people with bipolar disorder seek care during depression, when the pattern looks indistinguishable from unipolar depression. Hypomania can feel productive and creative rather than impairing, so it is often not reported as a symptom. The average time from first mood episode to a bipolar diagnosis is around ten years. Careful history-taking that asks about lifelong mood patterns, family history of bipolar disorder, and response to past antidepressants is the most reliable way to identify the diagnosis earlier.

Treatment is anchored on mood stabilizers (lithium, valproate, lamotrigine) and/or atypical antipsychotics (quetiapine, lurasidone, cariprazine, lumateperone, aripiprazole). Lithium has the strongest evidence base for bipolar I, including a reduction in suicide risk. Lamotrigine is particularly effective for the depressive pole of bipolar II. Antipsychotics like quetiapine and lurasidone work across both poles. Psychotherapy (interpersonal and social rhythm therapy, family-focused therapy, cognitive behavioral therapy) adds measurable benefit alongside medication.

Antidepressants in bipolar disorder are controversial. They can lift depression but also carry a risk of triggering hypomania, mania, or rapid cycling, especially in bipolar I. The consensus is to use antidepressants only alongside a mood stabilizer, only when other strategies have failed, and to discontinue them once depression has remitted. For bipolar II, the evidence for antidepressant monotherapy is more mixed but the same cautious approach applies. In practice, whether to use an antidepressant at all is an individual decision made case by case, based on the specific diagnosis, the history of mood episodes, and how a person has responded to medications before.

Mood temperaments are stable, lifelong baseline patterns; the cyclothymic and hyperthymic temperaments are considered milder expressions of the same biology that produces bipolar mood episodes. A patient with a hyperthymic temperament who presents in depression may be misdiagnosed with unipolar depression and prescribed an antidepressant alone; identifying the temperament can change both the diagnosis and the medication choice. The TEMPS-A questionnaire at /resources/temps-a/ is one tool used to estimate temperament; see /resources/temperament/ for the underlying clinical reasoning.