Focus on Bipolar Mood Stability First

When treating bipolar disorder, I think it's critical to gain bipolar mood stability first and only then tweak up or down as needed. That means that if you're in a depression right now (and let's face it, that's when people seek help the most), the goal isn't to treat depression, per se, but rather to gain bipolar stability. Of course, I'm not the only one who thinks this. The esteemed psychiatrist Dr. Jim Phelps agrees: treatment should focus on bipolar mood stability first.¹ 

What Does 'Bipolar Mood Stability' Mean?

Bipolar mood stability indicates a mood that is consistent. The mood is known as stable when it doesn't cycle or switch from one mood to another. You can be stable but still depressed, manic, or hypomanic, but, obviously, the goal is to be stable in euthymia (a "normal" mood or no presence of a diagnosable bipolar mood).

Treatment for Bipolar Mood Stability

When you get treatment, your mood is either up (mania or hypomania), down (depression), or sideways (mixed). (I'm referring to moods where both hypomania/mania symptoms and depression symptoms are present simultaneously as "mixed." Mixed moods are, by their very nature, considered unstable.)

Now, if you're up or down, you might think treating in the opposite direction would make sense. This isn't actually what is recommended, however. If you treat to bring down an up mood or up a down mood, you may bring about the opposite mood or even, in some cases, induce a mixed mood or cycling of mood. Doing this actually makes the situation worse. Bipolar is a funny beast that way, and that's what makes bipolar so tricky to treat.

So, the recommendation is that bipolar treatment should focus on bipolar mood stability first.

What Does Bipolar Mood Stability Treatment Look Like?

This means that medications that stabilize mood should be used first. Also, importantly, antidepressants should be avoided first. I know if you're depressed, that sounds awful, but one of the things we know about bipolar treatment is that antidepressants, particularly when used alone, can make bipolar disorder worse. (This is a complicated topic.¹)

Mood stabilizers are usually lithium or an anticonvulsant like valproate (Depakote), but they can also be certain antipsychotics. (Many would argue not to try an antipsychotic right out of the gate because of the side effect profile. I'll leave that as an exercise up to the reader.)²

(Note that certain mood-stabilizing agents are specifically approved for the treatment of a mixed mood.)

Once Bipolar Mood Stability Is Achieved

So, once a person is treated with one or more mood-stabilizing agents, bipolar mood stability should (in theory) be achieved. It's only then that one should look at elevating or depressing that stable mood. This typically means adding a medication that is anti-manic, like carbamazepine (Equatro) or aripiprazole (Abilify), or adding a medication that is anti-depression, like quetiapine (Seroquel) or lurasidone (Latuda). 

Now, as if all this weren't complicated enough, some agents are stabilizing and elevating. Some are stabilizing and anti-manic. And some are specifically indicated for maintenance treatment.³ This, of course, is why we see psychiatrists. They are the ones with the knowledge and experience to know what you need and when you need it.

What's the Point?

The point is this: focusing on bipolar mood stability can be tedious and seem to add an extra step to your treatment. It is, though, an essential aspect of treatment, however tedious it may feel. It's important to recognize this so you can work with your psychiatrist to achieve both bipolar mood stability and euthymia. 

Sources

1. Phelps, J. (2021, December 5). Expert Guidelines for Bipolar Treatment. Psych. https://psycheducation.org/blog/expert-guidelines-for-bipolar-treatment/

2. Phelps, J. (2021c, December 5). The Basics of Bipolar Treatment. Psych. https://psycheducation.org/blog/the-basics-of-bipolar-treatment/

3. Soreff, S., MD. (n.d.). Bipolar Disorder Treatment & Management: Approach Considerations, Indications for Inpatient Management, Considerations for Partial Hospitalization or Day Treatment. https://emedicine.medscape.com/article/286342-treatment#d12