Bipolar Disorder Treatment: What I Look For Before Prescribing

Have you ever had stretches where your mood, your energy, and your sleep seem to shift together, and not in a way you chose? Maybe there are weeks where you need very little sleep and feel driven to start a dozen new things, followed by weeks where getting out of bed takes everything you have, or maybe you have only ever been treated for depression and something about that never quite fit.

That kind of pattern is worth a careful look, and it is one of the places where I slow down the most with the people I see. I am a board-certified psychiatric nurse practitioner (PMHNP-BC) in Brea, and I want to walk you through how I think about bipolar disorder treatment, what I look for before I ever write a prescription, and what the first months of care usually look like, so the process feels a little less like a mystery.

How I think about bipolar disorder treatment

When someone comes in wondering about bipolar disorder, I am much less interested in how you feel today than in the shape of your mood over time. Most people come in during a low point, because that is when it hurts the most, and a single visit during a low point can look exactly like depression. So I want to hear about the whole timeline: the hard seasons, the seasons when you felt unusually good or unusually driven, how you slept through each of them, and what the people closest to you noticed.

I also want to understand what you have been carrying. A lot of people I see with mood swings have spent years being told they are too much, or lazy, or that they just need to try harder, and some of that weight was never theirs to carry in the first place. Part of my job is helping you set that down. A diagnosis, if we land on one, is a tool that helps us choose the right care. It does not describe who you are, and it does not get to decide what your life looks like.

This is also where I probably differ from a "here, try this pill and see what happens" approach. I pay close attention to how a medication works with your brain chemistry, and that part matters a great deal with bipolar disorder. But I am just as interested in your sleep, your stress, your relationships, and how you see yourself, because those shape whether any medication has a fair chance to work. We are treating a person, not a symptom list.

Why does the diagnosis matter so much before prescribing?

With most conditions, if the first medication is not quite right, we adjust and keep going. Bipolar disorder is different in one important way. The medications most often used for depression, the antidepressants, can sometimes push a person with bipolar disorder toward a high, or make mood cycles come faster, especially when they are taken on their own without a mood stabilizer. An international task force of bipolar experts reviewed the research on this and recommended that people with bipolar I disorder take an antidepressant only alongside a mood stabilizer, if at all [2].

That is why I would rather take an extra visit to understand your history than rush to a prescription. It is also why I do not blame anyone who was treated for depression first. Bipolar disorder is usually diagnosed from symptoms and lifetime history, since there is no blood test or brain scan for it yet [1], and the highs are often the part people do not think to mention. A large review of the research found that, on average, almost six years pass between the first symptoms of bipolar disorder and the first time it is properly treated [3]. If that has been your story, you are in good company, and it is not too late to get the right plan in place.

What do I look for at a first visit?

The first visit is mostly a conversation, and most of the questions are about the past, not only the present. I will usually ask whether you have ever had a stretch of several days where you needed much less sleep than usual and did not feel tired, where your thoughts or your speech moved faster than normal, or where you spent money, took risks, or made big decisions in a way that later surprised you. I will ask how you felt on any antidepressant you have taken before, because feeling wired, irritable, or unable to sleep on an antidepressant is a useful clue. I will also ask about your family, since bipolar disorder tends to run in families, and about pregnancy and the months after childbirth, which can be a time when bipolar symptoms first appear [1].

I may ask you to fill out a short questionnaire called the Mood Disorder Questionnaire. It is a single page of yes or no questions about times you may have felt more energetic or more "up" than usual. In the original study, it correctly flagged about 73 percent of people with bipolar disorder and correctly ruled it out in about 90 percent of people without it [4]. That makes it a good starting point for a conversation, but it does not make the diagnosis by itself, and I never treat a score as the final word.

If you are comfortable with it, it can help a lot to bring someone who knows you well, or to ask them beforehand what they have noticed. Highs are often easier to see from the outside, and a partner or a parent may remember a season you have half forgotten. I also want to rule out other things that can look like mood swings, such as thyroid problems, sleep disorders, substances, or ADHD, so lab work is sometimes part of the first steps.

What is the difference between bipolar I, bipolar II, and cyclothymia?

You may have seen these names and wondered how they relate. They describe different shapes of the same basic pattern, and the shape helps decide the treatment.

Many people with bipolar II spend far more of their time depressed than high, which is one more reason it is so often treated as depression alone.

How is a first medication chosen?

I tend to think of a mood stabilizer as the keel on a sailboat. The keel does not stop the wind or the waves, and you still feel the weather. What it does is keep the boat from tipping over when a gust comes, so you can keep moving in the direction you want to go. That is what we are aiming for with bipolar treatment: you still have a full range of feelings, and the swings stop taking over your life.

The medications with the strongest research behind them include lithium, lamotrigine, divalproex, and some newer medications such as quetiapine and lurasidone [5]. Which one makes sense for you depends a lot on your own pattern. If depression is the bigger problem, some options fit better, and if highs are the bigger problem, others do. I also think about side effects you most want to avoid, your weight and metabolic health, your kidneys and thyroid, other medications you take, and whether pregnancy is part of your plans, because some of these medications are not a good choice during pregnancy [5].

Lithium deserves its own mention, because people are often nervous about it. It is one of the oldest treatments in psychiatry, and it is still one of the best studied. A large review of 48 randomized trials found that lithium lowered the number of suicides in people with mood disorders compared with placebo [6]. It does need regular blood tests to keep the level in a safe range, and I will walk you through exactly what those look like. Lamotrigine, another common option, has to be started at a low dose and raised slowly over several weeks, because raising it too fast increases the risk of a serious rash. These details are a big part of what giving a medication an honest try really means.

If you have already tried a few medications that did not work the way you hoped, GeneSight testing is something I may bring up. The process is simple: I put together a profile that includes the medications you have been on, the ones that did not work and the ones we might want to adjust or build on, and the test looks at how your body is likely to process different medications based on your genes. It does not hand us an answer. What it does is give us more information so we can personalize your plan instead of guessing. Cost can vary, and in many cases insurance covers part or even all of it depending on your situation, so it is worth asking about rather than assuming. You can read more in this article on GeneSight testing.

What does follow-up look like in the first few months?

Early on, I usually want to see you every two to four weeks. Some of that is for lab work, such as lithium levels, kidney and thyroid checks, or blood sugar and cholesterol for some of the newer medications. Most of it is simply so we can talk about how you are sleeping, how your mood has moved, and how the medication feels in your body.

I often ask people to keep a short daily note of their sleep and their mood, because it gives us something more solid than memory to look at together. A few weeks of that can show us patterns that are very hard to see from the inside.

People with bipolar disorder carry a higher risk of suicidal thoughts than the general population, especially during depressive episodes. I do not share that to scare anyone. I share it because it is exactly why I want us to stay in close contact, so that if something shifts, we can catch it early, talk it through, and make sure you have the right support. If you ever notice thoughts of harming yourself, reach out to me right away, and if you are in crisis, call or text 988.

Do you need therapy as well as medication?

For most people, therapy makes the medication work better. A review of 39 randomized trials found that people with bipolar disorder who did a structured therapy alongside their medication had fewer relapses than people who had medication with only usual support [7]. The kinds of therapy that seem to help most teach practical skills, such as spotting early warning signs, protecting a steady sleep schedule, and bringing family into the plan.

Sleep is worth naming on its own. A few nights of short sleep can be one of the first signs of a high, and it can also help set one off, so a steady bedtime and wake time is one of the most protective habits you can build. If you are not sure what a therapist does compared with a prescriber, this article on therapists, psychiatrists, and psychiatric nurse practitioners explains how the roles fit together.

How long does bipolar treatment last?

Bipolar disorder is usually a long-term condition, and treatment usually is too. Medication works best when it is taken consistently, including during the stretches when you feel well [1]. I want to be honest that this can be the hardest part. When a high feels good, or when things have been calm for a long time, it is very natural to wonder whether you still need the medication.

Those are good questions, and I would much rather you bring them to me than quietly stop on your own. Stopping some of these medications suddenly, lithium in particular, can raise the chance of a new episode. If a change makes sense, we plan it together and make it slowly, with a clear plan for what we will watch for.

Frequently asked questions

Can a psychiatric nurse practitioner treat bipolar disorder in California?

Yes. As a board-certified psychiatric nurse practitioner, I evaluate and diagnose bipolar disorder, prescribe medication when it is appropriate, order and follow the lab work that goes with it, and manage that care over time. Many people find this practice by searching for a psychiatrist, but the care here is provided by a PMHNP-BC. You can see more about what that looks like on the psychiatric evaluation page and the medication management page.

Can bipolar disorder be mistaken for depression?

Yes, and it happens often. People usually seek help when they feel low, and milder highs can be easy to miss or can even feel like finally being yourself. That is why I ask so many questions about the past, and why a history of feeling wired or unable to sleep on an antidepressant is worth mentioning [2].

Will I have to take medication for the rest of my life?

Many people with bipolar disorder do stay on some form of medication long term, because it lowers the chance of new episodes. That said, the plan is yours as much as mine, and we review it regularly. The dose, the medication, and the role of therapy can all change over time as you learn what keeps you steady.

Can I be treated for bipolar disorder by video?

Often, yes. Many follow-up visits work well by video, and lab work can be done at a lab near you. This article on online psychiatric care in California explains how those visits work.

Does insurance cover bipolar treatment?

Cost can vary, and in many cases insurance covers part or even all of the visits and lab work depending on your plan, so it is worth asking about rather than assuming. When paperwork is needed for coverage, the provider is able to submit documentation on your behalf.

One small step

For the next seven days, write down two things each morning: how many hours you slept, and your mood on a scale from one to ten. If someone close to you is willing, ask them whether they have ever noticed a stretch when you seemed unusually up or unusually low. Bring both to your first appointment.

A last thought

I believe we are all on our own journey, and that struggling is part of it. A lot of the time it is how we grow and learn who we are. But some people are carrying more than their share, and with mood swings that nobody has named, that load can feel confusing as well as heavy, because you are trying to make sense of something that keeps changing under your feet. Doing that alone is not just hard, it is not fair. That is the part I want to help with, so you can feel steady enough to move toward the life you want and, honestly, start thriving.

If you are ready to talk through what has been going on, use the contact form and let me know a little about it. You will hear back within one business day to get you scheduled. If depression has been the bigger part of your story so far, this article on starting depression treatment may help in the meantime, and if several medications have already not worked, this article on treatment-resistant depression covers the options that come next.

References

1. National Institute of Mental Health. Bipolar Disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder
2. Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. American Journal of Psychiatry, 2013;170(11):1249-1262. https://pubmed.ncbi.nlm.nih.gov/24030475/
3. Dagani J, Signorini G, Nielssen O, et al. Meta-analysis of the interval between the onset and management of bipolar disorder. Canadian Journal of Psychiatry, 2017;62(4):247-258. https://pmc.ncbi.nlm.nih.gov/articles/PMC5407551/
4. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. American Journal of Psychiatry, 2000;157(11):1873-1875. https://pubmed.ncbi.nlm.nih.gov/11058490/
5. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 2018;20(2):97-170. https://pubmed.ncbi.nlm.nih.gov/29536616/
6. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ, 2013;346:f3646. https://pubmed.ncbi.nlm.nih.gov/23814104/
7. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. JAMA Psychiatry, 2021;78(2):141-150. https://pubmed.ncbi.nlm.nih.gov/33052390/

This article is education rather than medical advice, and it is not a recommendation for any specific treatment or medication. Please talk with your healthcare provider about your own situation. If you are in crisis, call or text 988 to reach the Suicide and Crisis Lifeline.