social work essay bipolar assessment

Understanding Bipolar Disorder: An In-Depth Essay

From euphoric highs to crushing lows, the human mind can orchestrate a symphony of emotions that leaves both sufferers and observers in awe of its raw, uncontrollable power. This emotional rollercoaster is a hallmark of bipolar disorder, a complex mental health condition that affects millions of people worldwide. As we delve into the intricacies of this disorder, we’ll explore its various facets, from its definition and types to its impact on individuals and society at large.

What is Bipolar Disorder?

Bipolar disorder, formerly known as manic depression, is a mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). These mood episodes can last for days, weeks, or even months, significantly impacting a person’s energy levels, activity, behavior, and ability to function in daily life.

The concept of bipolar disorder has evolved over time, with researchers and mental health professionals gaining a deeper Understanding the Concept of Mundo Bipolar – a term that encapsulates the unique world experienced by those living with this condition. This perspective acknowledges the multifaceted nature of bipolar disorder and its profound impact on an individual’s perception of reality.

Types of Bipolar Disorder

Bipolar disorder is not a one-size-fits-all condition. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes several types of bipolar and related disorders:

1. Bipolar I Disorder: Characterized by at least one manic episode, which may be preceded or followed by hypomanic or major depressive episodes.

2. Bipolar II Disorder: Defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic episodes.

3. Cyclothymic Disorder: A milder form of bipolar disorder, involving numerous periods of hypomanic and depressive symptoms lasting for at least two years.

4. Other Specified and Unspecified Bipolar and Related Disorders: These categories include bipolar-like disorders that don’t meet the criteria for the aforementioned diagnoses.

Understanding these distinctions is crucial for accurate diagnosis and effective treatment planning.

Causes and Risk Factors

The exact cause of bipolar disorder remains unknown, but research suggests that a combination of factors contributes to its development:

1. Genetics: Bipolar disorder tends to run in families, indicating a strong genetic component. However, having a family history doesn’t guarantee that an individual will develop the condition.

2. Brain Structure and Function: Studies have shown differences in brain structure and function between people with bipolar disorder and those without. These differences may contribute to the disorder’s symptoms.

3. Environmental Factors: Stressful life events, trauma, or significant life changes may trigger the onset of bipolar disorder in susceptible individuals.

4. Neurotransmitter Imbalances: Abnormalities in neurotransmitter systems, particularly those involving serotonin, norepinephrine, and dopamine, may play a role in bipolar disorder.

5. Circadian Rhythm Disruptions: Disturbances in the body’s natural daily rhythms, such as sleep-wake cycles, have been linked to bipolar disorder.

Common Symptoms of Bipolar Disorder

The symptoms of bipolar disorder can vary widely between individuals and even within the same person over time. However, the core features involve distinct episodes of mania (or hypomania) and depression.

Manic Episode Symptoms: – Elevated mood or euphoria – Increased energy and activity – Decreased need for sleep – Racing thoughts and rapid speech – Impulsivity and risk-taking behavior – Grandiose beliefs or inflated self-esteem – Distractibility and difficulty concentrating

Depressive Episode Symptoms: – Persistent sadness or emptiness – Loss of interest in previously enjoyed activities – Fatigue and decreased energy – Changes in appetite and weight – Sleep disturbances (insomnia or excessive sleeping) – Difficulty concentrating and making decisions – Feelings of worthlessness or guilt – Thoughts of death or suicide

It’s important to note that some individuals may experience mixed episodes, where symptoms of both mania and depression occur simultaneously.

Diagnostic Criteria for Bipolar Disorder

Diagnosing bipolar disorder can be challenging, as its symptoms can overlap with other mental health conditions. Mental health professionals use the criteria outlined in the DSM-5 to make an accurate diagnosis. These criteria include:

1. The presence of at least one manic or hypomanic episode (for Bipolar I and II, respectively) 2. The occurrence of at least one major depressive episode (for Bipolar II) 3. The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning 4. The symptoms are not better explained by another mental disorder or medical condition

A comprehensive evaluation typically involves a detailed medical history, physical examination, and sometimes laboratory tests to rule out other potential causes of symptoms.

Distinguishing Bipolar Disorder from other Mental Health Conditions

Bipolar disorder shares symptoms with several other mental health conditions, which can complicate diagnosis. Some conditions that may be mistaken for bipolar disorder include:

1. Major Depressive Disorder: While both conditions involve depressive episodes, bipolar disorder is distinguished by the presence of manic or hypomanic episodes.

2. Borderline Personality Disorder: This condition can involve rapid mood swings, but they are typically triggered by interpersonal events and last for shorter periods than bipolar mood episodes.

3. Attention-Deficit/Hyperactivity Disorder (ADHD): The hyperactivity and impulsivity seen in ADHD can resemble manic symptoms, but ADHD symptoms are typically chronic rather than episodic.

4. Schizophrenia: While both conditions can involve psychotic symptoms, schizophrenia is characterized by persistent delusions and hallucinations rather than mood episodes.

Accurate differentiation is crucial for appropriate treatment, as the management strategies for these conditions can differ significantly.

Effects of Bipolar Disorder on Personal Relationships

Bipolar disorder can have profound effects on personal relationships. The unpredictable nature of mood swings can strain even the strongest bonds between partners, family members, and friends. During manic episodes, individuals may engage in risky or hurtful behaviors that damage trust. Conversely, depressive episodes can lead to withdrawal and emotional unavailability, leaving loved ones feeling helpless and frustrated.

Communication often becomes a significant challenge, as the person with bipolar disorder may struggle to express their needs or understand the impact of their behavior on others. Moreover, the caregiver burden on partners or family members can be substantial, leading to stress, burnout, and sometimes resentment.

However, with proper treatment, education, and support, many individuals with bipolar disorder maintain healthy, fulfilling relationships. Open communication, boundary-setting, and mutual understanding are key components of navigating relationships affected by bipolar disorder.

Challenges Faced by Individuals with Bipolar Disorder

Living with bipolar disorder presents numerous challenges that extend beyond managing mood symptoms. Some of the most common difficulties include:

1. Employment Issues: The episodic nature of bipolar disorder can lead to inconsistent job performance, difficulties maintaining employment, and career setbacks.

2. Financial Instability: Impulsive spending during manic episodes and inability to work during severe depressive episodes can result in significant financial problems.

3. Academic Struggles: For students, bipolar disorder can interfere with concentration, attendance, and overall academic performance.

4. Substance Abuse: Many individuals with bipolar disorder turn to drugs or alcohol as a form of self-medication, leading to co-occurring substance use disorders.

5. Physical Health Complications: Bipolar disorder is associated with an increased risk of various physical health problems, including cardiovascular disease, diabetes, and obesity.

6. Legal Issues: Manic episodes can sometimes lead to legal troubles due to reckless behavior or poor judgment.

7. Self-Esteem and Identity Concerns: The cyclical nature of bipolar disorder can leave individuals questioning their sense of self and struggling with self-esteem.

Societal Stigma and Misunderstandings

Despite increased awareness of mental health issues in recent years, bipolar disorder continues to be surrounded by stigma and misconceptions. Common misunderstandings include:

1. Bipolar disorder is just mood swings: This trivializes the severity and impact of the condition.

2. People with bipolar disorder are always either manic or depressed: In reality, many individuals experience periods of stable mood between episodes.

3. Bipolar disorder makes people violent or dangerous: While manic episodes can lead to agitation, most individuals with bipolar disorder are not violent.

4. Bipolar disorder is a character flaw or weakness: It’s a legitimate medical condition, not a personal failing.

These misconceptions can lead to discrimination in various aspects of life, including employment, housing, and social interactions. They can also prevent individuals from seeking help due to fear of judgment or rejection.

Combating stigma requires ongoing education, open dialogue, and representation of accurate portrayals of bipolar disorder in media and public discourse.

Medication Options for Bipolar Disorder

Medication is a cornerstone of bipolar disorder treatment. The primary goals of pharmacological interventions are to stabilize mood, prevent relapses, and manage acute episodes. Common medications used in bipolar disorder treatment include:

1. Mood Stabilizers: These are the foundation of bipolar disorder treatment. Examples include: – Lithium: One of the oldest and most effective treatments for bipolar disorder – Valproic acid (Depakene) and divalproex sodium (Depakote) – Carbamazepine (Tegretol, Carbatrol) – Lamotrigine (Lamictal)

2. Antipsychotics: These can help manage manic or mixed episodes. Some commonly prescribed antipsychotics include: – Olanzapine (Zyprexa) – Risperidone (Risperdal) – Quetiapine (Seroquel) – Aripiprazole (Abilify)

3. Antidepressants: These may be prescribed cautiously to manage depressive episodes, always in combination with a mood stabilizer to prevent triggering mania. Examples include: – Fluoxetine (Prozac) – Sertraline (Zoloft) – Bupropion (Wellbutrin)

4. Anti-anxiety Medications: These may be used short-term to help with anxiety symptoms or sleep disturbances.

It’s crucial to note that medication regimens are highly individualized. What works for one person may not work for another, and it often takes time and patience to find the right combination and dosage.

Therapeutic Approaches for Bipolar Disorder

While medication is essential, psychotherapy plays a vital role in the comprehensive treatment of bipolar disorder. Several evidence-based therapeutic approaches have shown effectiveness:

1. Cognitive Behavioral Therapy (CBT): CBT helps individuals identify and change negative thought patterns and behaviors associated with mood episodes. It can improve coping skills, reduce symptoms, and prevent relapse.

2. Interpersonal and Social Rhythm Therapy (IPSRT): This therapy focuses on stabilizing daily routines and improving interpersonal relationships. It’s particularly effective in managing the disruptions to circadian rhythms often seen in bipolar disorder.

3. Family-Focused Therapy: This approach involves family members in treatment, educating them about the disorder and improving family communication and problem-solving skills.

4. Psychoeducation: Education about bipolar disorder, its symptoms, and management strategies can empower individuals to take an active role in their treatment.

5. Dialectical Behavior Therapy (DBT): Originally developed for borderline personality disorder, DBT can be helpful for individuals with bipolar disorder in managing emotions and improving interpersonal effectiveness.

6. Mindfulness-Based Cognitive Therapy: This combines elements of CBT with mindfulness techniques to help prevent depressive relapse.

These therapies can be delivered individually, in groups, or even online, providing flexibility to meet diverse needs and preferences.

Lifestyle Changes to Support Mental Health

In addition to medication and therapy, certain lifestyle modifications can significantly support the management of bipolar disorder:

1. Establishing a Consistent Sleep Schedule: Regular sleep patterns can help stabilize mood and prevent episodes.

2. Stress Management: Techniques such as meditation, deep breathing exercises, or yoga can help manage stress, a common trigger for mood episodes.

3. Regular Exercise: Physical activity has been shown to have mood-stabilizing effects and can improve overall well-being.

4. Healthy Diet: A balanced diet can support overall health and may help stabilize mood.

5. Avoiding Alcohol and Drugs: Substance use can interfere with medication effectiveness and trigger mood episodes.

6. Maintaining a Mood Chart: Tracking daily moods, sleep patterns, and life events can help identify triggers and early warning signs of episodes.

7. Building a Support Network: Having a strong support system of friends, family, or support groups can provide crucial emotional support.

8. Developing a Crisis Plan: Creating a plan for what to do during severe mood episodes can provide a sense of control and ensure quick access to help when needed.

Choosing a Focus for the Essay

When writing an essay on bipolar disorder, it’s important to choose a specific focus or angle. Some potential topics could include:

1. The historical evolution of bipolar disorder diagnosis and treatment 2. The impact of bipolar disorder on creativity and artistic expression 3. Challenges in diagnosing bipolar disorder in children and adolescents 4. The role of genetics in bipolar disorder 5. Bipolar disorder and its relationship to other mental health conditions 6. The economic impact of bipolar disorder on individuals and society 7. Cultural variations in the presentation and treatment of bipolar disorder 8. Emerging treatments and future directions in bipolar disorder research

Choosing a focused topic allows for a more in-depth exploration and can make the essay more engaging and informative.

Structuring the Essay

A well-structured essay on bipolar disorder should include:

1. Introduction: Provide a brief overview of bipolar disorder and state the essay’s main focus or thesis.

2. Background Information: Offer essential context about bipolar disorder, including its definition, types, and prevalence.

3. Main Body: Divide the main content into logical sections, each addressing a specific aspect of the chosen topic. Use subheadings to improve readability.

4. Discussion: Analyze the information presented, discussing implications, controversies, or areas for further research.

5. Conclusion: Summarize the main points and restate the thesis in light of the evidence presented. Consider ending with thoughts on future directions or a call to action.

Remember to use transitions between sections to ensure a smooth flow of ideas.

Addressing Controversial Topics

When writing about bipolar disorder, you may encounter controversial or sensitive topics. These might include:

1. The overdiagnosis or underdiagnosis of bipolar disorder 2. The role of pharmaceutical companies in shaping bipolar disorder treatment 3. The use of electroconvulsive therapy (ECT) in treatment-resistant cases 4. The potential link between creativity and bipolar disorder 5. The ethics of genetic testing for bipolar disorder susceptibility

When addressing these topics:

– Present balanced viewpoints, acknowledging different perspectives – Rely on credible, peer-reviewed sources rather than anecdotal evidence – Avoid sensationalism or stigmatizing language – Clearly distinguish between established facts and areas of ongoing debate or uncertainty

Providing Reliable Sources

Using reliable sources is crucial when writing about a complex medical condition like bipolar disorder. Some reputable sources include:

1. Peer-reviewed academic journals (e.g., Journal of Affective Disorders, Bipolar Disorders) 2. Professional organizations (e.g., American Psychiatric Association, National Institute of Mental Health) 3. Reputable mental health websites (e.g., National Alliance on Mental Illness, Mental Health America) 4. Government health agencies (e.g., Centers for Disease Control and Prevention, World Health Organization)

When citing sources:

– Use the most recent information available, as understanding of bipolar disorder is continually evolving – Properly attribute all information to its original source – Consider including a mix of primary research articles and review papers for a comprehensive perspective

Bipolar disorder is a complex and challenging mental health condition that affects millions of individuals worldwide. Its impact extends far beyond mood swings, touching every aspect of a person’s life from relationships and career to physical health and self-identity. While the road to managing bipolar disorder can be difficult, advances in understanding and treatment offer hope for improved outcomes.

As our knowledge of bipolar disorder continues to grow, so does our ability to provide effective support and treatment. By combining medication, psychotherapy, lifestyle modifications, and a strong support system, many individuals with bipolar disorder lead fulfilling, productive lives. However, challenges remain, particularly in areas of early diagnosis

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Diagnosis and management of bipolar disorders

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• 1 Precision Medicine Center of Excellence in Mood Disorders, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
• 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
• Correspondence to: F S Goes fgoes1{at}jhmi.edu

Bipolar disorders (BDs) are recurrent and sometimes chronic disorders of mood that affect around 2% of the world’s population and encompass a spectrum between severe elevated and excitable mood states (mania) to the dysphoria, low energy, and despondency of depressive episodes. The illness commonly starts in young adults and is a leading cause of disability and premature mortality. The clinical manifestations of bipolar disorder can be markedly varied between and within individuals across their lifespan. Early diagnosis is challenging and misdiagnoses are frequent, potentially resulting in missed early intervention and increasing the risk of iatrogenic harm. Over 15 approved treatments exist for the various phases of bipolar disorder, but outcomes are often suboptimal owing to insufficient efficacy, side effects, or lack of availability. Lithium, the first approved treatment for bipolar disorder, continues to be the most effective drug overall, although full remission is only seen in a subset of patients. Newer atypical antipsychotics are increasingly being found to be effective in the treatment of bipolar depression; however, their long term tolerability and safety are uncertain. For many with bipolar disorder, combination therapy and adjunctive psychotherapy might be necessary to treat symptoms across different phases of illness. Several classes of medications exist for treating bipolar disorder but predicting which medication is likely to be most effective or tolerable is not yet possible. As pathophysiological insights into the causes of bipolar disorders are revealed, a new era of targeted treatments aimed at causal mechanisms, be they pharmacological or psychosocial, will hopefully be developed. For the time being, however, clinical judgment, shared decision making, and empirical follow-up remain essential elements of clinical care. This review provides an overview of the clinical features, diagnostic subtypes, and major treatment modalities available to treat people with bipolar disorder, highlighting recent advances and ongoing therapeutic challenges.

Introduction

Abnormal states of mood, ranging from excesses of despondency, psychic slowness, diminished motivation, and impaired cognitive functioning on the one hand, and exhilaration, heightened energy, and increased cognitive and motoric activity on the other, have been described since antiquity. 1 However, the syndrome in which both these pathological states occur in a single individual was first described in the medical literature in 1854, 2 although its fullest description was made by the German psychiatrist Emil Kraepelin at the turn of the 19th century. 3 Kraepelin emphasized the periodicity of the illness and proposed an underlying trivariate model of mood, thought (cognition), and volition (activity) to account for the classic forms of mania and depression and the various admixed presentations subsequently know as mixed states. 3 These initial descriptions of manic depressive illness encompassed most recurrent mood syndromes with relapsing remitting course, minimal interepisode morbidity, and a wide spectrum of “colorings of mood” that pass “without a sharp boundary” from the “rudiment of more severe disorders…into the domain of personal predisposition.” 3 Although Kraepelin’s clinical description of bipolar disorder (BD) remains the cornerstone of today’s clinical description, more modern conceptions of bipolar disorder have differentiated manic depressive illness from recurrent depression, 4 partly based on differences in family history and the relative specificity of lithium carbonate and mood stabilizing anticonvulsants as anti-manic and prophylactic agents in bipolar disorder. While the boundaries of bipolar disorder remain a matter of controversy, 5 this review will focus on modern clinical conceptions of bipolar disorder, highlighting what is known about its causes, prognosis, and treatments, while also exploring novel areas of inquiry.

Sources and selection criteria

PubMed and Embase were searched for articles published from January 2000 to February 2023 using the search terms “bipolar disorder”, “bipolar type I”, “bipolar type II”, and “bipolar spectrum”, each with an additional search term related to each major section of the review article (“definition”, “diagnosis”, “nosology”, “prevalence”, “epidemiology”, “comorbid”, “precursor”, “prodrome”, “treatment”, “screening”, “disparity/ies”, “outcome”, “course”, “genetics”, “imaging”, “treatment”, “pharmacotherapy”, “psychotherapy”, “neurostimulation”, “convulsive therapy”, “transmagnetic”, “direct current stimulation”, “suicide/suicidal”, and “precision”). Searches were prioritized for systematic reviews and meta-analyses, followed by randomized controlled trials. For topics where randomized trials were not relevant, searches also included narrative reviews and key observational studies. Case reports and small observations studies or randomized controlled trials of fewer than 50 patients were excluded.

Modern definitions of bipolar disorder

In the 1970s, the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders reflected the prototypes of mania initially described by Kraepelin, following the “neo-Kraepelinian” model in psychiatric nosology. To meet the primary requirement for a manic episode, an individual must experience elevated or excessively irritable mood for at least a week, accompanied by at least three other typical syndromic features of mania, such as increased activity, increased speed of thoughts, rapid speech, changes in esteem, decreased need for sleep, or excessive engagement in impulsive or pleasurable activities. Psychotic symptoms and admission to hospital can be part of the diagnostic picture but are not essential to the diagnosis. In 1994, Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV) carved out bipolar disorder type II (BD-II) as a separate diagnosis comprising milder presentations of mania called hypomania. The diagnostic criteria for BD-II are similar to those for bipolar disorder type I (BD-I), except for a shorter minimal duration of symptoms (four days) and the lack of need for significant role impairment during hypomania, which might be associated with enhanced functioning in some individuals. While the duration criteria for hypomania remain controversial, BD-II has been widely accepted and shown to be as common as (if not more common than) BD-I. 6 The ICD-11 (international classification of diseases, 11th revision) included BD-II as a diagnostic category in 2019, allowing greater flexibility in its requirement of hypomania needing to last several days.

The other significant difference between the two major diagnostic systems has been their consideration of mixed symptoms. Mixed states, initially described by Kraepelin as many potential concurrent combinations of manic and depressive symptoms, were more strictly defined by DSM as a week or more with full syndromic criteria for both manic and depressive episodes. In DSM-5, this highly restrictive criterion was changed to encompass a broader conception of subsyndromal mixed symptoms (consisting of at least three contrapolar symptoms) in either manic, hypomanic, or depressive episodes. In ICD-11, mixed symptoms are still considered to be an episode, with the requirement of several prominent symptoms of the countervailing mood state, a less stringent requirement that more closely aligns with Kraepelin's broader conception of mixed states. 7

Epidemiology

Using DSM-IV criteria, the National Comorbidity Study replication 6 found similar lifetime prevalence rates for BD-I (1.0%) and BD-II (1.1%) among men and women. Subthreshold symptoms of hypomania (bipolar spectrum disorder) were more common, with prevalence rate estimates of 2.4%. 6 Incidence rates, which largely focus on BD-I, have been estimated at approximately 6.1 per 100 000 person years (95% confidence interval 4.7 to 8.1). 8 Estimates of the incidence and lifetime prevalence of bipolar disorder show moderate variations according to the method of diagnosis (performed by lay interviewers in a research context v clinically trained interviews) and the racial, ethnic, and demographic context. 9 Higher income, westernized countries have slightly higher rates of bipolar disorder, 10 which might reflect a combination of westernized centricity in the specific idioms used to understand and elicit symptoms, as well as a greater knowledge, acceptance, and conceptualization of emotional symptoms as psychiatric disorders.

Causes of bipolar disorder

Like other common psychiatric disorders, bipolar disorder is likely caused by a complex interplay of multiple factors, both at the population level and within individuals, 11 which can be best conceptualized at various levels of analysis, including genetics, brain networks, psychological functioning, social support, and other biological and environmental factors. Because knowledge about the causes of bipolar disorder remains in its infancy, for pragmatic purposes, most research has followed a reductionistic model that will ultimately need to be synthesized for a more coherent view of the pathophysiology that underlies the condition.

Insights from genetics

From its earliest descriptions, bipolar disorder has been observed to run in families. Indeed, family history is the strongest individual risk factor for developing the disorder, with first degree relatives having an approximately eightfold higher risk of developing bipolar disorder compared with the baseline population rates of ~1%. 12 While family studies cannot separate the effects of genetics from behavioral or cultural transmission, twin and adoption studies have been used to confirm that the majority of the familial risk is genetic in origin, with heritability estimates of approximately 60-80%. 13 14 There have been fewer studies of BD-II, but its heritability has been found to be smaller (~46%) 15 and closer to that of more common disorders such as major depressive disorder or generalized anxiety. 15 16 Nevertheless, significant heritability does not necessarily imply the presence of genes of large effect, since the genetic risk for bipolar disorder appears likely to be spread across many common variants of small effect sizes. 16 17 Ongoing studies of rare variations have found preliminary evidence for variants of slightly higher effect sizes, with initial evidence of convergence with common variations in genes associated with the synapse and the postsynaptic density. 18 19

While the likelihood that the testing of single variants or genes will be useful for diagnostic purposes is low, analyses known as polygenic risk studies can sum across all the risk loci and have some ability to discriminate cases from controls, albeit at the group level rather than the individual level. 20 These polygenic risk scores can also be used to identify shared genetic risk factors across other medical and psychiatric disorders. Bipolar disorder has strong evidence for common variant based coheritability with schizophrenia (genetic correlation (r g ) 0.69) and major depressive disorder (r g 0.48). BD-I has stronger coheritability with schizophrenia compared with BD-II, which is more strongly genetically correlated with major depressive disorder (r g 0.66). 16 Lower coheritability was observed with attention deficit hyperactivity disorder (r g 0.21), anorexia nervosa (0.20), and autism spectrum disorder (r g 0.21). 16 These correlations provide evidence for shared genetic risk factors between bipolar disorder and other major psychiatric syndromes, a pattern also corroborated by recent nationwide registry based family studies. 12 14 Nevertheless, despite their potential usefulness, polygenic risk scores must currently be interpreted with caution given their lack of populational representation and lingering concerns of residual confounds such as gene-environment correlations. 21

Insights from neuroimaging

Similarly to the early genetic studies, small initial studies had limited replication, leading to the formation of large worldwide consortiums such as ENIGMA (enhancing neuroimaging genetics through meta-analysis) which led to substantially larger sample sizes and improved reproducibility. In its volumetric analyses of subcortical structures from MRI (magnetic resonance imaging) of patients with bipolar disorder, the ENIGMA consortium found modest decreases in the volume of the thalamus (Cohen’s d −0.15), the hippocampus (−0.23), and the amygdala (−0.11), with an increased volume seen only in the lateral ventricles (+0.26). 22 Meta-analyses of cortical regions similarly found small reductions in cortical thickness broadly across the parietal, temporal, and frontal cortices (Cohen’s d −0.11 to −0.29) but no changes in cortical surface area. 23 In more recent meta-analyses of white matter tracts using diffuse tension imaging, widespread but modest decreases in white matter integrity were found throughout the brain in bipolar disorder, most notably in the corpus callosum and bilateral cinguli (Cohen’s d −0.39 to −0.46). 24 While these findings are likely to be highly replicable, they do not, as yet, have clinical application. This is because they reflect differences at a group level rather than an individual level, 25 and because many of these patterns are also seen across other psychiatric disorders 26 and could be either shared risk factors or the effects of confounding factors such as medical comorbidities, medications, co-occurring substance misuse, or the consequences (rather than causes) of living with mental illness. 27 Efforts to collate and meta-analyze large samples utilizing longitudinal designs 28 task based, resting state functional MRI measurents, 29 as well as other measures of molecular imaging (magnetic resonance spectroscopy and positron emission tomography) are ongoing but not as yet synthesized in large scale meta-analyses.

Environmental risk factors

Because of the difficulty in measuring and studying the relevant and often common environmental risk factors for a complex illness like bipolar disorder, there has been less research on how environmental risk factors could cause or modify bipolar disorder. Evidence for intrauterine risk factors is mixed and less compelling than such evidence in disorders like schizophrenia. 30 Preliminary evidence suggests that prominent seasonal changes in solar radiation, potentially through its effects on circadian rhythm, can be associated with an earlier onset of bipolar disorder 31 and a higher likelihood of experiencing a depressive episode at onset. 31 However, the major focus of environmental studies in bipolar disorder has been on traumatic and stressful life events in early childhood 32 and in adulthood. 33 The effects of such adverse events are complex, but on a broad level have been associated with earlier onset of bipolar disorder, a worse illness course, greater prevalence of psychotic symptoms, 34 substance misuse and psychiatric comorbidities, and a higher risk of suicide attempts. 32 35 Perhaps uniquely in bipolar disorder, evidence also indicates that positive life events associated with goal attainment can also increase the risk of developing elevated states. 36

Comorbidity

Bipolar disorder rarely manifests in isolation, with comorbidity rates indicating elevated lifetime risk of several co-occurring symptoms and comorbid disorders, particularly anxiety, attentional disorders, substance misuse disorders, and personality disorders. 37 38 The causes of such comorbidity can be varied and complex: they could reflect a mixed presentation artifactually separated by current diagnostic criteria; they might also reflect independent illnesses; or they might represent the downstream effects of one disorder increasing the risk of developing another disorder. 39 Anxiety disorders tend to occur before the frank onset of manic or hypomanic symptoms, suggesting that they could in part reflect prodromal symptoms that manifest early in the lifespan. 37 Similarly, subthreshold and syndromic symptoms of attention deficit/hyperactivity disorder are also observed across the lifespan of people with bipolar disorder, but particularly in early onset bipolar disorder. 40 On the other hand, alcohol and substance misuse disorders occur more evenly before and after the onset of bipolar disorder, consistent with a more bidirectional causal association. 41

The association between bipolar disorder and comorbid personality disorders is similarly complex. Milder manifestations of persistent mood instability (cyclothymia) or low mood (dysthymia) have previously been considered to be temperamental variants of bipolar disorder, 42 but are now classified as related but separate disorders. In people with persistent emotional dysregulation, making the diagnosis of bipolar disorder can be particularly challenging, 43 since the boundaries between longstanding mood instability and phasic changes in mood state can be difficult to distinguish. While symptom overlap can lead to artificially inflated prevalence rates of personality disorders in bipolar disorder, 44 the elevated rates of most personality disorders in bipolar disorder, particularly those related to emotional instability, are likely reflective of an important clinical phenomenon that is understudied, particularly with regard to treatment implications. 45 In general, people with comorbidities tend to have greater symptom burden and functional impairment and have lower response rates to treatment. 46 47 Data on approaches to treat specific comorbid disorders in bipolar disorder are limited, 48 49 and clinicians are often left to rely on their clinical judgment. The most parsimonious approach is to treat primary illness as fully as possible before considering additional treatment options for remaining comorbid symptoms. For certain comorbidities, such as anxiety symptoms and disorders of attention, first line pharmacological treatment—namely, antidepressants and stimulants, should be used with caution, since they might increase the long term risks of mood switching or overall mood instability. 50 51

Like other major mental illnesses, bipolar disorder is also associated with an increased prevalence of common medical disorders such as obesity, hyperlipidemia, coronary artery disease, chronic obstructive pulmonary disease, and thyroid dysfunction. 52 These have been attributed to increase risk factors such as physical inactivity, poor nutrition, smoking, and increased use of addictive substances, 53 but some could also be consequences of specific treatments, such as the atypical antipsychotics and mood stabilizers. 54 Along with poor access to care, this medical burden likely accounts for much of the increased standardized mortality (approximately 2.6 times higher) in people with bipolar disorder, 55 highlighting the need to utilize treatments with better long term side effect profiles, and the need for better integration with medical care.

Precursors and prodromes: who develops bipolar disorder?

While more widespread screening and better accessibility to mental health providers should in principle shorten the time to diagnosis and treatment, early manifestation of symptoms in those who ultimately go on to be diagnosed with bipolar disorder is generally non-specific. 56 In particular, high risk offspring studies of adolescents with a parent with bipolar disorder have found symptoms of anxiety and attentional/disruptive disorders to be frequent in early adolescence, followed by higher rates of depression and sleep disturbance in later teenage years. 56 57 Subthreshold symptoms of mania, such as prolonged increases in energy, elated mood, racing thoughts, and mood lability are also more commonly found in children with prodromal symptoms (meta-analytic prevalence estimates ranging from 30-50%). 58 59 Still, when considered individually, none of these symptoms or disorders are sensitive or specific enough to accurately identify individuals who will transition to bipolar disorder. Ongoing approaches to consider these clinical factors together to improve accuracy have a promising but modest ability to identify people who will develop bipolar disorder, 60 emphasizing the need for further studies before implementation.

Screening for bipolar disorder

Manic episodes can vary from easily identifiable prototypical presentations to milder or less typical symptoms that can be challenging to diagnose. Ideally, a full diagnostic evaluation with access to close informants is performed on patients presenting to clinical care; however, evaluations can be hurried in routine clinical care, and the ability to recall previous episodes might be limited. In this context, the use of screening scales can be a helpful addition to clinical care, although screening scales must be regarded as an impetus for a confirmatory clinical interview rather than a diagnostic instrument by themselves. The two most widely used and openly available screening scales are the mood disorders questionnaire (based on the DSM-IV criteria for hypomania) 61 and the hypomania check list (HCL-32), 62 that represent a broader overview of symptoms proposed to be part of a broader bipolar spectrum.

Racial/ethnic disparities

Although community surveys using structured or semi-structured diagnostic instruments, have provided little evidence for variation across ethnic groups, 63 64 observational studies based on clinical diagnoses in healthcare settings have found a disproportionately higher rate of diagnosis of schizophrenia relative to bipolar disorder in black people. 65 Consistent with similar disparities seen across medicine, these differences in clinical diagnoses are likely influenced by a complex mix of varying clinical presentations, differing rates of comorbid conditions, poorer access to care, greater social and economic burden, as well as the potential effect of subtle biases of healthcare professionals. 65 While further research is necessary to identify driving factors responsible for diagnostic disparities, clinicians should be wary of making a rudimentary diagnosis in patients from marginalized backgrounds, ensuring comprehensive data gathering and a careful diagnostic formulation that incorporates shared decision making between patient and provider.

Bipolar disorder is a recurrent illness, but its longitudinal course is heterogeneous and difficult to predict. 46 66 The few available long term studies of BD-I and BD-II have found a consistent average rate of recurrence of 0.40 mood episodes per year in historical studies 67 and 0.44 mood episodes per year in more recent studies. 68 The median time to relapse is estimated to be 1.44 years, with higher relapse rates seen in BD-I (0.81 years) than in BD-II (1.63 years) and no differences observed with respect to age or sex. 1 2 In addition to focusing on episodes, an important development in research and clinical care of bipolar disorder has been the recognition of the burden of subsyndromal symptoms. Although milder in severity, these symptoms can be long lasting, functionally impairing, and can themselves be a risk factor for episode relapse. 69 Recent cohort studies have also found that a substantial proportion of patients with bipolar disorder (20-30%) continue to have poor outcomes even after receiving guideline based care. 46 70 Risk factors that contribute to this poor outcome include transdiagnostic indicators of adversity such as substance misuse, low educational attainment, socioeconomic hardship, and comorbid disorders. As expected, those with more severe past illness activity, including those with rapid cycling, were also more likely to remain symptomatically and psychosocially impaired. 46 71 72

The primary focus of treating bipolar disorder has been to manage the manic, mixed, or depressive episodes that present to clinical care and to subsequently prevent recurrence of future episodes. Owing to the relapse remitting nature of the illness, randomized controlled trials are essential to determine treatment efficacy, as the observation of clinical improvement could just represent the ebbs and flows of the natural history of the illness. In the United States, the FDA (Food and Drug Administration) requires at least two large scale placebo controlled trials (phase 3) to show significant evidence of efficacy before approving a treatment. Phase 3 studies of bipolar disorder are generally separated into short term studies of mania (3-4 weeks), short term studies for bipolar depression (4-6 weeks), and longer term maintenance studies to evaluate prophylactic activity against future mood episodes (usually lasting one year). Although the most rigorous evaluation of phase 3 studies would be to require two broadly representative and independent randomized controlled trials, the FDA permits consideration of so called enriched design trials that follow participants after an initial response and tolerability has been shown to an investigational drug. Because of this initial selection, such trials can be biased against comparator agents, and could be less generalizable to patients seen in clinical practice.

A summary of the agents approved by the FDA for treatment of bipolar disorder is in table 1 , which references the key clinical trials demonstrating efficacy. Figure 1 and supplementary table 1 are a comparison of treatments for mania, depression, and maintenance. Effect sizes reflect the odds ratios or relative risks of obtaining response (defined as ≥50% improvement from baseline) in cases versus controls and were extracted from meta-analyses of randomized controlled trials for bipolar depression 86 and maintenance, 94 as well as a network meta-analysis of randomized controlled trials in bipolar mania. 73 Effect sizes are likely to be comparable for each phase of treatment, but not across the different phases, since methodological differences exist between the three meta-analytic studies.

FDA approved medications for bipolar disorder

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Summary of treatment response rates (defined as ≥50% improvement from baseline) of modern clinical trials for acute mania, acute bipolar depression, and long term recurrence. Meta-analytic estimates were extracted from recent meta-analyses or network meta-analyses of acute mania, 73 acute bipolar depression, 86 and bipolar maintenance studies 94

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Acute treatment of mania

As mania is characterized by impaired judgment, individuals can be at risk for engaging in high risk, potentially dangerous behaviors that can have substantial personal, occupational, and financial consequences. Therefore, treatment of mania is often considered a psychiatric emergency and is, when possible, best performed in the safety of an inpatient unit. While the primary treatment for mania is pharmacological, diminished insight can impede patients' willingness to accept treatment, emphasizing the significance of a balanced therapeutic approach that incorporates shared decision making frameworks as much as possible to promote treatment adherence.

The three main classes of anti-manic treatments are lithium, mood stabilizing anticonvulsants (divalproate and carbamazepine), and antipsychotic medications. Almost all antipsychotics are effective in treating mania, with the more potent dopamine D2 receptor antagonists such as risperidone and haloperidol demonstrating slightly higher efficacy ( fig 1 ). 73 In the United States, the FDA has approved the use of all second generation antipsychotics for treating mania except for lurasidone and brexpriprazole. Compared with mood stabilizing medications, second generation antipsychotics have a faster onset of action, making them a first line treatment for more severe manic symptoms that require rapid treatment. 99 The choice of which specific second generation antipsychotic to use depends on a balance of efficacy, tolerability concerns, and cost considerations (see table 1 ). Notably, the FDA has placed a black box warning on all antipsychotics for increasing the risk of cerebral vascular accidents in the elderly. 100 While this was primarily focused on the use of antipsychotics in dementia, this likely class effect should be taken into account when considering the use of antipsychotics in the elderly.

Traditional mood stabilizers, such as lithium, divalproate, and carbamazepine are also effective in the treatment of active mania ( fig 1 ). Since lithium also has a robust prophylactic effect (see section on prevention of mood episodes below) it is often recommended as first line treatment and can be considered as monotherapy when rapid symptom reduction is not clinically indicated. On the other hand, other anticonvulsants such as lamotrigine, gabapentin, topiramate, and oxcarbazepine have not been found to be effective for the treatment of mania or mixed episodes. 101 Although the empirical evidence for polypharmacy is limited, 102 combination treatment in acute mania, usually consisting of a mood stabilizer and a second generation antipsychotic, is commonly used in clinical practice despite the higher burden of side effects. Following resolution of an acute mania, consideration should be given to transitioning to monotherapy with an agent with proven prophylactic activity.

Pharmacological approaches to bipolar depression

Depressed episodes are usually more common than mania or hypomania, 103 104 and often represent the primary reason for individuals with bipolar disorder to seek treatment. Nevertheless, because early antidepressant randomized controlled trials did not distinguish between unipolar and bipolar depressive episodes, it has only been in the past two decades that large scale randomized controlled trials have been conducted specifically for bipolar depression. As such trials are almost exclusively funded by pharmaceutical companies, they have focused on the second generation antipsychotics and newer anticonvulsants still under patent. These trials have shown moderate but robust effects for most recent second generation antipsychotics, five of which have received FDA approval for treating bipolar depression ( table 1 ). No head-to-head trials have been conducted among these agents, so the choice of medication depends on expected side effects and cost considerations. For example, quetiapine has robust antidepressant efficacy data but is associated with sedation, weight gain, and adverse cardiovascular outcomes. 105 Other recently approved medications such as lurasidone, cariprazine, and lumateperone have better side effect profiles but show more modest antidepressant activity. 106

Among the mood stabilizing anticonvulsants, lamotrigine has limited evidence for acute antidepressant activity, 107 possibly owing to the need for an 8 week titration to reach the full dose of 200 mg. However, as discussed below, lamotrigine can still be considered for mild to moderate acute symptoms owing to its generally tolerable side effect profile and proven effectiveness in preventing the recurrence of depressive episodes. Divalproate and carbamazepine have some evidence of being effective antidepressants in small studies, but as there has been no large scale confirmatory study, they should be considered second or third line options. 86 Lithium has been studied for the treatment of bipolar depression as a comparator to quetiapine and was not found to have a significant acute antidepressant effect. 88

Antidepressants

Owing to the limited options of FDA approved medications for bipolar depression and concerns of metabolic side effects from long term second generation antipsychotic use, clinicians often resort to the use of traditional antidepressants for the treatment of bipolar depression 108 despite the lack of FDA approval for such agents. Indeed, recent randomized clinical trials of antidepressants in bipolar depression have not shown an effect for paroxetine, 89 109 bupropion, 109 or agomelatine. 110 Beyond the question of efficacy, another concern regarding antidepressants in bipolar disorder is their potential to worsen the course of illness by either promoting mixed or manic symptoms or inducing more subtle degrees of mood instability and cycle acceleration. 111 However, the risk of switching to full mania while being treated with mood stabilizers appears to be modest, with a meta-analysis of randomized clinical trials and clinical cohort studies showing the rates of mood switching over an average follow-up of five months to be approximately 15.3% in people with bipolar disorder treated on antidepressants compared with 13.8% in those without antidepressant treatment. 111 The risk of switching appears to be higher in the first 1-2 years of treatment in people with BD-I, and in those treated with a tricyclic antidepressant 112 or the dual reuptake inhibitor venlafaxine. 113 Overall, while the available data have methodological limitations, most guidelines do not recommend the use of antidepressants in bipolar disorder, or recommend them only after agents with more robust evidence have been tried. That they remain so widely used despite the equivocal evidence base reflects the unmet need for treatment of depression, concerns about the long term side effects of second generation antipsychotics, and the challenges of changing longstanding prescribing patterns.

Pharmacological approaches to prevention of recurrent episodes

Following treatment of the acute depressive or manic syndrome, the major focus of treatment is to prevent future episodes and minimize interepisodic subsyndromal symptoms. Most often, the medication that has been helpful in controlling the acute episode can be continued for prevention, particularly if clinical trial evidence exists for a maintenance effect. To show efficacy for prevention, studies must be sufficiently long to allow the accumulation of future episodes to occur and be potentially prevented by a therapeutic intervention. However, few long term treatment studies exist and most have utilized enriched designs that likely favor the drug seeking regulatory approval. As shown in figure 1 , meta-analyses 94 show prophylactic effect for most (olanzapine, risperidone, quetiapine, aripiprazole, asenapine) but not all (lurasidone, paliperidone) recently approved second generation antipsychotics. The effect sizes are generally comparable with monotherapy (odds ratio 0.42, 95% confidence interval 0.34 to 0.5) or as adjunctive therapy (odds ratio 0.37, 95% confidence interval 0.25 to 0.55). 94 Recent studies of lithium, which have generally used it as a (non-enriched) comparator drug, show a comparable protective effect (odds ratio 0.46, 95% confidence interval 0.28 to 0.75). 94 Among the mood stabilizing anticonvulsant drugs, a prophylactic effect has also been found for both divalproate and lamotrigine ( fig 1 and supplementary table 1), although only the latter has been granted regulatory approval for maintenance treatment. While there are subtle differences in effect sizes in drugs approved for maintenance ( fig 1 and table 1 ), the overlapping confidence intervals and methodological differences between studies prevent a strict comparison of the effect measures.

Guidelines often recommend lithium as a first line agent given its consistent evidence of prophylaxis, even when tested as the disadvantaged comparator drug in enriched drug designs. Like other medications, lithium has a unique set of side effects and ultimately the decision about which drug to use among those which are efficacious should be a decision carefully weighed and shared between patient and provider. The decision might be re-evaluated after substantial experience with the medication or at different stages in the long term treatment of bipolar disorder (see table 1 ).

Psychotherapeutic approaches

The frequent presence of residual symptoms, often associated with psychosocial and occupational dysfunction, has led to renewed interest in psychotherapeutic and psychosocial approaches to bipolar disorder. Given the impairment of judgment seen in mania, psychotherapy has more of a supportive and educational role in the treatment of mania, whereas it can be more of a primary focus in the treatment of depressive states. On a broad level, psychotherapeutic approaches effective for acute depression, such as cognitive behavioral therapy, interpersonal therapy, behavioral activation, and mindfulness based strategies, can also be recommended for acute depressive states in individuals with bipolar disorder. 114 Evidence for more targeted psychotherapy trials for bipolar disorder is more limited, but meta-analyses have found evidence for decreased recurrence (odds ratio 0.56; 95% confidence interval 0.43 to 0.74) 115 and improvement of subthreshold interepisodic depressive and manic symptoms with cognitive behavioral therapy, family based therapy, interpersonal and social rhythm therapy, and psychoeducation. 115 Recent investigations have also focused on targeted forms of psychotherapy to improve cognition 116 117 118 as well as psychosocial and occupational functioning. 119 120 Although these studies show evidence of a moderate effect, they remain preliminary, methodologically diverse, and require replication on a larger scale. 121

The implementation of evidence based psychotherapy as a treatment faces several challenges, including clinical training, fidelity monitoring, and adequate reimbursement. Novel approaches, leveraging the greater tractability of digital tools 122 and allied healthcare workers, 123 are promising means of lessening the implementation gap; however, these approaches require validation and evidence of clinical utility similar to traditional methods.

Neurostimulation approaches

For individuals with bipolar disorder who cannot tolerate or do not respond well to standard pharmacotherapy or psychotherapeutic approaches, neurostimulation techniques such as repetitive transcranial magnetic stimulation or electric convulsive therapy should be considered as second or third line treatments. Electric convulsive therapy has shown response rates of approximately 60-80% in severe acute depressions 124 125 and 50-60% in cases with treatment resistant depression. 126 These response rates compare favorably with those of pharmacological treatment, which are likely to be closer to ~50% and ~30% in subjects with moderate to severe depression and treatment resistant depression, respectively. 127 Although the safety of electric convulsive therapy is well established, relatively few medical centers have it available, and its acceptability is limited by cognitive side effects, which are usually short term, but which can be more significant with longer courses and with bilateral electrode placement. 128 While there have been fewer studies of electric convulsive therapy for bipolar depression compared with major depressive disorder, it appears to be similarly effective and might show earlier response. 129 Anecdotal evidence also suggests electric convulsive therapy that is useful in refractory mania. 130

Compared with electric convulsive therapy, repetitive transcranial magnetic stimulation has no cognitive side effects and is generally well tolerated. Repetitive transcranial magnetic stimulation acts by generating a magnetic field to depolarize local neural tissue and induce excitatory or inhibitory effects depending on the frequency of stimulation. The most studied FDA approved form of repetitive transcranial magnetic stimulation applies high frequency (10 Hz) excitatory pulses to the left prefrontal cortex for 30-40 minutes a day for six weeks. 131 Like electric convulsive therapy, repetitive transcranial magnetic stimulation has been primarily studied in treatment resistant depression and has been found to have moderate effect, with about one third of patients having a significant treatment response compared with those treated with pharmacotherapy. 131 Recent innovations in transcranial magnetic stimulation have included the use of a novel, larger coil to stimulate a larger degree of the prefrontal cortex (deep transcranial magnetic stimulation), 132 and a shortened (three minutes), higher frequency intermittent means of stimulation known as theta burst stimulation that appears to be comparable to conventional (10 Hz) repetitive transcranial magnetic stimulation. 133 A preliminary trial has recently assessed a new accelerated protocol of theta burst stimulation marked by 10 sessions a day for five days. It found that theta burst stimulation had a greater effect on people with treatment resistant depression compared with treatment as usual, although larger studies are needed to confirm these findings. 134

Conventional repetitive transcranial magnetic stimulation (10 Hz) studies in bipolar disorder have been limited by small sample sizes but have generally shown similar effects compared with major depressive disorder. 135 However, a proof of concept study of single session theta burst stimulation did not show efficacy in bipolar depression, 136 reiterating the need for specific trials for bipolar depression. Given the lack of such trials in bipolar disorder, repetitive transcranial magnetic stimulation should be considered a potentially promising but as yet unproven treatment for bipolar depression.

The other major form of neurostimulation studied in both unipolar and bipolar depression is transcranial direct current stimulation, an easily implemented method of delivering a low amplitude electrical current to the prefrontal area of the brain that could lead to local changes in neuronal excitability. 137 Like repetitive transcranial magnetic stimulation, transcranial direct current stimulation is well tolerated and has been mostly studied in unipolar depression, but has not yet generated sufficient evidence to be approved by a regulatory agency. 138 Small studies have been performed in bipolar depression, but the results have been mixed and require further research before use in clinical settings. 137 138 139 Finally, the evidence for more invasive neurostimulation studies such as vagal nerve stimulation and deep brain stimulation remains extremely limited and is currently insufficient for clinical use. 140 141

Treatment resistance in bipolar disorder

As in major depressive disorder, the use of term treatment resistance in bipolar disorder is controversial since differentiating whether persistent symptoms are caused by low treatment adherence, poor tolerability, the presence of comorbid disorders, or are the result of true treatment resistance, is an essential but often challenging clinical task. Treatment resistance should only be considered after two or three trials of evidence based monotherapy, adjunctive therapy, or both. 142 In difficult-to-treat mania, two or more medications from different mechanistic classes are typically used, with electric convulsive therapy 143 and clozapine 144 being considered if more conventional anti-manic treatments fail. In bipolar depression, it is common to combine antidepressants with anti-manic agents, despite limited evidence for efficacy. 145 Adjunctive therapies such as bright light therapy, 146 the dopamine D2/3 receptor agonist pramipexole, 147 and ketamine 148 149 have shown promising results in small open label trials that require further study.

Treatment considerations to reduce suicide in bipolar disorder

The risk of completed suicide is high across the subtypes of bipolar disorder, with estimated rates of 10-15% across the lifespan. 150 151 152 Lifetime rates of suicide attempts are much higher, with almost half of all individuals with bipolar disorder reporting at least one attempt. 153 Across a population and, often within individuals, the causes of suicide attempts and completed suicides are likely to be multifactorial, 154 affected by various risk factors, such as symptomatic illness, environmental stressors, comorbidities (particularly substance misuse), trait impulsivity, interpersonal conflict, loneliness, or socioeconomic distress. 155 156 Risk is highest in depressive and dysphoric/mixed episodes 157 158 and is particularly high in the transitional period following an acute admission to hospital. 159 Among the available treatments, lithium has potential antisuicidal properties. 160 However, since suicide is a rare event, with very few to zero suicides within a typical clinical trial, moderate evidence for this effect emerges only in the setting of meta-analyses of clinical trials. 160 Several observational studies have shown lower mortality in patients on lithium treatment, 161 but such associations might not be causal, since lithium is potentially fatal in overdose and is often avoided by clinicians in patients at high risk of suicide.

The challenge of studying scarce events has led most studies to focus on the reduction of the more common phenomena of suicidal ideation and behavior as a proxy for actual suicides. A recent such multisite study of the Veterans Affairs medical system included a mixture of unipolar and bipolar disorder and was stopped prematurely for futility, indicating no overall effect of moderate dose lithium. 162 Appropriate limitations of this study have been noted, 163 164 including difficulties in recruitment, few patients with bipolar disorder (rather than major depressive disorder), low levels of compliance with lithium therapy, high rates of comorbidity, and a follow-up of only one year. Nevertheless, while the body of evidence suggests that lithium has a modest antisuicidal effect, its degree of protection and utility in complex patients with comorbidities and multiple risk factors remain matters for further study. Treatment of specific suicidal risk in patients with bipolar disorder must therefore also incorporate broader interventions based on the individual’s specific risk factors. 165 Such an approach would include societal interventions like means restriction 166 and a number of empirically tested suicide focused psychotherapy treatments. 167 168 Unfortunately, the availability of appropriate training, expertise, and care models for such treatments remains limited, even in higher income countries. 169

More scalable solutions, such as the deployment of shortened interventions via digital means could help to overcome this implementation gap; however, the effectiveness of such approaches cannot be assumed and requires empirical testing. For example, a recent large scale randomized controlled trial of an abbreviated online dialectical behavioral therapy skills training program was paradoxically associated with slightly increased risk of self-harm. 170

Treatment consideration in BD-II and bipolar spectrum conditions

Because people with BD-II primarily experience depressive symptoms and appear less likely to switch mood states compared with individuals with BD-I, 50 171 there has been a greater acceptance of the use of antidepressants in BD-II depression, including as monotherapy. 172 However, caution should be exercised when considering the use of antidepressants without a mood stabilizer in patients with BD-II who might also experience high rates of mood instability and rapid cycling. Such individuals can instead respond better to newer second generation antipsychotic agents such as quetiapine 173 and lumateperone, 93 which are supported by post hoc analyses of these more recent clinical trials with more BD-II patients. In addition, despite the absence of randomized controlled trials, open label studies have suggested that lithium and other mood stabilizers can have similar efficacy in BD-II, especially in the case of lamotrigine. 174

Psychotherapeutic approaches such as psychoeducation, cognitive behavioral therapy, and interpersonal and social rhythm therapy have been found to be helpful 115 and can be considered as the primary form of treatment for BD-II in some patients, although in most clinical scenarios BD-II is likely to occur in conjunction with psychopharmacology. While it can be tempting to consider BD-II a milder variant of BD-I, high rates of comorbid disorders, rapid cycling, and adverse consequences such as suicide attempts 175 176 highlight the need for clinical caution and the provision of multimodal treatment, focusing on mood improvement, emotional regulation, and better psychosocial functioning.

Precision medicine: can it be applied to improve the care of bipolar disorder?

The recent focus on precision medicine approaches to psychiatric disorders seeks to identify clinically relevant heterogeneity and identify characteristics at the level of the individual or subgroup that can be leveraged to identify and target more efficacious treatments. 1 177 178

The utility of such an approach was originally shown in oncology, where a subset of tumors had gene expression or DNA mutation signatures that could predict response to treatments specifically designed to target the aberrant molecular pathway. 179 While much of the emphasis of precision medicine has been on the eventual identification of biomarkers utilizing high throughput approaches (genetics and other “omics” based measurements), the concept of precision medicine is arguably much broader, encompassing improvements in measurement, potentially through the deployment of digital tools, as well as better conceptualization of contextual, cultural, and socioeconomic mechanisms associated with psychopathology. 180 181 Ultimately, the goal of precision psychiatry is to identify and target driving mechanisms, be they molecular, physiological, or psychosocial in nature. As such, precision psychiatry seeks what researchers and clinicians have often sought: to identify clinically relevant heterogeneity to improve prediction of outcomes and increase the likelihood of therapeutic success. The novelty being not so much the goals of the overarching approach, but the increasing availability of large samples, novel digital tools, analytical advances, and an increasing armamentarium of biological measurements that can be deployed at scale. 177

Although not unique to bipolar disorder, several clinical decision points along the life course of bipolar disorder would benefit from a precision medicine approach. For example, making an early diagnosis is often not possible based on clinical symptoms alone, since such symptoms are usually non-specific. A precision medicine approach could also be particularly relevant in helping to identify subsets of patients for whom the use of antidepressants could be beneficial or harmful. Admittedly, precision medicine approaches to bipolar disorder are still in their infancy, and larger, clinically relevant, longitudinal, and reliable phenotypes are needed to provide the infrastructure for precision medicine approaches. Such data remain challenging to obtain at scale, leading to renewed efforts to utilize the extant clinical infrastructure and electronic medical records to help emulate traditional longitudinal analyses. Electronic medical records can help provide such data, but challenges such as missingness, limited quality control, and potential biases in care 182 need to be resolved with carefully considered analytical designs. 183

Emerging treatments

Two novel atypical antipsychotics, amilsupride and bifeprunox, are currently being tested in phase 3 trials ( NCT05169710 and NCT00134459 ) and could gain approval for bipolar depression in the near future if these pivotal trials show a significant antidepressant effect. These drugs could offer advantages such as greater antidepressant effects, fewer side effects, and better long term tolerability, but these assumptions must be tested empirically. Other near term possibilities include novel rapid antidepressant treatments, such as (es)ketamine that putatively targets the glutamatergic system, and has been recently approved for treatment resistant depression, but which have not yet been tested in phase 3 studies in bipolar depression. Small studies have shown comparable effects of intravenous ketamine, 149 184 in bipolar depression with no short term evidence of increased mood switching or mood instability. Larger phase 2 studies ( NCT05004896 ) are being conducted which will need to be followed by larger phase 3 studies. Other therapies targeting the glutamatergic system have generally failed phase 3 trials in treatment resistant depression, making them unlikely to be tested in bipolar depression. One exception could be the combination of dextromethorphan and its pharmacokinetic (CYP2D6) inhibitor bupropion, which was recently approved for treatment resistant depression but has yet to be tested in bipolar depression. Similarly, the novel GABAergic compound zuranolone is currently being evaluated by the FDA for the treatment of major depressive disorder and could also be subsequently studied in bipolar depression.

Unfortunately, given the general efficacy for most patients of available treatments, few scientific and financial incentives exist to perform large scale studies of novel treatment in mania. Encouraging results have been seen in small studies of mania with the selective estrogen receptor modulator 185 tamoxifen and its active metabolite endoxifen, both of which are hypothesized to inhibit protein kinase C, a potential mechanistic target of lithium treatment. These studies remain small, however, and anti-estrogenic side effects have potentially dulled interest in performing larger studies.

Finally, several compounds targeting alternative pathophysiological mechanisms implicated in bipolar disorder have been trialed in phase 2 academic studies. The most studied has been N -acetylcysteine, a putative mitochondrial modulator, which initially showed promising results only to be followed by null findings in larger more recent studies. 186 Similarly, although small initial studies of anti-inflammatory agents provided impetus for further study, subsequent phase 2 studies of the non-steroidal agent celecoxib, 187 the anti-inflammatory antibiotic minocycline, 187 and the antibody infliximab (a tumor necrosis factor antagonist) 188 have not shown efficacy for bipolar depression. Secondary analyses have suggested that specific anti-inflammatory agents might be effective only for a subset of patients, such as those with elevated markers of inflammation or a history of childhood adversity 189 ; however, such hypotheses must be confirmed in adequately powered independent studies.

Several international guidelines for the treatment of bipolar disorder have been published in the past decade, 102 190 191 192 providing a list of recommended treatments with efficacy in at least one large randomized controlled trial. Since effect sizes tend to be moderate and broadly comparable across classes, all guidelines allow for significant choice among first line agents, acknowledging that clinical characteristics, such as history of response or tolerability, severity of symptoms, presence of mixed features, or rapid cycling can sometimes over-ride guideline recommendations. For acute mania requiring rapid treatment, all guidelines prioritize the use of second generation antipsychotics such as aripiprazole, quetiapine, risperidone, asenapine, and cariprazine. 102 192 193 Combination treatment is considered based on symptom severity, tolerability, and patient choice, with most guidelines recommending lithium or divalproate along with a second generation antipsychotic for mania with psychosis, severe agitation, or prominent mixed symptoms. While effective, haloperidol is usually considered a second choice option owing to its propensity to cause extrapyramidal symptoms. 102 192 193 Uniformly, all guidelines agree on the need to taper antidepressants in manic or mixed episodes.

For maintenance treatment, guidelines are generally consistent in recommending lithium if tolerated and without relative contraindications, such as baseline renal disease. 194 The second most recommended maintenance treatment is quetiapine, followed by aripiprazole for patients with prominent manic episodes and lamotrigine for patients with predominant depressive episodes. 194 Most guidelines recommend considering prophylactic properties when initially choosing treatment for acute manic episodes, although others suggests that acute maintenance treatments can be cross tapered with maintenance medications after several months of full reponse. 193

For bipolar depression, recent guidelines recommend specific second generation antipsychotics such as quetiapine, lurasidone, and cariprazine 102 192 193 For more moderate symptoms, consideration is given to first using lamotrigine and lithium. Guidelines remain cautious about the use of antidepressants (selective serotonin reuptake inhibitors, venlafaxine, or bupropion) in patients with BP-I, restricting them to second or third line treatments and always in the context of an anti-manic agent. However, for patients with BP-II and no rapid cycling, several guidelines allow for the use of carefully monitored antidepressant monotherapy.

Bipolar disorder is a highly recognizable syndrome with many effective treatment options, including the longstanding gold standard therapy lithium. However, a significant proportion of patients do not respond well to current treatments, leading to negative consequences, poor quality of life, and potentially shortened lifespan. Several novel treatments are being developed but limited knowledge of the biology of bipolar disorder remains a major challenge for novel drug discovery. Hope remains that the insights of genetics, neuroimaging, and other investigative modalities could soon be able to inform the development of rational treatments aimed to mitigate the underlying pathophysiology associated with bipolar disorder. At the same time, however, efforts are needed to bridge the implementation gap and provide truly innovative and integrative care for patients with bipolar disorder. 195 Owing to the complexity of bipolar disorder, few patients can be said to be receiving optimized care across the various domains of mental health that are affected in those with bipolar disorder. Fortunately, the need for improvement is now well documented, 196 and concerted efforts at the scale necessary to be truly innovative and integrative are now on the horizon.

Questions for future research

Among adolescents and young adults who manifest common mental disorders such as anxiety or depressive or attentional disorders, who will be at high risk for developing bipolar disorder?

Can we predict the outcomes for patients following a first manic or hypomanic episode? This will help to inform who will require lifelong treatment and who can be tapered off medications after sustained recovery.

Are there reliable clinical features and biomarkers that can sufficiently predict response to specific medications or classes of medication?

What are the long term consequences of lifelong treatments with the major classes of medications used in bipolar disorder? Can we predict and prevent medical morbidity caused by medications?

Can we understand in a mechanistic manner the pathophysiological processes that lead to abnormal mood states in bipolar disorder?

Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

Contributors: FSG performed the planning, conduct, and reporting of the work described in the article. FSG accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Competing interests: I have read and understood the BMJ policy on declaration of interests and declare no conflicts of interest.

Patient involvement: FSG discussed of the manuscript, its main points, and potential missing points with three patients in his practice who have lived with longstanding bipolar disorder. These additional viewpoints were incorporated during the drafting of the manuscript.

Provenance and peer review: Commissioned; externally peer reviewed.

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Bipolar Disorder

Yes, i'm studying to be a social worker. yes, i have a mental illness..

I have a mental illness and I am studying to be a social worker.

Two distinct memories stand out as I write this: the day I was accepted into a prestigious school of social work — and the day I was diagnosed with bipolar 1  disorder. Now that I am half-way through my social work degree, I can see how those two pivotal moments in my life have collided to give me purpose and motivation to keep fighting — for my own wellness and for those who still feel silenced or marginalized.

• What is Bipolar disorder ?

It started off as a nuisance. It was March of 2017, and one night I couldn’t sleep. I didn’t think much of it, chalking it up to stress. Then I didn’t sleep the next night, or the night after that . By day three, I refused to go inside because of the paranoia I was experiencing, despite it being -20 degrees Celsius outside. I developed frostbite on my toes. I wandered around the vast city I lived in without sleep or food, talking nonsensically and rapidly to anyone who would listen. I vividly remember the fourth night of being awake. It was St. Patrick’s Day and I was sprawled outside Wendy’s with nothing but spilled, cold coffee to my name. I decided I should probably see a doctor. After a rapid assessment of my presentation, my doctor sent me to the ER for an assessment by a psychiatrist, who explained I was experiencing a manic episode requiring hospitalization, proceeding to diagnose me with bipolar 1 disorder. After resting my brain for a month in the hospital, I was placed on medication that leveled out my highs and lows to allow me to lead a fulfilling life with minimal symptoms. On my discharge date, I walked out of that hospital with new hope, a fresh perspective, a calm mind and the tools to manage my illness. I have never returned.

I then decided I wanted to be a social worker so I could be a light in someone’s darkness, mirroring the people who had been a light in my own distress. Three personal essays, two references, a resume and a list of volunteer and work experiences later, my application was mailed off — on the exact deadline to apply.

When a letter arrived in the mail, I assumed the worst. I didn’t even want to open it. When I did, the only word I saw was, “Congratulations!” before I started crying. I thought, how could someone like me, mentally ill with bipolar disorder , be accepted into such a rigorous program? I questioned whether I was deserving to have that seat or not. Surely, there were other people more qualified, right?

I am writing this exactly two years after receiving that piece of paper accepting me into their program. I was chosen for this profession, not because of my illness, but because my illness is not  correlated with my ability to be a good social worker. I am just as deserving to be in this program as any of my other hardworking classmates. I will soon be working in the field, dedicating my professional life to helping others.

If you have a mental illness and want to work in the helping field, please believe me when I say the following:

1. Despite the rampant stigma that somehow being mentally ill exempts you from being a health care provider, that is not true. I am proof that is not true. One of my favorite quotes is: “I love when people who have been through hell walk out of the flames carrying buckets of water for those still consumed by the fire.” Recovering from bipolar disorder felt like hell, yet those experiences have prepped me to be a caring, considerate social worker carrying those buckets of water for people behind me still in the fire. You cannot learn empathy from a book, but I certainly learned it through my experiences with bipolar . I am not grateful for this illness, but I am grateful for the lessons it has taught me.

2.  Living with a mental illness does not make you incompetent. It may even give you a leg up because you can understand, deeply, what it means to struggle. You can relate to clients/patients/customers in a way that will make them trust you, talk to you and have confidence in you.

3.  View your illness as a strength, not a weakness. Remember, it’s not a character flaw.

4.  If you have bipolar or any other mental illness , that is out of your control and not your fault. You can control making the choice to live your life passionately despite of, and because of, your illness.

Yes, I have bipolar disorder .

Yes, I was admitted to a psychiatric facility when I was sick. Yes, I take medication every day to regulate my mood. Yes, I see a psychiatrist.

Yes, I made the Dean’s list. Yes, I have been appointed to the School’s student committee. Yes, I volunteer with non-profits, work with people with disabilities and sit on a board of directors.

I will not be just a social worker. I will be an understanding, empathetic, passionate, mentally ill social worker.

And that is more than OK.

Whatever your dream is, never let the fear of accomplishing it with a mental illness hold you back. Your illness is part of you — take it with you, but do not let it dictate where you go.

We want to hear your story.

Do you want to share your story? Click here to find out how.

Getty image via pogorelova

POTS / living my best life / advocate

Evidence-Based Psychotherapies for Bipolar Disorder

Information & authors, metrics & citations, view options, clinical context, rationale for adjunctive psychotherapy in bipolar disorder, treatment strategies and evidence, psychoeducation.

Peer Support

Questions and controversy, recommendations, unmet needs and future directions, information, published in.

• Mood Disorders-Bipolar
• Psychotherapy
• cognitive-behavioral therapy
• interpersonal and social rhythm therapy
• psychoeducation

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Diagnosing and treating bipolar spectrum disorders

Patients with bipolar disorder cycle between two or more mood states, such as mania, hypomania, or depression

Vol. 53 No. 1 Print version: page 36

• Bipolar Disorder

CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

• Discuss how psychologists’ understanding of bipolar disorder has changed over the past 3 decades.
• Describe mood states, symptoms, and diagnostic criteria for the four bipolar spectrum disorders.
• List front-line pharmacological and psychological treatments for bipolar disorder.

For more information on earning CE credit for this article, go to CE Corner .

In the 1990s, bipolar disorder was seen as a severe, rare, incurable condition found only in adults. Medication, primarily lithium, was the sole treatment offered to most patients. Today, experts are learning that the disorder is more common—affecting about 4% of U.S. children and adults—and presents along a diverse continuum. More than half of patients have their first mood symptoms in childhood or adolescence, a full range of treatments exist, and people with the condition can survive and thrive (Moreira, A. L., et al., The Journal of Clinical Psychiatry , Vol. 78, No. 9, 2017; Van Meter, A., et al., The Journal of Clinical Psychiatry , Vol. 80, No. 3, 2019).

“The more we study bipolar disorder, the more we appreciate its complexity, especially around the onset of symptoms and in the underserved,” said Manpreet K. Singh, MD, an associate professor of psychiatry and behavioral sciences at Stanford University. “There isn’t going to be a single genetic marker, research tool, or treatment plan that resolves this complexity.”

Psychologists and psychiatrists studying bipolar disorder are characterizing complexities of the condition, including its earliest symptoms, longitudinal course, and the psychological factors that increase risk of recurrences. They are also applying new approaches (such as studying vascular contributions to the condition) and technologies (including using wearable devices) to obtain rich new data.

All of this is driving two major shifts that are already proving life-changing for patients: earlier and more accurate diagnosis and increasingly personalized treatments.

“For a long time, there has been so much stigma, so much confusion, and so much uncertainty about this illness,” said Eric A. Youngstrom, PhD, a professor of psychology, neuroscience, and psychiatry at the University of North Carolina at Chapel Hill who studies bipolar disorder. “We now have a revolutionary new view for diagnosing and treating bipolar disorder that I’m positive can make a difference in people’s lives.”

Complex diagnosis

Bipolar disorder is an episodic condition in which patients cycle between two or more mood states. Diagnosis is typically a two-step process: Clinicians first diagnose mood episodes—such as mania, hypomania, or depression—and then they diagnose the disorder itself.

Mania is a distinct period of an elevated or irritable mood, along with persistent goal-directed behavior or energy, that lasts at least 1 week and potentially up to a few months and causes marked impairment, according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Common symptoms include grandiosity, a decreased need for sleep, and excessive risky activity. A hypomanic episode is less severe: It lasts at least 4 days but does not cause marked impairment.

A depressive episode—which includes symptoms such as loss of interest, weight loss or gain, and thoughts of suicide—lasts 2 or more weeks and causes both impairment and distress. Mixed states, which are some of the hardest to treat, consist of phases with both manic and depressive symptoms. People with mixed states often have extreme irritability, volatility, and a high risk for suicide.

Euthymia, defined as mood functioning within normal limits, is crucial in diagnosing bipolar disorder because it helps clinicians find the beginning of a mood episode such as mania or hypomania. A patient who rapidly cycles between manic and depressive symptoms without a clear euthymia, for example, may be experiencing anxiety or attention-deficit/hyperactivity disorder (ADHD) rather than a mood disorder.

The DSM-5 lists four major categories of bipolar spectrum disorders, as well as versions of the illness induced by substances and other medical conditions, such as stroke or traumatic brain injury.

Bipolar I disorder is characterized by manic or mixed episodes, with or without depression, while bipolar II disorder involves episodes of hypomania and depression. Cyclothymic disorder involves depressive and hypomanic symptoms that cause impairment but do not meet the severity or duration criteria for bipolar I or II. The clinical picture of these disorders, including symptoms, prognosis, and comorbidities, typically looks similar in children and adults.

A fourth category, known as “other specified bipolar and related disorder,” describes patients with episodic mood symptoms who do not meet the criteria for the other three disorders—for example, a patient with recurrent manic symptoms that cause impairment but last less than 1 week. This disorder is more common than bipolar I or II, especially in children and adolescents, and carries a similar risk for co-occurring psychiatric conditions, suicide attempts, and family history of bipolar disorder. Research also suggests that in patients with a family history of the illness, about half go on to develop bipolar I or II (Axelson, D. A., et al., Journal of the American Academy of Child & Adolescent Psychiatry , Vol. 50, No. 10, 2011).

Experts argue that this points to the importance of providing support early on, even if it is not yet clear whether a patient will develop more severe mood symptoms (Singh, M. K., et al., Bipolar Disorders , Vol. 22, No. 7, 2020).

“The field needs to move toward something similar to what we see in heart disease, where we don’t wait for the full manifestation of the illness before acting,” said Benjamin Goldstein, MD, PhD, a professor of psychiatry and pharmacology at the University of Toronto and director of the Centre for Addiction and Mental Health’s Centre for Youth Bipolar Disorder in Toronto.

Earlier identification

Unfortunately, psychology and psychiatry have a poor record when it comes to the timely and accurate diagnosis of bipolar disorder, with a high rate of missed diagnoses and an average lag time of 5 or more years between the onset of mood symptoms and a diagnosis of bipolar disorder (Jensen-Doss, A., et al., Journal of Consulting and Clinical Psychology , Vol. 82, No. 6, 2014; Marchand, W. R., et al., Journal of Psychiatric Practice , Vol. 12, No. 2, 2006).

Part of the problem is that with their diverse range of states and symptoms, bipolar spectrum disorders can look like major depression, anxiety, psychosis, substance use disorders, autism spectrum disorders, ADHD, personality disorders, or conduct disorders.

Consider two patients who visited a mental health clinic. Tamika, an 11-year-old girl, came in with her mother, who reported that her daughter had sudden increases in anger, aggression, and trouble sleeping. At home, Tamika threw toys and broke dishes; at school, she was loud and disruptive. Lea, an 18-year-old in her senior year of high school, came in by herself, reporting problems with attention and anxiety about graduation and going to college. She thought she had ADHD. Could either of these patients have bipolar disorder?

To simplify the process of assessment and cut down on diagnostic errors when patients like Tamika or Lea come into a clinic, Youngstrom and his colleagues advocate that clinicians use a probability-based approach to diagnosis—akin to counting cards in blackjack—and they have created and tested a freely available model for doing so.

Youngstrom’s evidence-based assessment (EBA) model relies on an algorithm that makes risk calculations using the clinical evidence base. For example, compared with someone with no family history of mood disorders, a person’s chance of having bipolar disorder is 5 times higher if a parent or sibling has it, but only 2.5 times higher if a grandparent, aunt, or uncle does. The EBA model walks clinicians through a step-by-step evaluation that includes benchmark rates of various disorders, recommendations for high-quality clinical questionnaires, and reminders to ask about mitigating factors such as substance use, trauma, and bereavement ( Cognitive and Behavioral Practice , Vol. 22, No. 1, 2015). Unlike machine-learning approaches, the EBA method keeps the clinician in the driver’s seat, choosing whether to obtain more information and when and how to begin treatment.

Using the EBA model, a clinician diagnosed Lea with bipolar II disorder. By looking at screening questionnaires, gathering family history, and asking focused questions during the clinical interview, her provider found evidence that built the case for bipolar. Lea often slept less than usual yet had more energy. During such periods, she was more likely to fight with her mother and friends. And her father, who no longer lived at home, had bipolar disorder. Tamika, on the other hand, did not meet the criteria for any bipolar spectrum disorder. Instead, her clinical interview uncovered a recent sexual assault, leading to a diagnosis of post-traumatic stress disorder.

In some cases, a clinician may not reach 100% certainty that a patient has bipolar disorder, but early psychosocial and lifestyle interventions can improve long-term prospects, Goldstein said, especially in youth. “The more we can support young brains in developing healthy executive functioning, the better youth will be able to manage the illness if it strikes them,” he said.

Family-focused therapy (FFT), an intervention that teaches patients and family members about bipolar disorder and helps them communicate and solve problems related to mood episodes, can reduce depression and suicidal ideation in youth at risk for bipolar disorder (Miklowitz, D. J., et al., JAMA Psychiatry , Vol. 77, No. 5, 2020).

“When kids are showing early warning signs of bipolar disorder, the stress faced by families can be overwhelming, but how parents deal with these early signs can make a huge difference in kids’ outcomes,” said psychologist David Miklowitz, PhD, a professor of psychiatry at the University of California, Los Angeles.

Long-term treatment

Front-line treatment for most patients with bipolar disorder typically still includes medication, but there is also a growing recognition among many clinicians that drugs alone are not sufficient.

“We’re now realizing we can’t just treat everyone with medications,” said Miklowitz. “Psychoeducational treatment is very important in helping people learn how to cope with the disorder.”

Before starting psychotherapy, most patients who seek help during an acute episode of mania or depression receive an antipsychotic drug or mood stabilizer. Lithium is still considered the gold standard for both youth and adults, but it tends to work best for patients with bipolar I and a family history of the disorder (Grof, P., Neuropsychobiology , Vol. 62, No. 1, 2010). Long-term use of lithium, however, can lead to chronic kidney or thyroid problems, so providers and patients should carefully monitor side effects and seek the support of a physician when necessary (Forlenza, O. V., et al., The British Journal of Psychiatry , Vol. 215, No. 5, 2019).

Another issue is that patients may stop taking lithium once they feel stable, which puts them at high risk for additional mood episodes, hospitalization, and suicide (Prajapati, A. R., et al., Psychological Medicine , Vol. 51, No. 7, 2021). For that reason, experts say it is particularly important to combine medications with psychotherapy.

Increasingly, psychopharmacology research is offering alternatives, such as the new antipsychotic drug lurasidone (Pikalov, A., et al., International Journal of Bipolar Disorders , Vol. 5, No. 9, 2017) and the anesthetic ketamine, which has been proven effective for treatment-resistant depression (Kryst, J., et al., Pharmacological Reports , Vol. 72, 2020). Rapid transcranial magnetic stimulation, which involves electrical activation of the frontal cortex, is also showing promise for depression and may help patients with bipolar disorder, Miklowitz said, but more research is needed (Nguyen, T. D., et al., Journal of Affective Disorders , Vol. 279, 2021).

“Many people who live with bipolar disorder spend more days depressed than they do manic,” said Singh. “Researchers are now putting some muscle and grease into understanding how we treat bipolar depression over the long term.”

Once a patient is stable, psychotherapy can help them learn to navigate life with bipolar disorder. FFT, which Miklowitz developed, educates patients and their families about the disorder, including how to recognize early warning signs of a mood episode, such as altered sleep patterns. Typically delivered after a person’s first or second mood episode and lasting up to 9 months, FFT helps families create a relapse prevention plan and learn how to communicate effectively ( Family Process , Vol. 55, No. 3, 2016).

“With this disorder, psychotherapy is typically time-limited,” Miklowitz said. “Research has shown that 3-, 6-, or 9-month treatments focused on education and skill-building are effective in preventing recurrences and improving overall functioning.”

Psychosocial interventions such as FFT can be modified to help patients manage the symptoms of bipolar disorder across the life span. In adults, the sessions often include a spouse and cover additional concerns, such as physical intimacy. For older adults, sessions may include an adult child who is a caretaker. Clinicians may also incorporate neuropsychological testing to determine whether a patient is also experiencing dementia.

Interpersonal and social rhythm therapy (IPSRT), developed by psychologist Ellen Frank, PhD, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine, and her colleagues, also delivers psychoeducation and helps patients regulate their daily routines, including work, social interactions, and sleep-wake cycles. IPSRT has been shown to reduce manic and depressive symptoms and to improve overall functioning in people with bipolar spectrum disorders (Steardo, L., et al., Annals of General Psychiatry , Vol. 19, No. 15, 2020). Cognitive behavioral therapy, dialectical behavior therapy, and group therapy—which offers the added benefit of peer support—are similarly effective (Novick, D. M., & Swartz, H. A., Focus , Vol. 17, No. 3, 2019; Goldstein, T. R., et al., Journal of Child and Adolescent Psychopharmacology , Vol. 25, No. 2, 2015).

IPSRT works partly by stabilizing mood through establishing regular sleep-wake cycles. Another inexpensive, low-risk way to regulate sleep is with blue light-blocking glasses, which help trigger melatonin production. Indeed, early evidence indicates that wearing blue light–blocking glasses before bedtime can help stabilize manic symptoms (Hester, L., et al., Chronobiology International , Vol. 38, No. 10, 2021).

Growing evidence also supports lifestyle changes in nutrition and physical activity. Eating and exercising in accordance with U.S. Department of Health and Human Services guidelines can improve emotional well-being, Goldstein said, and it can also boost cardiovascular health, which is implicated in bipolar disorder. Research by Goldstein and others shows that chronic inflammation harms brain health and may predict worse treatment outcomes in bipolar disorder ( Bipolar Disorders , Vol. 22, No. 5, 2020).

For older patients, cognitive rehabilitation therapies, which are currently still in early trials, may become increasingly important, Miklowitz said. Research suggests that memory and other cognitive functions can deteriorate over time with successive mood episodes, and such therapies may help patients regain functioning (Solé, B., et al., International Journal of Neuropsychopharmacology , Vol. 20, No. 8, 2017).

To fully support patients with bipolar disorder, a coordinated effort between psychologists, who excel at developing and delivering psychosocial interventions, and psychiatrists, who have a sophisticated understanding of how medications can help, is crucial—and can even ameliorate depressive symptoms (Van der Voort, T. Y. G., et al., The British Journal of Psychiatry , Vol. 206, No. 5, 2018).

“It takes a village to treat bipolar disorder,” said Singh. “When patients, caregivers, psychiatrists, and allied mental health professionals work collaboratively, outcomes may be better than treatment by either a psychologist or psychiatrist alone.”

Opportunities for research

Even with these major strides in diagnosing and treating bipolar disorder, challenges remain. For one, interventions for bipolar depression are still less effective than those used for unipolar depression, and clinicians urgently need better options for their patients, said Goldstein. Some mood episodes, such as mixed states, and certain symptoms, such as irritability, attention problems, and anhedonia—or lack of motivation—also remain tough to treat, said Singh, and may ultimately require a multipronged approach. “Our patients are hungry for it. Usually, it’s those symptoms that linger that bring them to see us,” she said.

More attention is also needed to the longitudinal course of the illness, researchers say, which can continue to help delineate tailored treatment options. Clinicians hope to increasingly make personalized recommendations for medication and psychotherapy based on a patient’s symptom presentation, genetic risk, family history, recent environmental stressors, lifestyle factors, and more. For example, providers may soon be able to better predict which patients will do well with a 6-month course of psychotherapy and which will require regular check-ins with a provider.

Researchers are also further exploring how wearable devices and smartphone apps can help patients track and manage mood symptoms. Miklowitz is testing a version of FFT that includes app-based mood tracking and communication skill-building tasks in an effort to improve patient engagement and outcomes ( Journal of Affective Disorders , Vol. 281, 2021).

While research continues to home in on effective treatments, Youngstrom has directed his focus toward improving early recognition. That work involves comparing different questionnaires and rating scales, making them as short and convenient as possible without compromising accuracy, and improving accessibility for a variety of mental health providers and even patients.

“We’re reaching a point where we can deliver shortcuts that allow clinicians to work faster, be more accurate, and deliver better outcomes for their patients,” he said. “The science really does make this possible.”

Diagnosing bipolar disorders

Mood episodes.

• Elevated or irritable mood and persistent goal-directed behavior or energy
• Lasts at least 1 week
• Causes marked impairment
• Lasts at least 4 days
• Does not cause marked impairment
• Depressed mood or loss of interest in life
• Lasts at least 2 weeks
• Causes impairment and distress
• Episode includes both manic and depressive symptoms
• “Mixed mania” lasts at least 1 week or triggers hospitalization
• “Mixed hypomania” lasts at least 4 days with both depressed and hypomanic symptoms
• “Mixed depression” lasts at least 2 weeks with additional manic symptoms

Bipolar disorders

• Manic or mixed-manic episodes required for diagnosis
• Can diagnose with or without depressive episodes
• No history of manic or mixed episodes
• Diagnosis requires combination of hypomania and depression

Cyclothymia

• Combination of depresive and hypomanic episodes, but patients do not meet criteria for bipolar II

Other specified bipolar and related disorder

• Manic symptoms that do not fit into the other diagnostic categories
• Common diagnosis for children and adolescents

Further reading

Evidence-based assessment Youngstrom, E. A., et al., Wikiversity, 2021

Expanding bipolar outreach during college Singh, M. K., et al., Journal of Affective Disorders , 2021

The bipolar disorder survival guide (3rd ed.) Miklowitz, D. J., Guilford Press, 2019

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Recommended Reading

• New research reveals that bipolar spectrum disorders are more prevalent, treatable, and complex than experts once thought.
• More than half of patients have their first mood symptoms in childhood or adolescence, and accurate assessment is crucial for early intervention.
• Front-line treatment typically involves a combination of medication and psychotherapy.

Contact APA

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• Open access
• Published: 07 July 2015

Psychosocial treatment and interventions for bipolar disorder: a systematic review

• Stella Miziou 1 ,
• Eirini Tsitsipa 1 ,
• Stefania Moysidou 1 ,
• Vangelis Karavelas 2 ,
• Dimos Dimelis 2 ,
• Vagia Polyzoidou 3 &
• Konstantinos N Fountoulakis 2  

Annals of General Psychiatry volume  14 , Article number:  19 ( 2015 ) Cite this article

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Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Several psychotherapeutic techniques have tried to fill this gap, but which intervention is suitable for each patient remains unknown and it depends on the phase of the illness.

The papers were located with searches in PubMed/MEDLINE through May 1st 2015 with a combination of key words. The review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

The search returned 7,332 papers; after the deletion of duplicates, 6,124 remained and eventually 78 were included for the analysis. The literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and only in a selected subgroup of patients at an early stage of the disease who have very good, if not complete remission, of the acute episode. Cognitive-behavioural therapy and interpersonal and social rhythms therapy could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes.

The current review suggests that the literature supports the usefulness only of specific psychosocial interventions targeting specific aspects of BD in selected subgroups of patients.

Our contemporary understanding of bipolar disorder (BD) suggests that there is an unfavorable outcome in a significant proportion of patients [ 1 , 2 ]. In spite of recent advances in pharmacological treatment, many BD patients will eventually develop chronicity with significant general disability and burden. The burden will be significant also for their families and the society as a whole [ 3 , 4 ]. Today, we also know that unfortunately, symptomatic remission is not identical and does not imply functional recovery [ 5 – 7 ].

Since pharmacological treatment often fails to address all the patients’ needs, there is a growing need for the development and implementation of effective and affordable interventions, tailored to the individual patient [ 8 ]. The early successful treatment, with full recovery if possible, as well as the management of subsyndromal symptoms and of psychosocial stress and poor adherence are factors predicting earlier relapse and poor overall outcome [ 9 , 10 ].

In this frame, there are several specific adjunctive psychotherapies which have been developed with the aim of filling the above gaps and eventually improve the illness outcome [ 11 ], but it is still unclear whether they truly work and which patients are eligible and when [ 12 – 19 ].

The current study is a systematic review of the efficacy of available psychosocial interventions for the treatment of adult patients with BD.

Reports investigating psychotherapy and psychosocial interventions in BD patient samples were located with searches in Pubmed/MEDLINE through May 1, 2015. Only reports in English language were included.

The Pubmed database was searched using the search terms ‘bipolar’ and ‘psychotherapy’ or ‘cognitive-behavioral’ or ‘CBT’ or ‘psychoeducation’ or ‘interpersonal and social rhythm therapy’ or ‘IPSRT’ or ‘family intervention’ or ‘family therapy’ or ‘group therapy’ or ‘intensive psychosocial intervention’ or ‘cognitive remediation’ or ‘functional remediation’ or ‘Mindfulness’.

The following rules were applied for the selection of papers:

Papers in English language.

Randomized controlled trials.

This review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) statement [ 20 ].

The search returned 7,332 papers, and after the deletion of duplicates 6,124 remained for further assessment. After assessing these papers on the basis of title and abstract, the remaining papers were (Figure  1 ). The number of paper reported for each intervention includes RCTs, post hoc analyses and meta-analyses together.

The PRISMA flowchart.

Cognitive-behavioural therapy (CBT)

The efficacy of CBT in BD was investigated in 14 studies which utilized CBT as adjunct treatment to pharmacotherapy or treatment as usual (TAU). They utilized some kind of control intervention which should not be considered as an adequate placebo. It is also interesting that the oldest study was conducted in 2003.

This first study lasted 12 months and concerned 103 BD-I patients during the acute depressive phase and randomized them to 14 sessions of CBT or a control intervention. There was not any placebo condition. These authors reported that at end point fewer patients in the CBT group relapsed in comparison to controls (44 vs. 75%; HR = 0.40, P  = 0.004), had shorter episode duration, less admissions and mood symptoms, and higher social functioning [ 21 ]. It was disappointing that the extension of this study (18 months follow-up) was negative concerning the relapse rate [ 22 ].

A second trial included 52 BD patients and was also negative concerning the long-term efficacy after comparing CBT plus additional emotive techniques vs. TAU [ 23 ]. On the other hand, the comparison of CBT plus psychoeducation vs. TAU in 40 BD patients reported a beneficial effect even after 5 years in terms of symptoms and social–occupational functioning. However, that study did not report the rate of recurrences and the time to recurrence [ 24 ]. A study in 79 BD patients (52 BD-I and 27 BD-II) compared CBT plus psychoeducation vs. psychoeducation alone and reported that the combined treatment group had 50% fewer depressed days per month, while at the same time the psychoeducation alone group had more antidepressant use [ 25 ]. Another study on 41 BD patients randomized to CBT vs. TAU reported similar results and an improvement in symptoms, frequency and duration of episodes [ 26 ].

An 18-month study compared CBT vs. TAU in 253 BD patients and reported that at end point, there were no differences between groups with more than half of the patients having a recurrence. It is interesting that a post hoc analysis suggested that CBT was significantly more effective than TAU in those patients with fewer than 12 previous episodes, but less effective in those with more episodes [ 13 ]. Similar negative results were reported concerning the number of episodes and time to relapse by another 12-month study of CBT vs. TAU in 50 BD patients in remission [ 17 ]. Again, negative findings concerning the relapse rate were reported by a 2-year study on 76 BD patients randomized to receive 20 sessions of CBT vs. support therapy [ 15 ]. Finally, the use of combined CBT and pharmacotherapy in 40 patients with refractory bipolar disorder suggested that the combination group had less hospitalization events in comparison to the group in the 12-month evaluation ( P  = 0.015) and lower depression and anxiety in the 6-month ( P  = 0.006; P  = 0.019), 12-month ( P  = 0.001; P  < 0.001) and 5-year ( P  < 0.001, P  < 0.001) evaluation time points. However it is interesting that after the 5-year follow-up, 88.9% of patients in the control group and 20% of patients in the combination group showed persistent affective symptoms and difficulties in social–occupational functioning [ 27 ].

The use of CBT in BD comorbid with social anxiety disorder is of doubtful efficacy [ 28 ], while there are some preliminary data on the efficacy of an Internet-based CBT intervention [ 29 ] as well as recovery-focused add-on CBT [ 30 ] and CBT for insomnia [ 31 ] in comparison to TAU.

The review of the available data so far give limited support for the usefulness of CBT during the acute phase of bipolar depression as adjunctive treatment in patients with BD, but definitely not for the maintenance phase. During the maintenance phase, booster sessions might be necessary, but the data are generally overall negative. Probably, patients at earlier stages of the illness might benefit more from CBT. Unfortunately the type of patients who are more likely to benefit from CBT constitutes a minority in usual clinical practice.

Psychoeducation

The basic concept behind psychoeducation for BD concerns the training of patients regarding the overall awareness of the disorder, treatment adherence, avoiding of substance abuse and early detection of new episodes. The efficacy of psychoeducation in BD was investigated in 30 studies, all of which utilized psychoeducation as adjunct treatment to pharmacotherapy or TAU. All these studies utilize some kind of control intervention which should not be considered as an adequate placebo. It is also interesting that the oldest study was conducted in 1991.

The earliest psychoeducational study was open and uncontrolled and reported that giving information about lithium improved the overall attitude towards treatment [ 32 , 33 ]. A similar small study was conducted a few years later and reported similar results [ 34 ]. However, the first study on the wide teaching of patients to recognize and identify the components of their disease with emphasis on early symptoms of relapse and recurrence and to seek professional help as early as possible had not been conducted until 1999. It included 69 patients for 18 months and compared psychoeducation (limited number of sessions; 7–12) vs. TAU. It reported a significant prolongation of the time to first manic relapse ( P  = 0.008) and significant reductions in the number of manic relapses over 18 months (30 vs. 52%; P  = 0.013) as well as improved overall social functioning. Psychoeducation had no effect on depressive relapses [ 35 ].

In a more systematic way, the efficacy of the adjunctive group psychoeducation was tested by the Barcelona group. Their trial included 120 euthymic BD patients who were randomly assigned to 21 sessions of group psychoeducation vs. non-specific group meetings. The study included a follow-up with a duration of 2 and 5 years. The results suggested that psychoeducation exerted a beneficial effect on the rate of and the time to recurrence as well as concerning hospitalizations per patient. At the end of the 2-year follow-up, 23 subjects (92%) in the control group fulfilled the criteria for recurrence versus 15 patients (60%) in the psychoeducation group ( P  < 0.01). This beneficial effect was high and was not reduced after 5 years (any episode 0.79 vs. 0.87; mania 0.40 vs. 0.57; hypomania 0.27 vs. 0.42 and mixed episodes 0.34 vs. 0.61), except for depressive episodes (0.91 vs. 0.80) [ 36 – 38 ].

The literature suggests that psychoeducation should be broad and that enhanced relapse prevention alone does not seem to work. This was the conclusion from another study with a different design. That study reported that only occupational functioning, but not time to recurrence, improved with an intervention consisting of training community mental health teams to deliver enhanced relapse prevention [ 39 ]. Additionally, a study with a 12-month follow-up and with a similar design to the first study of the Barcelona group, but with 16 sessions, reported no differences between groups in mood symptoms, psychosocial functioning and quality of life. It did find, however, that there was a difference in the subjectively perceived overall clinical improvement by subjects who received psychoeducation. The authors suggested that characteristics of the sample could explain this discrepancy, as patients with a more advanced stage of disease might have a worse response to psychoeducation [ 16 ]. In accordance with the above, a post hoc analysis of the original Barcelona data revealed that patients with more than seven episodes did not show significant improvement with group psychoeducation in time to recurrence, and those with more than 14 episodes did not benefit from the treatment in terms of time spent ill [ 40 ]. A 2-year follow-up in 108 BD patients investigated psychoeducation plus pharmacotherapy vs. pharmacotherapy alone. Psychoeducation concerned eight, 50-min sessions of psychological education, followed by monthly telephone follow-up care and psychological support. The results suggested that psychoeducation improved medication compliance ( P  = 0.008) and quality of life ( P  < 0.001) and had fewer hospitalizations ( P  < 0.001) [ 41 ]. Another study randomized 80 BD patients to either the psychoeducation or the control group and reported that the psychoeducation group scored significantly higher on functioning levels (emotional functioning, intellectual functioning, feelings of stigmatization, social withdrawal, household relations, relations with friends, participating in social activities, daily activities and recreational activities, taking initiative and self-sufficiency, and occupation) ( P  < 0.05) compared with the control group after psychoeducation [ 42 ].

A prospective 5-year follow-up of 120 BD patients suggested that group psychoeducation might be more cost-effective [ 43 ]. In support of the cost-effectiveness of psychoeducation was one trial in 204 BD patients which compared 20 sessions of CBT vs. 6 sessions of group psychoeducation and reported that overall the outcome was similar in the two groups in terms of reduction of symptoms and likelihood of relapse, but psychoeducation was associated with a decrease of costs ($180 per subject vs. $1,200 per subject for CBT) [ 44 ] Currently, there are some proposals of online psychoeducation programmes, but results are still inconclusive or pending [ 45 , 46 ].

More complex multimodal approaches and multicomponent care packages have been developed and usually psychoeducation is a core element. One of these packages also included CBT and elements of dialectical behaviour therapy and social rhythms and has shown a beneficial effect after the 1-year follow-up in comparison to TAU [ 47 ]. Another included a combination of CBT plus psychoeducation and reported that it was more effective in comparison to TAU in 40 refractory BD patients concerning hospitalization and residual symptoms at 12 months follow-up [ 27 ]. A collaborative care study on 138 patients and follow-up of 12 months also gave positive results [ 48 ]. One multicentred Italian study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to BD-I disorder. It included 137 recruited families, of which 70 were allocated to the experimental group and 67 to the TAU group. At the end of the intervention, significant improvements in patients’ social functioning and relatives’ burden were found in the treated group compared to TAU [ 49 ]. In general, the beneficial effect seems to be present concerning manic but not depressive episodes [ 50 , 51 ], while a benefit on social role function and quality of life seems also to be present [ 50 ].

The comparison of 12 sessions of psychoeducation vs. TAU in 71 BD patients reported that at 6 weeks, the intervention improved treatment adherence [ 52 ], while another on 61 BD-II patients reported no significant effect on the regulation of biological rhythms when compared to standard pharmacological treatment [ 53 ]. No significant effect was reported concerning the quality of life by another recent study on 61 young bipolar adults [ 54 ]. On the contrary, a trial on 47 BD patients reported that a psychoeducation programme designed for internalized stigmatization may have positive effects on the internalized stigmatization levels of patients with bipolar disorder [ 55 ].

There is preliminary evidence that a Web-based treatment approach in BD (‘Living with Bipolar’—LWB intervention) is feasible and potentially effective [ 56 ]; however, other Web-based attempts returned negative results [ 57 ]. Automated mobile-phone intervention is another option and it has been reported to be feasible, acceptable and might enhance the impact of brief psychoeducation on depressive symptoms in BD. However, sustainment of gains from symptom self-management mobile interventions, once stopped, may be limited [ 58 ].

One meta-analysis of 16 studies, 8 of which provided data on relapse reported that psychoeducation appeared to be effective in preventing any relapse (OR: 1.98–2.75; NNT: 5–7) and manic/hypomanic relapse (OR: 1.68–2.52; NNT: 6–8), but not depressive relapse. That meta-analysis reported that group, but not individually, delivered interventions were effective against both poles of relapse [ 59 ].

In summary, the literature suggests that interventions of 6-month group psychoeducation seem to exert a long-lasting prophylactic effect. However this is rather restricted to manic episodes and to patients at the earlier stages of the disease who have achieved remission before the intervention has started. Although the mechanism of action of psychoeducation remains unknown, it is highly likely that the beneficial effect is mediated by the enhancement of treatment adherence, the promoting of lifestyle regularity and healthy habits and the teaching of early detection of prodromal signs.

Interpersonal and social rhythm therapy (IPSRT)

Interpersonal and social rhythm therapy is based on the hypothesis that in vulnerable individuals, the experience of stressful life events and unstable or disrupted daily routines can lead to affective episodes via circadian rhythm instability [ 18 ]. In this frame, IPSRT includes the management of affective symptoms through improvement of adherence to medication and stabilizing social rhythms and the resolution of interpersonal problems. Four papers investigating its efficacy were identified.

The first study concerning its efficacy in BD included 175 acutely ill BD patients and followed them for 2 years. It included four treatment groups, reflecting IPSRT vs. intensive clinical management during the acute and the maintenance phase. The results revealed no difference between interventions in terms of time to remission and in the proportion of patients achieving remission (70 vs. 72%), although those patients who received IPSRT during the acute treatment phase survived longer without an episode and showed higher regularity of social rhythms [ 60 ]. In spite of some encouraging findings from post hoc analysis, there were eventually no significant differences between genders and concerning the improvement in occupational functioning [ 61 ]. More recently, a 12-week study in which unmedicated depressed BD-II patients were randomized to IPSRT ( N  = 14) vs. treatment with quetiapine (up to 300 mg/day; N  = 11), showed that both groups experienced significant reduction in symptoms over time, but there were no group-by-time interactions. Response and drop-out rates were similar [ 62 ]. Finally, one 78-week trial investigated the efficacy of IPSRT vs. specialist supportive care on depressive and mania outcomes and social functioning, and mania outcomes in 100 young BD patients. The results revealed no significant difference between therapies [ 63 ].

Overall, there are no convincing data on the usefulness of IPSRT during the maintenance phase of BD. There are, however, some data suggesting that if applied early and particularly already during the acute phase, it might prolong the time to relapse.

Family intervention

The standard family intervention for BD targets the whole family and not only the patient and includes elements of psychoeducation, communication enhancement and problem-solving skills training. It also includes support and self-care training for caregivers. Fifteen papers concerning the efficacy of family intervention in BD were found.

The first study on this intervention took part in 1991 and reported that carer-focused interventions improve the knowledge of the illness [ 64 ]. Since then, there have been a number of studies which in general support the use of adjunctive family-focused treatment. There are different designs and approaches which were tested in essentially open trials.

One intervention design consists of 21 1-h sessions which combine psychoeducation, communication skills training and problem-solving training. The sessions take place at home and included both the patient and his/her family during the post-episode period. The treatment has shown its efficacy vs. crisis management in 101 BD patients in reducing relapses (35 vs. 54%) and increasing time to relapse (53 vs. 73 weeks, respectively) [ 65 , 66 ]. It was also reported to reduce hospitalization risk compared with individual treatment (12 vs. 60%) [ 67 ]. It is important that the benefits extended to the 2-year follow-up were particularly useful for depressive symptoms, in families with high expressed emotion and for the improvement of medication adherence [ 66 ]. Similar results were reported by a study of 81 BD patients and 33 family dyads, which reported that the odds ratio for hospitalization at 1-year follow-up was related with high perceived criticism (by the patients from their relatives), poor adherence and with the relatives’ lack of knowledge concerning BD (OR: 3.3; 95% CI 1.3–8.6) [ 68 ].

Adjunctive psychoeducational marital intervention in acutely ill patients was reported to have a beneficial effect concerning medication adherence and global functioning, but not for symptoms [ 69 ]. Neither adjunctive family therapy nor adjunctive multifamily group therapy improves the recovery rate from acute bipolar episodes when compared with pharmacotherapy alone [ 14 ]. These interventions could be beneficial for patients from families with high levels of impairment and could result in a reduction of both the number of depressive episodes and the time spent in depression (Cohen d  = 0.7–1.0) [ 70 ]. In this frame, in those patients who recovered from the intake episode, multifamily group therapy was associated with the lowest hospitalization risk [ 71 ].

Another format included a 90-min duration, delivered to caregivers of euthymic BD patients; after 15-months, it was reported to have both reduced the risk of recurrence in comparison to a control group (42 vs. 66%; NNT: 4.1 with 95% CI 2.4–19.1) and also to have delayed recurrence [ 72 ]. It was particularly efficacious in the prevention of hypomanic/manic episodes and also in the reduction of the overall family burden [ 73 ]. It had been shown before that carer-focused interventions improve the knowledge of the illness [ 64 ], reduce burden [ 74 ] and also reduce the general and mental health risk of caregivers [ 75 ].

Another format of intervention included 12 sessions of group psychoeducation for the patients and their families. It has been f o und superior to TAU in 58 BD patients concerning the prevention of relapses, the decrease of manic symptoms and the improvement of medication adherence [ 76 ]. Finally, the comparison of family-based therapy (FBT) vs. brief psychoeducation (crisis management) in 108 patients with BD reported that the outcome depended on the existing levels of appropriate self-sacrifice [ 77 ].

Overall, the literature supports the conclusion that interventions which focus on families and caregivers exert a beneficial impact on family members, but the effect on the patients themselves is controversial. The effect includes issues ranging from subjective well-being to general health, but it is almost certain that there is a beneficial effect on issues like treatment adherence.

Intensive psychosocial intervention

There are three papers investigating various methods of intensive psychosocial intervention. ‘Intensive’ psychotherapy has been tested on 293 acutely depressive BD outpatients in a multi-site study. Patients were randomized to 3 sessions of psychoeducation vs. up to 30 sessions of intensive psychotherapy (family-focused therapy, IPSRT or CBT). The results suggested that the intensive psychotherapy group showed higher recovery rates, shorter times to recovery and greater likelihood of being clinically well in comparison to patients on short intervention [ 78 ]. The functional outcome was also reported to be better after 1 year [ 79 ]. A second trial randomized 138 BD patients to receive collaborative care (contracting, psychoeducation, problem-solving treatment, systematic relapse prevention and monitoring of outcomes) vs. TAU. The results suggested that collaborative care had a significant and clinically relevant effect on the number of months with depressive symptoms, as well as on severity of depressive symptoms, but there was no effect on symptoms of mania or on treatment adherence [ 48 ].

Cognitive remediation (CR) and functional remediation (FR)

Cognitive remediation and functional remediation tailored to the needs of BD patients include education on neurocognitive deficits, communication, autonomy and stress management. There are five papers on the efficacy of CR and FR.

One uncontrolled study in 15 BD patients applied a type of CR and focused on mood monitoring and residual depressive symptoms, organization, planning and time management, attention and memory. The results suggested that there was an improvement of residual depressive symptoms, executive functions and general functioning. Patients with greater neurocognitive impairment had less benefit from the intervention [ 80 ]. The combination of neurocognitive techniques with psychoeducation and problem solving within an ecological framework was tested in a multicentre trial in 239 euthymic BD patients with a moderate–severe degree of functional impairment ( N  = 77) vs. psychoeducation ( N  = 82) and vs. TAU ( N  = 80). At end point, the combined programme was superior to TAU, but not to psychoeducation alone [ 81 , 82 ]. Finally, a small study in 37 BD and schizoaffective patients tested social cognition and interaction training (SCIT) as adjunctive to TAU ( N  = 21) vs. TAU alone ( N  = 16). There was no difference between groups concerning social functioning, but there was a superiority of the combination group in the improvement of emotion perception, theory of mind, hostile attribution bias and depressive symptoms [ 83 ]. A post hoc analysis using data of 53 BD-II outpatients compared FR vs. psychoeducation and vs. TAU, but the results were negative [ 84 ].

Mindfulness-based interventions

Mindfulness-based intervention aims to enhance the ability to keep one’s attention on purpose in the present moment and non-judgmentally. Specifically for BD patients, it includes education about the illness and relapse-prevention, combination of cognitive therapy and training in mindfulness meditation to increase the awareness of the patterns of thoughts, feelings and bodily sensations and the development of a different way (non-judgementally) of relating to thoughts, feelings and bodily sensations. It also promotes the ability of the patients to choose the most skilful response to thoughts, feelings or situations. There are eight studies on the efficacy of mindfulness-based intervention in BD.

The first study concerning the application of mindfulness-based cognitive therapy (MBCT) in BD tested it vs. waiting list and included only eight patients in each group. The results suggested a beneficial effect with a reduction in anxiety and depressive symptoms [ 85 ]. A second study included 23 BD patients and 10 healthy controls and investigated MBCT vs. waiting list and the results were compared with those of 10 healthy controls. The results suggested that following MBCT, there were significant improvements in BD patients concerning mindfulness, anxiety and emotion regulation, working memory, spatial memory and verbal fluency compared to the waiting list group [ 86 ]. The biggest study so far concerning MBCT included 95 BD patients and tested MBCT as adjunctive to TAU ( N  = 48) vs. TAU alone ( N  = 47) and followed the patients for 12 months. The results showed no difference between treatment groups in terms of relapse and recurrent rates of any mood episodes. There was some beneficial effect of MBCT on anxiety symptoms [ 87 , 88 ]. Recently, the focus has expanded to analyze the impact of MBCT on brain activity and cognitive functioning in BD, but the findings are difficult to interpret [ 86 , 89 , 90 ].

A study which applied dialectical behaviour therapy in which mindfulness represented a large component also reported some positive outcomes [ 91 ]. One study on mindfulness training reported negative results in BD patients [ 92 ].

In conclusion, the literature does not support a beneficial effect of MBCT on the core issues of BD. There are some data suggesting a beneficial effect on anxiety in BD patients. So far, there are no data supporting its efficacy in the prevention of recurrences.

The current review suggests that the literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and unfortunately only in a selected subgroup of patients at an early stage of the disease who have very good if not complete remission of the acute episode. On the other hand, CBT and IPSRT could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes. A summary of the specific areas of efficacy for each of the above-mentioned interventions is shown in Table  1 .

An additional important conclusion is that concerning the quality of the data available: the studies on BD patients suffer from the same limitations and methodological problems as all psychotherapy trials do. It is well known that this kind of studies suffers from problems pertaining to blindness and the nature of the control intervention. Additionally, the training of the therapist and the setting itself might play an important role. It is quite different to apply the same intervention in specialized centres than in real-world settings in everyday clinical practice. Even worse, research is not done in a standardized way and the gathering of data is far from systematic. The studies are rarely registered, adverse events are not routinely assessed, outcomes are not hierarchically stated a priori and too many post hoc analyses have been published without being stated as such. There is a lack of replication of the same treatment by different research groups under the same conditions.

There are different theories on the mechanisms responsible for the efficacy of the psychosocial treatments. One suggestion concerns the enhancement of treatment adherence [ 93 ], while another proposes that improving lifestyle and especially biological rhythms, food intake and social zeitgebers could be the key factors [ 60 ]. Also, it has been proposed that the mechanism concerns the changing of dysfunctional attitudes [ 23 ], the improvement of family interactions [ 94 ] or the enhanced ability for the early identification of signs of relapse [ 35 ].

Overall, it seems that psychosocial interventions are more efficacious when applied on patients who are at an early stage of the disease and who were euthymic when recruited [ 14 , 95 ]. According to these post hoc analyses, a higher number of previous episodes [ 13 , 40 ] as well as a higher psychiatric morbidity and more severe functional impairment [ 96 ] might reduce treatment response, although the data are not conclusive [ 97 ]. Also, a differential effect has been proposed with neuroprotective strategies being better during the early stages [ 98 ] and rehabilitative interventions being preferable at later stages [ 99 ].

It is unclear whether IPSRT and CBT are efficacious during the acute episodes, but there are some data in support [ 13 , 60 , 78 ]. Maybe specific family environment characteristics might influence the response to treatment [ 70 , 100 ]. Probably, there were subpopulations who especially benefited from these treatments [ 13 , 70 ], but these assumptions are based on post hoc analyses alone.

It should be mentioned that most of the research concerns pure and classic BD-I patients, although there are some rare data concerning special populations such as BD-II [ 36 , 62 ], schizoaffective disorder [ 101 , 102 ], patients with high suicide risk [ 85 , 103 , 104 ] and patients with comorbid substance abuse [ 105 , 106 ].

It is interesting to note that the literature suggests that the benefits of psychosocial interventions if achieved could last for up to 5 years [ 36 , 107 ], although some patients might need booster sessions [ 23 , 108 ]. The complete range of the effect these interventions have is still uncharted. Although it is reasonable to expect a beneficial effect in a number of problems, including suicidality, research data on these issues are virtually non-existent [ 103 , 104 ].

Conclusions

In conclusion, the literature supports the notion that adjunctive specific psychological treatments can improve specific illness outcomes. Although the data are rare, it seems reasonable that any such intervention should be applied as early as possible and should always be tailored to the specific needs of the patient in the context of personalized patient care, since it is accepted that both the patients and their relatives have different needs and problems depending on the stage of the illness.

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Miziou, S., Tsitsipa, E., Moysidou, S. et al. Psychosocial treatment and interventions for bipolar disorder: a systematic review. Ann Gen Psychiatry 14 , 19 (2015). https://doi.org/10.1186/s12991-015-0057-z

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How to Write a Biopsychosocial Assessment

Biopsychosocial assessments help health professionals assess what biological, psychological and social factors could be impacting their client's health. This comprehensive assessment creates a foundation for understanding the factors contributing to your patient's well-being and enables clinicians to develop an effective treatment plan.

Mental health professionals typically conduct a biopsychosocial assessment as  part of the initial assessment  with clients. We've created this guide to help you learn how to use biopsychosocial assessment questions and write a report.

A biopsychosocial assessment helps counselors, social workers, and other behavioral health professionals learn about their clients on multiple levels and better understand their subjective viewpoints. As a result, biopsychosocial assessments enable therapists to diagnose and effectively treat their clients.

Mental health professionals typically conduct a biopsychosocial assessment as  part of the initial assessment with clients. If you would like to use biopsychosocial assessments to learn more about your clients, we have information to help you get started. In this post, we'll explore the components of a biopsychosocial assessment, questions to ask clients, and how to write a report.

• What Is Included in a Biopsychosocial Assessment

How to Write a Biopsychosocial Assessment as a Mental Health Professional

Tips to remember when writing a biopsychosocial assessment, using technology to reduce your documentation burden, understanding the biopsychosocial model of mental health.

Biopsychosocial assessments are based on the biopsychosocial model  proposed by Dr. George Engel . According to Engel's model, a person's body and mind are not separate entities. In other words, a person's biological, social and psychological states all intertwine and impact their well-being.

For example, if a patient experiences a physical illness while lacking social support, they may become depressed or anxious. Similarly, if a person has depression, they might withdraw from their friends and family and neglect self-care, impacting their physical and social wellness.

Is a Biopsychosocial Assessment Necessary?

The biopsychosocial assessment is often necessary when psychological factors alone do not explain the presence of a mental health condition. Psychological factors do not consider the many social and biological factors that can impact one's mental state.

Mental health professionals recognize the need to view clients holistically and consider how various aspects of a person's life might contribute to a mental health issue, impair functioning or maintain a disorder.

Biopsychosocial Assessment Intake Form

Download our biopsychosocial intake form to streamline the collection of client data

What is Included in a Biopsychosocial Assessment?

Biological Factors

Psychological Factors

Social Factors

As you can tell by its name, the biopsychosocial model includes three components: biological, psychological and social factors. You'll want to focus on these aspects as you gather data for your assessment via patient questionnaires and face-to-face interviews. To show you what to cover, here are descriptions of each component:

1. Biological Factors

Biological factors refer to aspects of an individual's physical makeup, such as genes, physiology, hormones, neurotransmitters, chemistry, brain structures and organ system functioning. Many mental conditions are  caused by a combination of biological , psychological, genetic and environmental factors.

Since genes can play a part in a person's mental health and increase the risk of developing certain disorders, counselors should consider a client's family history during their initial meeting.

You might take the following information about your client into account:

• Immune response
• Environmental toxins
• Physical traumas
• Sleep/Exercise habits

Biological questions help you understand a client's medical issues and history, which can impact other areas of their life. Consider asking your client to fill out a questionnaire about their personal medical and mental health history, their family's medical and mental health history, their substance use history, and their current sleep, diet and exercise habits.

You might ask questions such as:

• Who is your current primary care physician?
• Are you on medications? If so, what are they?
• Are you allergic to any medications?
• Do you have a personal or family history of substance abuse or mental health disorders?
• Are you experiencing any medical problems that are impacting your life?
• What medical or surgical issues have you had in the past?

2. Psychological Factors

Psychological factors refer to a person's thought processes and how they influence mental states and behavior. Psychological factors can impact a person's physical well-being and vice versa.

For example, one study found that at least  36% of patients with chronic pain  experienced depressive symptoms. Chronic pain and depression are correlated — as the pain worsens, so does the risk, duration and severity of depression. According to the American Psychological Association,  more than 55% of adults  who live with chronic pain also have symptoms of anxiety and depression.

To understand your clients better, consider psychological factors and related information, such as:

• Personality
• Psychological traumas
• Coping skills
• Suicidal ideation
• Reaction to illness

The psychological component of the biopsychosocial assessment offers a more accurate look at a patient's thoughts, behaviors and feelings. To identify psychological factors that may be influencing your client's health, you can give them a questionnaire containing a current symptom checklist and a checklist of emotional and behavioral issues.

You might also ask the following questions:

• What brings you in today?
• How long have you been experiencing this problem?
• How would you describe yourself?
• What are your strengths and weaknesses?
• Have you had counseling in the past?
• Have you had suicidal or homicidal thoughts?
• What do you feel is your greatest need right now?
• What do you hope to gain from therapy?

3. Social Factors

Social factors include relationships, culture, money, family, work and housing. Research shows that social determinants, such as education and socioeconomic status, can  significantly impact mental health . For example, higher income levels often correlate with positive mental health due to access to effective health care, sufficient food security and safe housing. Alternatively, income volatility, debt and perceived job security can have a substantial impact on mental health.

To learn about a client's social circumstances and how these factors influence their mental and physical health, you might focus on the following:

• Family relationships
• Social support
• Marital status
• Cultural influences
• Food security
• Discrimination
• Income level
• Living situation
• Military service
• Spiritual or religious background
• Hobbies and recreational activities
• Financial status
• Sexual history
• Legal history
• Educational background
• Employment status and work history
• Access to affordable health care

Ask questions that help you understand your client's past and current relationships, work-related stressors, finances and involvement in their community. You might ask:

• Are you involved with any community organizations?
• Who is in your family?
• Who do you live with, and who do you see most often?
• Are there any problems in your family now, or were there issues in the past?
• How much support do you expect from family members?
• Do you have close friends?
• Are there any issues with your friendships?
• Who can you rely on for support?
• Have you ever been arrested?
• Were you ever sentenced for a crime?
• What kind of work do you currently do?
• What have you done in the past?
• How much work-related stress is in your life?
• Have you ever served in the military?

After you've gathered data about your client, you can write a biopsychosocial assessment report. Your report will help you understand your client as a whole individual to devise an effective treatment plan. You can also share your assessment with colleagues or physicians to coordinate care.

Here's a biopsychosocial assessment outline to help you get started:

Basic Information

Begin your report with basic information about your client. This should include:

• Identifying information: Include identifying information such as your client's name, gender, date of birth and marital status.
• Referral: Provide the name of the person or agency who referred the client to you. Include the type of assistance they sought.
• Presenting problem: Describe the reason the client came to you. Include the client's definition of their problem, how long they've been experiencing the issue and what they expect to gain from your services. Also, describe what the client has done in the past to try to resolve the issue.
• Source of data: List everything you used to gather data for your reports, such as questionnaires, interviews, observations, test results and records from the referring agency. Describe your client's involvement in compiling the information.
• General description of the client: Briefly describe your client's appearance, mood and level of cooperation during the interview. List any problems the client has with memory, thinking or speech. Note any signs of anxiety, depression or other mental health issues.

Client's History and Current Functioning

Examine the client's history and current functioning and include relevant details. Address the following areas when writing your report:

• Family history:  Describe the client's family members, including details about the client's childhood relationships and who they grew up with. List family members' history of substance abuse, legal problems or psychiatric disorders.
• Educational background:  Write about your client's educational experience, challenges they may have faced and current goals.
• Employment status and history:  Include your client's current employment status and occupation, an overview of their work history and any special skills or training they have.
• Religious or spiritual beliefs and practices:  Mention if your client identifies with a religion or spiritual beliefs. Include any involvement they may have with a religious community.
• Military service and history:  Mention if your client was or wasn't in the military. If they served in the military, describe their role, the dates they served, any highly stressful experiences they had and the type of discharge they received.
• Current and past medical background:  Describe your client's current general health and functioning. Mention any history of disease, accidents and medication. Consider their family's medical history.
• Mental health history:  Describe your client's mental health history, including current or previous experiences of abuse, violence, trauma or neglect.
• History of substance abuse:  If your client has a substance abuse background, list all current and past experiences with drugs or alcohol. Include any medical treatment or rehabilitation they received.
• Social and recreational activities:  Describe your client's social network, including significant relationships. Mention if your client is involved in the community or has hobbies.
• Basic life functioning:  Add your client's current functioning level and if they can meet their basic life needs, such as obtaining housing and food. Write if they require assistance.
• Present legal concerns or past issues:  Include any legal concerns your client has or dealt with in the past, including marital issues or domestic violence.
• Client's strengths and resources:  Evaluate how your client copes with issues. Mention their strengths and limitations.
• Other environmental or psychosocial assessment factors:  Describe other factors that may influence your client's mental health, such as discrimination or sexuality issues.

Your Assessment and Recommendations

After you provide an overview of your client's current and past psychological, biological and social states, it's time to include your professional assessment. You might offer the following information:

• Brief summary:  In about three to five sentences, summarize what you've already written in your report, including your client's primary problem and any associated factors. Describe your client's level of urgency regarding the problem. Mention any secondary issues or concerns your client shared.
• Client's appearance:  Describe how your client appeared during the interview, including signs of anxiety or depression and any memory or speech issues. If you also conducted a mental status exam during your initial meeting with a client, include it in this section.
• Your  observations :  Provide your observations of the client and their current state. Discuss your assessment of the client's motivation to use your service and modify behaviors.
• Diagnosis:  Include your diagnosis and any diagnoses your client claimed they'd been given in the past by other therapists.
• Goals and recommendations:  Identify long-term and short-term goals. Describe the type of treatment you think is best for your client and any suggestions for services and resources. Include how long you think your client should receive treatment.

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Write Better Biopsychosocial Assessments

In this webinar, we review the history of present illness, past psychiatric history, medical history, social history, and family history. We review how to properly document the level of care justification for payor sources. Finally, we cover how using an electronic medical record system to document mental health treatment can improve efficiency, allowing practitioners to devote their time and attention to individuals who need their assistance.

As you write your biopsychosocial assessment report, it's important to consider who will use your assessment to provide care. Here are tips to help communicate your assessment with colleagues and other care providers:

1. Differentiate Between Objective Facts and Subjective Impressions

Make sure to frame information in a way that separates facts from your impressions. Objective facts include things the client actually said, whereas subjective impressions include how the client appeared to you. Be sure to clarify who said, thought or did something in your report.

For example, to have an objective fact, you might write, "The client said he felt sad when he lost his mother." To state a subjective impression, you might write, "The client seemed sad when he talked about his mother." You'll want to be as objective and unbiased as possible.

2. Create a Balance of Information

Be sure to include a balance of information to ensure your evaluation is accurate and effective. Note the client's strengths, challenges, facts and impressions.

3. Present Information Based on Priority

Decide which problems are most important and need urgent attention. Spend more time writing about these issues in your report. You'll also want to present the primary issues first.

4. Consider Accuracy

Other physicians or therapists may read your report, so it's crucial to be as accurate as possible. Ensure you accurately convey what the client or other sources said or did, and remove or rewrite errors or misleading information.

5. Remove Irrelevant Details

You do not need to include everything the client said, thought, felt or did in your report. Instead, aim to include only relevant information.

It's also possible that your biopsychosocial assessment may not yield relevant information in all three factors. For instance, you may find that a patient's depression is associated with their living situation — a social factor — but cannot identify a biological factor that may contribute to their depression.

6. Keep It Consistent

All documentation should be organized in a logical manner that's easy to comprehend. For example, if your evaluation includes a diagnosis of major depressive disorder, your report should include detailed mentions of the client's loss of interest in pleasurable activities, sleep disturbances or appetite changes.

7. Clarify Symptoms and Experiences

While you do not have to ask every question outlined in a biopsychosocial assessment, you can ask relevant follow-up questions.

For example, if a client responds to the question "How much work-related stress is in your life?" with "I am extremely overwhelmed with work-related stress," you can ask follow-up questions about the intensity, frequency and onset of their experiences.

8. Supplement With Assessment Tools

You can use the following  assessment tools and templates  to make your evaluation more efficient and support your official diagnosis:

• Patient Health Questionnaire (PHQ-9)
• Kessler Psychological Distress Scale (K10)
• Patient Stress Questionnaire
• My Mood Monitor
• Mood Disorder Questionnaire (MDQ)
• Generalized Anxiety Disorder seven-item (GAD-7) scale
• Hamilton Anxiety Rating Scale (HAM-A)
• Life Events Checklist for DSM-5 (LEC-5)

Writing a biopsychosocial assessment is just part of your documentation workload as a behavioral health professional. In addition to evaluations, you likely have progress notes , psychotherapy notes, treatment plans, medical records, privacy notices, and consent forms to complete, organize and keep secure. Although these documents enable you to treat clients and provide the best care possible, they can also be time-consuming if you don't use document management tools .

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• Scan forms or questionnaires to keep digital files.
• Quickly and securely access clients' records from your phone, tablet or laptop.
• Keep all records, forms and notes organized and compliant with privacy laws.
• Take advantage of customizable templates and automatic data population to reduce documentation time.
• Ensure accurate, legible notes to enable better care coordination and faster reimbursement.
• Keep clients engaged and satisfied with the convenient patient portal.

Overall, ICANotes can help you run an efficient practice and allow you more time to focus on your clients.

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Examining diagnosis as a component of Social Workers’ scope of practice: a scoping review

• Original Paper
• Open access
• Published: 04 April 2022
• Volume 51 , pages 12–23, ( 2023 )

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• Deepy Sur PhD   ORCID: orcid.org/0000-0001-5961-4312 1 ,
• Rachelle Ashcroft PhD 2 ,
• Keith Adamson PhD 2 ,
• Nailisa Tanner MA, MLIS 3 ,
• Jenaya Webb MA, MI 4 ,
• Faisa Mohamud MSW 2 &
• Hala Shamsi MSW 2  

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Our study reports on a scoping review examining the role of diagnosis within social work practice in Canada and the United States (US). Adopting the process laid out by Arksey and O’Malley, the search captured 189 academic and grey literature drawn from six health and social sciences databases and published from January 1980 to April 2020. The majority of literature were based in the US, and studies covered a variety of practice settings including hospitals, community clinics, medical health clinics, and private practice. Various versions of the DSM was mentioned in over half of the publications that made mention of the use of a diagnostic tool. Four themes emerged from the analysis: professional positioning, clinical activities and diagnosis, contextual factors, and education and training. The focus on holistic care through intersecting identities and social determinants of health in social work provides a balance to the biomedical model adopted by the DSM. Further inclusion of social work perspectives in the development of the DSM may help raise awareness and inclusion of ecological factors in diagnosis. In addition, the lack of uniformity in the inclusion of diagnosis in social work curriculum has been noted as an opportunity to offer higher quality instruction and supervision to students to better utilize diagnostic tools. We suggest that expanding the scope of practice for social work to include diagnosis can help increase the capacity of the healthcare system to identify and address mental health concerns.

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From its inception, social work has placed health and mental health as a foundational locus of practice across a multitude of institutional and community settings (Ruth & Marshall, 2017 ). Social workers are the largest group of mental health professionals in Canada and the United States (US) (Harkness, 2011 ; O’Brien & Calderwood, 2010 ) and are essential for the assessment and treatment of a broad range of mental health concerns (Ashcroft et al., 2018 ; Kourgiantakis et al., 2020 ). Although social work’s scope of practice has continued to evolve over time to meet the needs of clients, inconsistencies in social work’s ability to diagnose mental disorders continue to exist (de Saxe Zerden et al., 2019 ; Harkness, 2011 ).

Social Work and Diagnosis

Diagnosis refers to the procedure used to identify the presence and cause of a disorder from the onset, course, and combination of signs and symptoms (Harkness, 2011 ; Othmer & Othmer, 2002 ). The purpose of diagnosis is to guide a course of treatment, and relies on sound assessment skills (Harkness, 2011 ). The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) remains a primary method used by regulated professionals to diagnose mental health conditions (American Psychiatric Association [APA], 2013a ). The characteristics of the mental health issues is specific to each person’s psychosocial, relational, and social functioning. The context in which these diagnostic encounters take place is also specific to the presentation of symptoms or chronic problems (Forrest et al., 2002 ). Having diagnostic privileges are instrumental for social work to help clients access needed mental health services (Austin, 2017 ; Rudoler et al., 2019 ). The challenge; however, is that social work’s scope of practice dramatically varies across geographic jurisdictions in terms of ability to diagnose and treat mental disorders.

In the US, social workers are critical to the mental health infrastructure. In 2006, there was an estimated 170,790 clinical social workers in the US, certified or licenced to assess, treat, and diagnose mental health disorders (Center for Health Workforce Studies, 2006 ; Harkness, 2011 ). Clinical social workers in the US have advocated over the past two decades to ensure that state regulatory bodies recognize assessment and diagnosis as part of social work scope of practice (Shah et al., 2019 ). These efforts have largely succeeded, with all but three states permitting master’s level clinical social workers to provide mental health diagnoses, given they meet experience and training requirements (Shah et al., 2019 ).

In Canada, the provinces of British Columbia, Alberta, Saskatchewan, and New Brunswick have incorporated diagnosis as a component of social workers’ scope of practice (New Brunswick Association of Social Workers [NBASW], 2017; NBASW, 2019). Both New Brunswick and Saskatchewan emphasized that extending diagnostic privileges to social workers would increase access to mental health services and decrease wait times (Austin, 2017 ; NBASW, 2017). In Ontario – Canada’s most populous province – social workers do not possess diagnostic privileges as part of their scope of practice, despite the precedence set in other jurisdictions (Austin, 2017 ). Instead, mental health diagnosis is a controlled act customarily carried out by physicians and psychologists (Canadian Mental Health Association Ontario, 2021 ; Government of Ontario, 2020 ). Increasing social workers’ capacity to conduct diagnosis would help improve access to needed mental health services (Harkness, 2011 ; Ratnasingham et al., 2012 ).

Building Social Work’s Capacity for Diagnosis

Legislation is a key component to enable social work’s ability to do diagnosing. For example, the Regulated Health Professions Act defines controlled acts as activities that can cause harm if not performed by a qualified person (Regulated Health Professions Act, 1991). The authority to perform controlled acts comes from legislation. Developing social work’s capacity for diagnosis requires legislation and the support of professional regulatory bodies (Harkness, 2011 ). Building a consistent foundation for social work to engage in diagnosis across all jurisdictions; however, requires more than just legislation. Across the US and Canada, a code of ethics unifies the profession of social work (Canadian Association of Social Workers [CASW] 2005; National Association of Social Workers [NASW], 2021). The values and principles laid out in this code informs all facets of social work practice, and this naturally extends to the role of diagnosis within the scope of the profession. Values such as service to humanity, integrity, and competence in professional practice (CASW, 2005) guide social workers to ensure that diagnoses serve patient and client needs and provides a frame for selecting and delivering effective interventions.

In addition, developing capacity for social workers to be successful diagnosticians requires diagnosis training in social work education, ongoing professional development, and adherence to a determined standard of care (Harkness, 2011 ; Kourgiantakis et al., 2020 ). Competent use of the DSM is beneficial to social workers, clients, and communities across a variety of settings (Kourgiantakis et al., 2020 ). Some jurisdictions have demonstrated commitment to regulating diagnostic privilege among social workers through academic coursework and training, clinical experience, and written examinations to assess competence (Austin, 2017 ; NBASW, 2017). Given the vast differences that exist in terms of social work’s diagnostic roles, there continues to be limited guidance regarding how to implement diagnosis abilities and build capacity for social workers.

The existing legacies of these efforts in both the US and Canada demonstrates that the movement towards diagnostic privileges for social workers is not a novel one. Yet, vast variations exist within social work pertaining to diagnosis. By conducting a scoping review of the literature, our aim is to help bring clarity by identifying the nature and extent of knowledge regarding social workers diagnosing. The findings from this review may inform social work’s response to changing mental health needs and address existing barriers preventing timely access to services (Ratnasingham et al., 2012 ). The following research question guides this scoping review: What can the literature tell us about social work’s scope of practice pertaining to diagnosis in Canada and the United States?

The purpose of our study is to chart and synthesize the literature on social workers engaging in activities of mental health diagnosis in Canada and the United States. This work will be disseminated to researchers, policy makers, educators, and practitioners to inform their practice. We chose a scoping review as our literature synthesis methodology, drawing from Colquhoun et al. ( 2014 ) who describe scoping reviews as “a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting, and synthesizing existing knowledge” (p. 1294). Additionally, in their influential article describing scoping review methods, Arksey and O’Malley ( 2005 ) argue that scoping reviews cover the literature in a broad, yet comprehensive manner, and are an effective way to collate and share the findings from a particular area of research with policy makers and practitioners. We followed Arksey and O’Malley ( 2005 )’s five-stage scoping review process: (i) identifying the research question, (ii) identifying relevant studies, (iii) study selection, (iv) charting the data and (v) collating, summarising, and reporting the results (p. 22). For this study, we continuously built on existing scoping review frameworks with a focus on the proposed research questions as a foundational guide for this work. To promote research transparency, the team developed a scoping review protocol and shared it via the open platform, Open Science Framework (Sur et al., 2020 ). Throughout the process, consultations with key stakeholders of the Ontario Association of Social Workers, including the President, Board of Directors, staff and a membership based advisory group assisted in providing additional social work perspectives and expertise on the data collected.

Search Strategy for Relevant Studies

We employed a broad scope in the present review to capture a wide range of study designs and publication types. Two members of the research team who are social sciences librarians (NT/JW), developed the pilot search strategy to yield a broad and comprehensive coverage of the topic. The search strategy was developed with three main components in mind: social workers AND diagnosing AND mental illness. The pilot search string was developed for PsycINFO (OVID interface) and reviewed by a third non-affiliated librarian using the PRESS Peer Review of Electronic Search Strategies Guidelines (McGowan et al., 2016 ).

The reviewed and revised search string was translated into six databases, selected for their thorough coverage across health and social sciences content: Social Services Abstracts (ProQuest), MedLine (OVID), CINAHL (EBSCO), Social Work Abstracts (OVID), and Applied Social Sciences Index and Abstracts (ProQuest). Searches in all six databases were run and results exported to Covidence software on May 3, 2020.

The database searches yielded 8,081 publications. The bibliographic citations for the 8,081 publications were imported onto Covidence, a web-based software that manages and streamlines systematic reviews. An additional eight articles retrieved from a hand search by RA/DS were also included for a total of 8,089 publications. After removing duplicates, 5,747 studies remained. Figure  1 presents a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the search and screening process.

PRISMA Chart

Study Selection

To select studies for examination, we conducted a two-stage screening process: (1) title and abstract screening and (2) full-text screening. The relevancy of studies for this scoping review was based on the following inclusion criteria: (i) the focus was on social work in Canada or the US, (ii) written in English or French, (iii) published between January 1980 and April 2020 iv), and focused primarily on social workers doing diagnosis.

Following an article title and abstract review by two research assistants supervised by two members of the primary investigator team (RA/DS), 664 articles were selected for a full-text review. Four research assistants conducted the full-text review, supervised by two members of the primary investigator team (RA/DS). The review was conducted using Covidence software, and a member of the primary investigator team (RA) resolved screening conflicts. Following full-text review, 189 articles met the inclusion criteria.

Data were charted for the 189 studies that met the inclusion criteria. The charting phase is an opportunity to illustrate the narrative emerging from the data by enumerating data points and generating an analysis of the themes from the charted data (Arksey & O’Malley, 2005 ). Variables for data extraction in the chart included: (1) authors, (2) year of publication, (3) type of publication (e.x., review, grey literature, journal article, book), (4) journal, (5) geographical location, (6) practice setting, (7) study purpose, (8) study methods, (9) sample, (10) key findings, (11) use of the term and activity for diagnosis, (12) diagnostic tool used, (13) alternative terms for diagnosis, (14) social worker’s role in diagnosis, (15) credentials/educational requirements, (16) barriers to implementing diagnosis, (17) facilitators to implementing diagnosis, (18) scope of practice, and (19) recommendations by the authors.

Data Analysis

Data analysis was completed by one research assistant to derive themes, with close supervision by two members of the investigative team (RA/DS). In addition, all members of the research team had opportunity to participate in the interpretation of themes at regular team meetings. We utilized thematic analysis to appraise and categorize the included studies (Braun & Clarke, 2006 ; Vaismoradi et al., 2013 ), which research team members have successfully used for data analysis in previous scoping reviews (Ashcroft et al., 2019 ). Thematic analysis is a method to guide identification, analysis, and reporting of relevant patterns (themes) in the data (Braun & Clarke, 2006 ). The six phases of thematic analysis outlined by Braun and Clarke ( 2006 ) was adapted to analyze our results. Thus, our analysis included familiarizing ourselves with the data, review of the charted data, written ideas about the charted data, team discussion about the charted data, identification of themes across the articles, categorization of themes in main categories and sub-categories, and a report of the analysis in the form of the results section below.

All of the publications included in the final sample were issued between January 1980 and April 2020. We chose the date January 1980 because it is the year the DSM -III was published and there was a shift towards including other clinicians outside of the psychiatry profession to diagnose. A 20-year span for publications identified for this scoping review provided important historical context with respect to legislation, emerging evidence and to identify and map the evidence available over time. The sample contained full books, select book chapters, empirical articles, theoretical journal articles, grey literature, and both systemic and literature reviews. Based on a numerical analysis, 182 publications were from the US, 4 from Canada, and 3 from both Canada and the US.

The sample covered a wide range of practice settings, with the most reference made to hospital, community medical and specialty mental health clinics, and multiple settings (i.e., a combination of settings such as hospitals, private practice, and community). An analysis of the stated objectives from the journal articles in the sample generated themes around education and training (i.e., assessing Master of Social Work [MSW] students’ confidence in their ability to diagnose), clinical activities (i.e., determining diagnostic concordance between different mental health professionals) and contextual factors (i.e., exploring how social workers view and utilize the medical diagnostic perspective). Our findings show 92% (N = 173) of the publications we appraised explicitly use the word ‘diagnosis’.

Alternative descriptions such as ‘assessment’ ‘screening’ ‘identifying’ ‘detecting’ and ‘evaluating’ were used either separately or in conjunction with ‘diagnosis’. The majority of articles, 85% (N = 161) used ‘diagnosis’ to refer to social workers engaged in clinical activity. Based on a numerical analysis of the relevant publications, social workers diagnosed independently in 58% (N = 110) of the work appraised. The publications we reviewed demonstrated social workers directly diagnosing using the DSM and other methods, providing collaborative consultation on psychosocial issues for the purposes of differential diagnosis, making diagnoses for court/legal purposes, and assigning diagnoses based on case vignettes for empirical research. Of the publications that noted the use of a diagnostic tool, 54% (N = 103) recorded using the DSM (II, III, IV, and V). However, some used terms like assessment in addition to diagnosis. Social workers utilized other assessment and diagnostic tools in several areas of health and mental health practice, such as substance use, mood disorders, post-traumatic stress disorder, child assessment tools, eating disorders, and autism.

Four themes emerged from our thematic analysis of the findings: (i) professional positioning; (ii) intersection of clinical activities and diagnosis; (iii) contextual factors that impact social workers ability or willingness to diagnose; and (iv) education and training.

Professional Positioning

Several publications emphasized that social work’s psychosocial and sociocultural lens during assessment adds value to the diagnostic process. Probst ( 2013 ) suggests that social work’s dominance in mental health service provision positions them to ensure that diagnoses draw a balance between psychiatric and ecological considerations. Barrera & Jordan ( 2011 ) noted that the post-modern, outside-the-box thinking social workers employ may allow them to gain important information about cultural context, enabling more accurate diagnosis for clients from various ethnic and racial backgrounds (Noël & Whaley, 2012 ). Building on this idea, Corcoran & Walsh ( 2016 ) observe that social workers’ awareness of the limitations of the DSM uniquely positions them to highlight all aspects of a client’s circumstances that could inform a diagnosis (i.e., strengths and resources). Social work is also distinguished by understanding the value of ongoing assessment, even after assigning a diagnosis, further increasing the potential for maintaining a rigorous standard of practice in this area (Corcoran & Walsh, 2016 ).

Additionally, social workers’ front-line position and presence in an extremely wide range of practice settings provide an opportunity to participate in the early identification of issues such as autism spectrum disorder (Dababnah et al., 2011 ) and borderline personality disorder (Eckrich, 1985 ). A social worker’s perspective on family and financial factors can prove essential when conducting a differential diagnosis for substance abuse issues (Gropper, 1992 ). Furthermore, social work’s role as the largest mental health care providers to those with psychiatric disorders supports the need for diagnosis as an important component of implementing evidence-based practice.

Professional Tensions

An extension of the first theme relates to the tensions that exist for social workers related to diagnosis because of social work’s professional values and the biomedical model of psychiatric diagnosis. Several authors posited that emphasizing diagnosis in social work diminishes the psychosocial lens characterizing the profession (Carney, 2014 ). Social work is known for using the Person-in-Environment (PIE) perspective to assess patients and clients, which emphasizes social, environmental and cultural factors (Corcoran & Walsh, 2016 ). Several publications highlighted how the biomedical model, to which DSM diagnosis is inextricably linked, is known to conflict with social work ethics and values, a sentiment that was expressed strongly in a series of publications dating as far back as the 1980’s (Kirk & Kutchins, 1988 ; Kutchins & Kirk, 1987 ; Kutchins & Kirk, 1988 ). This apprehension amongst social workers to fully endorse diagnosis has the potential to influence practice decisions. For example, Courtenay ( 1991 ) found that a bias against diagnosis and consequent underutilization of diagnostic tools could explain the under identification of borderline personality disorder in social agencies.

More recent publications in our sample showed that some social workers are apprehensive about the lasting stigma of a DSM diagnosis and its role in pathologizing the client rather than empowering them (Corrigan, 2004 ; Hitchens & Becker, 2014 ; Newman et al., 2007 ). With the non-multiaxial DSM-V, social workers are also concerned how the removal of an axis to note psychosocial stressors will affect their ability to provide a comprehensive diagnosis (Corcoran & Walsh, 2016 ). Some publications mentioned that the lack of a social work presence in the development of the DSM might be a barrier for social workers who diagnose. For example, few groups outside of psychiatry participate in the review and development of the DSM (Frances & Jones, 2014 ). One publication called for social workers to have a stronger voice with diagnosis by participating in the development of the DSM (Newman et al., 2007 ). Of note, social workers participated in task forces informing the DSM-III, and IV (Millon, 1983 ; Washburn, 2013 ). Considerable contributions have been made by Janet Williams who utilized classification from the DSM to conduct field trials of PIE to pay attention to psychosocial and environmental functioning (NASW Foundation, 2021 ). The APA developed the fifth edition of DSM through wide scale collaboration including thousands of clinicians many of whom were social workers, this was thought as a crucial step to ensure the manual had real world considerations (APA, 2013b).

We found that social workers recognize diagnosis to be an inextricable part of mental health practice. The profession has not developed an exact alternative to the DSM (Frazer et al., 2009 ). It is notable that PIE is commonly used as an alternative to commonly implement social work expertise and philosophy, especially since it is a client-centered approach (Karls & O’Keefe, 2008 ). It was developed for all areas of social work practice including medical and psychiatry allowing the classifying of social functioning to better understand client difficulties, perceptions and interactions within the context of their environments including mental health (Karls & O’Keefe, 2008 ). The need to elevate the social work voice and perspective in this context of the DSM is essential since many social workers, particularly in the US, are required to diagnose using the DSM (Phillips, 2013 ). Social workers in other areas where diagnosis is not a requirement are in a position to leverage this situation and draw attention to the ecological factors involved in diagnosis.

The social work profession has long expressed concerns about the pathologizing and stigmatizing effects diagnosis may have on patients and clients. To address the stigma piece, Corrigan ( 2007 ) recommends that social workers conceptualize diagnosis as a continuum and emphasize understanding the individual over normative statements about the groups they belong to. Furthermore, Corrigan ( 2007 ) adds that focusing on models of recovery rather than poor prognosis can mitigate the stigmatizing effects of diagnosis. Another perspective we reviewed advises social workers to focus on framing diagnosis in a positive light and delivering de-stigmatizing education about diagnoses to the public (Linton, 2014 ).

Clinical Activities and Diagnosis

Social workers demonstrate effectively assigning diagnoses and using their clinical judgement to rely on environmental and cultural clinical judgement where appropriate, which is supported by the DSM-IV as it notes that the nuances of individual’s cultural frame are important (Barrera & Jordan, 2011 ). Social workers are also often consulted to test the reliability and validity of various diagnostic and assessment tools (Guest, 2000 ) and to assess concordance between clinical judgement and DSM criteria for certain diagnoses (Hilbrand & Hirt, 1987 ). Issues such as diagnostic overshadowing and misdiagnosis amongst mental health clinicians must be considered when assessing how diagnosis are being implemented (Holub et al., 2018 ; Kirk & Kutchins, 1988 ).

Several publications described how social workers add value to collaborative processes of diagnoses in interdisciplinary team settings. In one perspective, Cotrell ( 2007 ) proposes that when diagnosing dementia, social work’s knowledge of the patient’s functional losses is an important component of differential diagnosis. Furthermore, social workers are participating in consultation roles to lend their psychosocial perspective. In one example, social workers consulted with pediatricians to add a psychosocial lens to diagnosis of ADHD, depression, anxiety, eating disorders, and family communication issues amongst a pediatric population (Geist & Simon, 1999 ). Researchers have also demonstrated interest in how mental health professions with different theoretical orientations approach and understand the biopsychosocial component of diagnosis (McFarland et al., 2018 ).

Social workers employed in interprofessional settings find that DSM diagnoses provide a common language for communicating with psychiatrists and other professionals (Hitchens & Becker, 2014 ; Ishibashi, 2005 ). Many social workers view enhancing their diagnosis skills as a career advantage (Lyter & Lyter, 2016 ). Furthermore, social workers recognize that diagnosis helps with implementing evidence-based interventions and guides referrals for service (Barsky, 2015 ). Regarding addressing the dominance of the biomedical model of diagnosis, Dewees ( 2002 ) provides a comprehensive perspective on social workers re-establishing their essential role in interprofessional contexts and seeking opportunities for critical dialogue. Social workers are uniquely positioned to critically examine prevailing beliefs about the biomedical model and foster an environment where open dialogue may thrive (Dewees, 2002 ).

Contextual Factors and Diagnosis

Our findings show that organizational factors impact social worker’s ability to diagnose mental health conditions. This includes billing practices, workload, and on-the-job supervision and support. For example, a national survey in the US indicated that while social workers consider the DSM an important part of their clinical practice, they feel pressured to use it for insurance billing purposes (Frazer et al., 2009 ). Another study noted that clinicians (including social workers) are more likely to diagnose bipolar disorder when they have a low patient load, or when they have more time (Becker & Lamb, 1994 ). Furthermore, our review of the literature demonstrates that social workers are knowledgeable about the benefits and limitations of the DSM. For example, social workers believe that as an assessment tool, the DSM provides a common language and encourages smooth interdisciplinary communication. However, diagnosing with the DSM also incurs concerning issues such as misdiagnosis, undermining environmental or cultural factors, and the potential for diagnosis to proliferate further stigma (Kutchins & Kirk, 1988 ). To address some of these concerns, the DSM offers the Cultural Formulation Interview to enhance clinical understanding and decision making for the purpose of clinical diagnosis and person-centered assessments (DeSilva et al., 2015 ).

Our review demonstrated that barriers to diagnosis are also influenced by the organizational context social workers are practicing in. For example, a study we reviewed showed that organizational factors in child welfare such as high caseloads and high staff turnover affected social workers’ ability to identify depression in caregivers (Chuang et al., 2014 ). Social workers also experience pressure to diagnose due to employer demands and insurance billing policies. In one study, social workers cite insurance billing as the most common reason for providing a DSM diagnosis, with half the participants claiming they would not use the DSM if it was not a requirement for billing (Frazer et al., 2009 ). Hitchens and Becker ( 2014 ) also found that the social workers felt obligated to record a diagnose in order to receive reimbursement for their services and continue to work with their clients. This pragmatic and nonclinical use of diagnosis raises questions around the consequences of linking diagnostic decisions to reimbursement, such as minimizing psychosocial concerns and benefitting agency survival over client or patient welfare (Frazer et al., 2009 ).

Education and Training

Our appraisal of the literature demonstrated that social workers are considering the impact of education and training on their diagnostic capacity. For example, social workers support the mandatory inclusion of courses on diagnosis in school curricula (Dziegielewski et al., 2002 ; Raffoul & Holmes, 1986 ). We also noted a gap between education and competence in identifying certain mental health issues. In one study, authors found a lack of association between social work education and identification of substance use disorders in caregivers (Chuang et al., 2014 ). Social work’s increased role in developing and updating the DSM was emphasized amongst educators, who also noted that students are capable of understanding the strengths and limitations of the DSM and using it in a nuanced manner (Lyter & Lyter, 2016 ). While educators have expressed concern about social work values conflicting with the traditional biomedical understanding of disorders, they also appreciate the role of the DSM in diagnosis and treatment planning and believe that the profession needs a stronger voice in further DSM revisions (Newman et al., 2007 ).

Several authors expressed concerns about education and training programs not adequately preparing social workers to become diagnosticians (see Barrera & Jordan, 2011 ; McLendon, 2014 ; Richardson, 2007 ). In one notable example, Ponniah et al. ( 2011 ) reported the results of a national survey examining the inclusion of structured diagnostic assessment training in accredited social work, clinical psychology, and psychiatry residency programs in the US. The authors found that while didactic training and clinical supervision in structured diagnostic assessment were offered by the majority of programs, MSW programs were amongst those more likely to provide didactic training without a clinical supervision requirement, therefore diverging from the ‘gold standard’ of training (Ponniah et al., 2011 ). A lack of uniformity on training requirements for diagnosis across different states may be yielding social workers who are inadequately prepared to diagnose compared to other trained professionals (Shah et al., 2019 ). Barrera & Jordan ( 2011 ) also examined the quality of diagnosis training social workers are receiving. They reported that while social work graduate programs are increasingly offering courses on diagnosis, this does not reflect an improvement in the quality of the training if students are not being taught how to properly use the DSM with people of color.

In addition to education and training, our review demonstrated concerns around professional competency. One author noted that social worker diagnosis leads to higher rates of misdiagnosis, particularly when the method used is unstructured, free-style interviews (Nugent, 2005 ). Earlier studies also examined inconsistencies in the clinical judgement of mental health professionals (including social workers) and whether practitioners are adequately equipped to use existing diagnostic classification systems (Becker & Lamb, 1994 ).

Schools of social work offering diagnostic training must ensure they are offering high quality training that is keeping up with new directions in the field. This includes incorporating diagnostic content related to minorities (Barrera & Jordan, 2011 ) and providing opportunities for diagnostic training and field placements in integrated care such as psychopathology, diagnostic interviewing, and medication management (Belsher et al., 2014 ). Lyter & Lyter ( 2016 ) advise social work educators to take a more active role in promoting the development of diagnostic classification systems and also furthering the biopsychosocial perspective in the current system. There are also suggestions for further research regarding the interest from social work students and clinical directors to have courses on structured diagnostic assessment (Ponniah et al., 2011 ).

To address the limitations of DSM diagnosis, several authors advised how to work both with the DSM and in parallel to it, by enhancing and supplementing the diagnostic process. Bransford & Blizard ( 2017 ) for example, note the lack of significance given to trauma etiology in the DSM-V and call upon social workers to supplement traditional diagnosis with trauma-informed assessments and interventions. Social workers are also encouraged to remain on top of new developments and literature which may enhance their understanding of strengths and limitations of the dominant diagnostic system, and also provide supplemental skills in assessment techniques and theories (Ahmedani & Perron, 2012 ). In our review we noticed that several authors encourage the social work profession to find its own voice and niche within diagnosis (see Levine, 2000 ; Probst, 2013 ).

This review sought to chart and synthesize the literature on social workers engaging in activities of diagnosis in Canada and the US. Characterizing the venues, methodologies, and examples of social work activities in the literature shows significant contributions of the profession in diagnostic practice. As the demand for mental health services continues to rise, it is imperative to effectively utilize social work’s contribution in diagnosis. Since the purpose of diagnosis is to direct the course of treatment, thorough and comprehensive assessment skills are necessary (Harkness, 2011 ). Our scoping review demonstrates the need to critically review social workers scope of practice and skills as they are crucial to addressing mental health backlog and community well-being especially with worldwide shifts in mental health overburden. Our scoping review found the term diagnosis is commonly used and the vast majority of literature uses the term in reference to clinical activity. It is concerning; however, that few articles are examining the jurisdictional variations and/or the professional scopes of practice issues that are arising in jurisdictions where diagnosis is not yet part of social work scope of practice. This is particularly problematic for places like Canada where legislated diagnosing is still in its infancy in many places.

In addition, the strengths of the profession have been highlighted, especially in improving the health of families, individuals and communities, particularly in key roles and functions across systems of care (de Saxe Zerden et al., 2019 ). Although the DSM along with International Classification of Diseases (ICD-11) is the dominant diagnosis tool, it is only one tool. Our review emphasized how social work brings an even more robust lens that can provide a greater understanding of strengths and contexts, which are often neglected if only using the DSM (Turner, 1984 , 2005 ). Several sources used diagnosis plus other terms like strengths-based assessment to illustrate that social work’s role includes yet extends beyond DSM, in fact social work has a role in conceptualizing what diagnosis is within their scope.

It can be argued given the strong influence of the biopsychosocial paradigm in clinical social work practice, that social workers can make critical contributions to the diagnostic process in the field of mental health. It is important to note that the goal of information gathering in the diagnostic process for any professional is to reduce diagnostic uncertainty enough to make optimal decisions about care (National Academies of Sciences, Engineering, and Medicine, 2015 ). Accuracy of a diagnosis is predicated on the ability to have a comprehensive picture of the client’s story that integrates the biological, psychological, and social world of the client. Social workers as independent practitioners or as members of the mental health team contribute biopsychosocial formulation, generate hypotheses about the origin, and causes of a patient’s symptoms, which are inclusive of biological, psychological, and social factors. This unique contribution is particularly important in an era where funders for mental health services are placing more emphasis on changing behavior, not people, in environments with complex psychosocial histories, and there has been little attention to the impact of the social environment or to biology on individuals (Berzoff & Drisko, 2015 ).

Social workers understand and utilize their professional responsibilities to ensure ethical and competent practice. As one of the largest providers of mental health services, social workers utilize comprehensive assessments to enhance well-being. Assessing client strengths is central to the relationship formed for accurate assessment and treatment. Social workers are also well positioned to understand the intersections of culture, gender and race and the need for ongoing review of environmental and social factors influencing outcomes. The process of diagnosis provides the framework within which many systems of access operate. Through this, intervention is often determined; social workers are critical to understanding the influence of social determinants on prognosis of quality of life. Diagnosis certainly organizes a clinical picture, deciphers intervention and subsequently a frame for pathways to care, social workers not only contribute to this frame but also understands the underpinning relationships between client and environment. The contextual person in environment approach is employed by social workers in a variety of settings, including vulnerable, impoverished, and disadvantaged populations. The profession is well suited to facilitate DSM diagnosis with a comprehensive biopsychosocial assessment by enabling a suitable intervention plan. Given the historical collaborative involvement of the social work profession in the development of diagnostic systems within the field of mental health such as the DSM, and The Psychodynamic Diagnostic Manual, the profession is well positioned to advocate for the controlled act of communicating a diagnosis pertaining to an individual’s full range of psychosocial functioning (Lingiardi & McWilliams, 2015 ). Advancing and supporting legislation to extend diagnostic privileges to social workers signals an opportunity to capture the complexity of human life and the critical perspective social workers offer to client interactions.

Despite there being some research that includes social work, very little research is being conducted to specifically advance our knowledge around diagnosing specific to the profession. This is problematic because the knowledge domain of diagnosis is rapidly evolving (Turner, 1984 , 2005 ). In the absence of advancement of knowledge related to diagnosis, the profession of social work will remain inhibited in this domain. In addition, there are varying opinions and perspectives related to diagnosis in social work. There needs to be more research to provide social work with professional guidance (Turner, 2005 ).

Clinical Activities

Social workers have a professional responsibility to maintain proficiency in theory and practice regardless of occupying a wide range of practice settings and roles. Similar to other care related professionals social workers must demonstrate a commitment to continuing education (Ontario College of Social Workers and Social Service Workers, 2021 ). This includes ensuring they have the necessary skills and knowledge to assess, document and plan for treatment plan as well as respecting informed consent (CASW, 2005). Many jurisdictions are struggling to meet growing demand for mental health services. The Mental Health Commission of Canada ( 2016 ) notes service, treatment, and supports need to be delivered in culturally safe and competent ways. This cultural safety is grounded in the recognition of cultural diversity but also acknowledges the imbalances of power that impact relationships between providers and service users. Formal social work training focuses intensely on cultural sensitivity and humility can enhance the quality of assessment and treatment as it extends to diagnosis. Given the large and widespread presence of the profession, many of these service gaps can be addressed with increased social work scope of practice.

Policy makers, professional associations, and regulatory bodies of social work should promote, in the best interest of the public, the expansion of diagnostic privileges to a qualified group of social workers. Current challenges accessing mental health and addictions services include long wait times, lack of understanding of services, uneven service quality between regions, and fragmentation (Government of Ontario, 2020 ). The profession of social work is not relegated to a particular practice setting but instead, is a role that spans across health and mental health. Social work holds the ability to evolve rapidly in the context of the future of health services including trauma approaches and integrated models. Providing social workers the environment and context to use the DSM appropriately in clinical work would help to significantly address barriers to access.

Contextual Factors

Since the emergence of the profession, social work has been intimately involved in the care of communities. The profession continues to connect social and environmental conditions to mental and physical outcomes and enhanced quality of life. Enabling social workers to reliably diagnose certain mental health conditions can alleviate barriers to access and lengthy wait times (Ratnasingham et al., 2012 ). Social workers are well-positioned to make a timely contribution to a more specialized diagnostic role in their practice settings. Uniquely, social workers are also positioned to not only diagnose, but provide comprehensive treatment including connections to community-based programs and services such as substance abuse treatment, shelters, and outreach programs. The US has clearly embedded diagnosis in the social work role and as such the profession scope is widely recognized to include this. We require more Canadian content as Canada is lagging behind in addressing the full scope of practice (Austin, 2017 ; Turner, 2005 ).

Mental health conditions can not only be diagnosed but also individuals, families and couples can be provided treatment for anxiety, depression, trauma, addiction, and many other mental health issues. This requires the comprehensive exploration of the capacity to create legislation that formalizes the contribution of social workers to the diagnostic process.

Education & Training

As part of a larger system, use of the DSM allows interprofessional and cross discipline colleagues to converse in common language, as such formal and professional training programs will require accurate learning of diagnostic categories (Newfoundland and Labrador College of Social Workers, 2020 ). Diagnosing using the DSM requires training, experience, and supervision. Training and educational prerequisite considerations ought to be a combination of academic, clinical experience, and specialization. Formalized training for social workers already includes and aligns with some aspects of mental health recognition as noted in the DSM. Further aligning academic requirements with clinical social work scope of practice will ensure appropriate levels of expertise are matched with high quality competencies. The strengthening of curriculum to not only include the recognition of symptoms but the ability to include differential diagnosis could be enhanced with schools of social work in Canada. In a study of social work educators and the use of the DSM classification system, Lyter & Lyter ( 2016 ) noted over 90% of respondents reported DSM content being included in the curriculum. Literature examined in this review noted the significant support from social workers to ensuring advanced preparation for any increase in scope of practice, including the legal authority to submit a DSM diagnosis for social workers amongst other professions (Lyter & Lyter, 2016 ).

Limitations

Given the broad nature of the research question, the findings may be similarly broad. Similarly, scoping reviews do not appraise quality (Arksey & O’Malley, 2005 ). Scoping review methodologies provide an overview of topic areas, as opposed to assessing for methodological quality. This scoping review examined the nature of the literature on the practice of diagnosing mental health disorders in Canada and the US and excluded other international literature.

Conclusions

In many jurisdictions social workers are integrated fully in a mental health system of care. Mental heath is a rapid growing concern requiring trained professionals to provide timely information about assessment, treatment approaches, and diagnosis information. This includes the recognition of symptoms and supporting recovery. Diagnosis is an essential and logical integration in social work scope of practice, especially since social workers bring extensive expertise and knowledge in their client interventions.

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Acknowledgements

Thank you to the two research assistants for data collection - Mishal Dar and Kandarp Patel, and Simon Lam for his support and review of the manuscript. And, thank you to Peter Donahue for reviewing the manuscript draft.

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Sur, D., Ashcroft, R., Adamson, K. et al. Examining diagnosis as a component of Social Workers’ scope of practice: a scoping review. Clin Soc Work J 51 , 12–23 (2023). https://doi.org/10.1007/s10615-022-00838-y

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Bipolar disorders are difficult to diagnose and treat, despite their global prevalence and pervasiveness. With the proper tools, however, clinicians and researchers alike are able to detect bipolar disorders in their patients and establish the proper treatment plans. Knowing the prevalence of bipolar disorders and other common diagnoses in a specific setting, gathering predictive information before the first visit, and screening patients with efficient, low-cost assessment options are a few of the ways that clinicians can be better prepared to detect bipolar disorders in their patients. Further, assessment should not halt once a diagnosis is established; brief, recurring measures to collect data about a patient’s current state throughout treatment offer important information about symptoms, progress, and how a treatment plan can be tailored to meet a client’s ongoing needs. This chapter equips clinicians and researchers with the tools to confidently diagnose their patients with bipolar disorders, suggesting tips to establish diagnostic hypotheses as well as specific assessments for both adults and youths for whom the diagnosis seems likely. Technology in particular offers the opportunity to access low-cost assessment options and administer ongoing measures to ensure that clinicians continue to meet their patients’ needs throughout the treatment process.

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Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses

Ursula mccormick.

1 Medical Services, Centerstone of Indiana, Bloomington, Indiana

Bethany Murray

2 Indiana University School of Nursing, Columbus, Indiana

Brittany McNew

This review article provides an overview of the frequency, burden of illness, diagnosis, and treatment of bipolar disorder (BD) from the perspective of the advanced practice nurses (APNs).

Data sources

PubMed searches were conducted using the following keywords: “bipolar disorder and primary care,” restricted to dates 2000 to present; “bipolar disorder and nurse practitioner”; and “bipolar disorder and clinical nurse specialist.” Selected articles were relevant to adult outpatient care in the United States, with a prioritization of articles written by APNs or published in nursing journals.

Conclusions

BD has a substantial lifetime prevalence in the population at 4%. Because the manic or depressive symptoms of BD tend to be severe and recurrent over a patient's lifetime, the condition is associated with significant burden to the individual, caregivers, and society. Clinician awareness that BD may be present increases the likelihood of successful recognition and appropriate treatment. A number of pharmacological and nonpharmacological treatments are available for acute and maintenance treatments, with the prospect of achieving reduced symptom burden and increased functioning for many patients.

Implications for practice

Awareness of the disease burden, diagnostic issues, and management choices in BD has the potential to enhance outcome in substantial proportions of patients.

Introduction

Bipolar disorder (BD) is a chronic illness associated with severely debilitating symptoms that can have profound effects on both patients and their caregivers (Miller, 2006 ). BD typically begins in adolescence or early adulthood and can have life‐long adverse effects on the patient's mental and physical health, educational and occupational functioning, and interpersonal relationships (Valente & Kennedy, 2010 ). Although not as common as major depressive disorder (MDD), the lifetime prevalence of BD in the United States is substantial (estimated at approximately 4%), with similar rates regardless of race, ethnicity, and gender (Ketter, 2010 ; Merikangas et al., 2007 ). Long‐term outcomes are persistently suboptimal (Geddes & Miklowitz, 2013 ). The economic burden of BD to society is enormous, totaling almost $120 billion in the United States in 2009. These costs include the direct costs of treatment and indirect costs from reduced employment, productivity, and functioning (Dilsaver, 2011 ). Given the burden of illness to the individual and to society, there is an urgent need to improve the care of patients with BD.

There is a growing recognition of the substantial contribution that advanced practice nurses (APNs) such as nurse practitioners (NPs) and clinical nurse specialists (CNSs) can make in the recognition and care of patients with BD (Culpepper, 2010 ; Miller, 2006 ). Most patients with BD present initially to primary care providers, but—through a lack of resources or expertise—many do not receive an adequate evaluation for possible bipolar diagnosis (Manning, 2010 ). Early recognition can lead to earlier initiation of effective therapy, with beneficial effects on both the short‐term outcome and the long‐term course of the illness (Geddes & Miklowitz, 2013 ; Manning, 2010 ). Patients with BD are also likely to have other psychiatric and medical comorbidities, and, therefore, rely on their primary care provider for holistic care (Kilbourne et al., 2004 ; Krishnan, 2005 ). Finally, the importance of collaborative, team‐based care is increasingly recognized in managing BD. APNs, by their training and experience, are well suited to facilitate optimal patient care in collaboration with the other healthcare team members (Bauer et al., 2006 ; Chung et al., 2007 ). An especially important role for APNs within primary care lies in the care of the patient, while specialists manage the bipolar illness. It is essential that these two specialties collaborate in order to stay abreast of each other's current phase of treatment.

This review provides an up‐to‐date discussion of the principles and practices of managing BD in the primary care setting. Our emphasis is on holistic, team‐oriented, multimodal approaches to care, which is compatible with the experience and therapeutic orientation of APNs.

Diagnosis of BD

Definitions in bd.

Patients with BD experience recurrent episodes of pathologic mood states, characterized by manic or depressive symptoms, which are interspersed by periods of relatively normal mood (euthymia; Figure ​ Figure1; 1 ; Vieta & Goikolea, 2005 ). Formal definitions of manic and depressive symptoms are included in the recently updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM‐5 ; American Psychiatric Association, 2013 ). Notably, the depressive episodes of BD are defined by the same criteria as MDD in the DSM‐5 , so that distinguishing BD from MDD frequently depends on identifying a history of manic or hypomanic symptoms (Table 1 ).

Mood range and associated mood diagnosis (Vieta & Goikolea, 2005 ).

Diagnostic criteria for BD diagnoses: Overview of DSM‐5

Adapted from DSM‐5 (American Psychiatric Association, 2013 ). Readers are referred to the full DSM‐5 criteria published by the American Psychiatric Association ( 2013 ) for establishing a bipolar diagnosis.

There are two major types of BD. Bipolar I disorder (BD I) is defined by the presence of at least one episode of mania, whereas bipolar II disorder (BD II) is characterized by at least one episode of hypomania and depression. The main distinction between mania and hypomania is the severity of the manic symptoms: mania results in severe functional impairment, it may manifest as psychotic symptoms, and often requires hospitalization; hypomania does not meet these criteria (American Psychiatric Association, 2013 ).

The duration of mood episodes is highly variable, both between patients and in an individual patient over time, but, in general, a hypomanic episode may last days to weeks, a manic episode lasts weeks to months, and a depressive episode may last months to years (Benazzi, 2007 ; Manning, 2010 ; Valente & Kennedy, 2010 ). Although a history of depressive episodes is not required to make a diagnosis of BD I by the DSM‐5 criteria, in practice most patients do experience depressive episodes; however, depressive episodes are required for a diagnosis of BD II. Long‐term studies show that patients with BD, regardless of the subtype, experience symptomatic episodes of depression more frequently and for longer durations than manic or hypomanic episodes (Baldessarini et al., 2010 ; Geddes & Miklowitz, 2013 ; Judd et al., 2003 ; Valente & Kennedy, 2010 ).

While a mood episode may consist solely of manic or depressive symptoms, it may also include a combination of these symptoms. Such episodes are newly defined in DSM‐5 as either a manic or hypomanic episode with mixed features or a depressive episode with mixed features, depending on which symptoms are predominant (American Psychiatric Association, 2013 ; Table 1 ).

Rapid cycling is a term describing the occurrence of at least four mood episodes within 1 year. Identification of rapid cycling is important, because these patients are less responsive to treatment. Rapid cycling should be considered a “red flag” that indicates the need for referral to specialist care.

Diagnostic criteria for BD

Successful assessment and treatment by the healthcare team requires knowledge of the episodic nature of BD. Diagnosis of a full‐blown manic episode may be relatively straightforward. If presenting to primary care, these patients may require immediate referral to specialist hospital care because of the risk of harm to self or others. However, more common in the primary care setting is the presentation of patients with depressive symptoms, who require a differentiation between BD and MDD (Cerimele, Chwastiak, Chan, Harrison, & Unutzer, 2013 ; Sasdelli et al., 2013 ). For this reason, all patients presenting with depressive symptoms should be assessed for a history of manic or hypomanic symptoms (Cerimele et al., 2013 ; Sasdelli et al., 2013 ; Valente & Kennedy, 2010 ).

Use of a bipolar screening tool is a time‐efficient first step in diagnosis, to be followed by a confirmatory clinical interview. The Mood Disorder Questionnaire (MDQ, Table 2 ) and the Composite International Diagnostic Interview, version 3.0 (CIDI 3.0), are commonly used screening tools in which scores above specific cut‐off values raise a suspicion of BD (Hirschfeld et al., 2000 ; Kessler & Ustun, 2004 ). Web‐based and electronic screening tools are also being developed with the aim of greater time efficiency (Gaynes et al., 2010 ; Gill, Chen, Grimes, & Klinkman, 2012 ). A comprehensive recent review of the screening tools in BD is provided by Hoyle, Elliott, and Comer ( 2015 ). While screening tools can help to recognize patients likely to have BD and can improve the efficiency of the clinical interview, it is important to note that case‐finding tools are not infallible and cannot replace the interview.

The Mood Disorder Questionnaire

Adapted from Hirschfeld et al. ( 2000 ).

The clinical interview should aim to establish the following (Manning, 2010 ; Price & Marzani‐Nissen, 2012 ):

• ▪ The presence of past or current episodes of manic or depressive symptoms, as described in DSM‐5
• ▪ The duration and severity of these episodes, including the presence of suicidal or homicidal ideation
• ▪ The impact of mood episodes on functioning in work, social, and family roles
• ▪ The presence of comorbidities (such as substance abuse, personality disorder, and anxiety disorder including posttraumatic stress disorder)
• ▪ The history of treatments administered and the response to treatments
• ▪ The family history.

In cases of continued diagnostic uncertainty, a formal diagnosis of BD may require a consultation with an experienced primary care physician, psychiatrist, psychologist, or APN to confirm the presence of DSM‐5 criteria, as well as to categorize the bipolar subtype that is present. The clinical interview, besides establishing the bipolar diagnosis, represents an important element in treatment planning, by helping to select the optimal medication(s) and the optimal site of treatment—either within primary care or by involving specialist psychiatric support. Finally, continued interviews over the course of treatment will help establish rapport and trust with the patient that encourages communication and enhances treatment adherence (Zolnierek & Dimatteo, 2009 ). Open dialogue between the healthcare worker and patient represents an essential element of patient interviews.

Other elements of the patient interview should include a physical examination and laboratory tests, with the particular aim to exclude disorders that can mimic bipolar symptoms, for example, hypothyroidism or hyperthyroidism, infection, and substance misuse (Krishnan, 2005 ). Psychiatric disorders (e.g., panic disorder, posttraumatic stress disorder) other than MDD can also mimic symptoms of BD and these should be considered in the differential diagnosis (Goldberg, 2010 ).

In establishing a BD diagnosis, it can be very informative to ask family members or close friends to provide a description of the patient's symptoms (with, of course, the patient's consent). Lack of insight is a characteristic of patients with BD, and hypomanic symptoms, in particular, may not be considered a manifestation of the illness by the patient. This is also an opportunity to assess the burden that family or friends may be experiencing as well as their current relationships with the patient (National Collaborating Centre for Mental Health [UK], 2006 ).

Misdiagnosis and underdiagnosis

Because MDD is more common than BD, and because MDD and BD have similar symptoms, it is very common for BD to be misdiagnosed as MDD (Manning, 2010 ; Miller, 2006 ). In one study, over 60% of patients who were eventually diagnosed with BD had previously been misdiagnosed with MDD.

A number of adverse consequences can result from the misdiagnosis and underdiagnosis of BD (Hirschfeld, 2007 ; Manning, 2010 ; McCombs, Ahn, Tencer, & Shi, 2007 ). Most importantly, patients with BD who are misdiagnosed with MDD may be treated with conventional antidepressant monotherapy. Compared with appropriately treated patients, such patients are less likely to respond, are at increased risk of a switch to mania, and may experience an acceleration of mood cycling (Manning, 2010 ; Miller, 2006 ; Sidor & Macqueen, 2011 ; Vieta & Valenti, 2013 ).

Sharing the diagnosis

Discussing the diagnosis with the patient is critical to laying a foundation for effective treatment. The acceptance of a BD diagnosis may be difficult and often occurs over time. The initial diagnosis is frequently provisional, and requires additional observations or confirmatory historical information. It can also be expected that patients will show resistance to the diagnosis, possibly because of the social stigma of having a mental illness. One of the best tools to facilitate acceptance of the diagnosis is motivational interviewing, which is a form of counseling that elicits and strengthens the patient's motivation for change through a process of collaboration and rapport. Motivational interviewing was developed for patients with an alcohol or drug problem, but has been applied more broadly in recent years (Laakso, 2012 ). Having patience and persistence in helping patients to “own” their BD, and take responsibility for managing it, is an important objective in motivational interviewing (Laakso, 2012 ).

Pharmacotherapy

Pharmacological treatment is fundamental for successfully managing patients with BD. For acute episodes, the objective is symptom reduction, with the ultimate goal of full remission. For maintenance treatment, the goal is to prevent the recurrences of mood episodes. Medications used in the treatment of BD include mood stabilizers (e.g., lithium, valproate, lamotrigine, and carbamazepine), atypical antipsychotics, and conventional antidepressants (Geddes & Miklowitz, 2013 ; Hirschfeld, Bowden, & Gitlin, 2002 ). Table 3 lists the medications that are approved by the U.S. Food and Drug Administration (FDA) in treating the different phases of BD.

Medications with FDA indication for treatment of BD

*Also used adjunctively but not FDA indicated.

A, adjunctive to a mood stabilizer; C, combination therapy with another mood stabilizer, antipsychotic, or antidepressant; M, monotherapy; RLAI risperidone long‐acting injectable; X, recommended in guidelines but not FDA indicated.

Mood stabilizers

Lithium was the first agent to be used in the treatment of BD. Although it has many limitations, including a delayed onset of action in the treatment of acute mania, limited efficacy in the treatment of bipolar depression, and a narrow therapeutic window, lithium still has an important role today (Geddes, Burgess, Hawton, Jamison, & Goodwin, 2004 ; Hirschfeld et al., 2002 ). In particular, lithium has shown efficacy in preventing recurrence of manic episodes and it is the only medication correlated with a reduced risk of suicide in BD. A study that reduced the lithium dosage (to increase its tolerability) reported no benefit from using lithium plus optimized personalized treatment when compared to optimized personalized treatment alone (Nierenberg et al., 2013 ).

Sodium valproate is the most commonly used mood stabilizer. It has a more rapid onset of action than lithium for the acute treatment of mania, and was superior to placebo as an acute therapy in the largest study performed to date (Bowden et al., 1994 ), but the evidence for its efficacy as a maintenance treatment for mania is not so robust (Geddes et al., 2010 ; Kessing, Hellmund, Geddes, Goodwin, & Andersen, 2011 ). Placebo‐controlled studies of carbamazepine describe significant efficacy in acute mania (Weisler, Kalali, & Ketter, 2004 ; Weisler et al., 2005 ). In the absence of long‐term controlled studies, a naturalistic study over an average of 10 years reported that carbamazepine is efficacious in most patients (Chen & Lin, 2012 ). Lamotrigine, in contrast to the other mood stabilizers, is more effective for preventing the recurrence of depressive than manic episodes of BD (Vieta & Valenti, 2013 ). Lamotrigine has also been investigated for the treatment of acute bipolar depression, but the evidence for efficacy is less convincing (Geddes, Calabrese, & Goodwin, 2009 ). A study of lamotrigine in acute mania reported no significant difference from placebo (Frye et al., 2000 ).

There are a number of safety and tolerability concerns with mood stabilizers that impact their long‐term use. Lithium requires regular monitoring of blood levels, because the therapeutic window is narrow. Lithium can cause progressive renal insufficiency and thyroid toxicity. After initial assessment of renal and thyroid functions, repeat monitoring of renal and thyroid functions every 6 months is recommended to ensure normal functioning (Price & Heninger, 1994 ). The most common adverse events associated with lithium include tremors as well as gastrointestinal problems such as nausea, vomiting, and diarrhea. Hepatotoxicity is the most common serious adverse event associated with valproate (risk: 1/20,000); other adverse effects include nausea, dizziness, somnolence, lethargy, infection, tinnitus, and cognitive impairment. Monitoring is required for hematologic abnormalities including low platelet count, low white blood count, and, in some cases, bone marrow suppression during valproate therapy (Martinez, Russell, & Hirschfeld, 1998 ). Carbamazepine is associated with reduced tolerability during rapid dose titration and its potential for interaction with other psychiatric and nonpsychiatric medications further limits its use (Grunze et al., 2009 ). Carbamazepine has an FDA boxed warning for agranulocytosis and aplastic anemia and is associated in approximately 10% of patients with the formation of a benign rash. Lamotrigine, which is overall the best‐tolerated medication in this class, can cause a rash like the Stevens–Johnson rash. Lamotrigine has been studied specifically in relation to fetal cleft palate formation; however, the evidence remains unconvincing. Fetal exposure to valproate, carbamazepine, and lithium can be teratogenic (Connolly & Thase, 2011 ; Dodd & Berk, 2004 ; Geddes & Miklowitz, 2013 ; Hirschfeld et al., 2002 ; Tatum, 2006 ).

Atypical antipsychotics

The atypical antipsychotics were developed in the modern era of psychopharmacology; all agents in this class have been studied by randomized controlled trials in the treatment of BD (Derry & Moore, 2007 ; Yatham et al., 2013 ). For the treatment of acute bipolar mania, all approved atypical antipsychotics (also called “second‐generation” antipsychotics) demonstrate efficacy and acceptable safety. For acute bipolar depression, however, few atypical antipsychotics have demonstrated efficacy. Only quetiapine (immediate‐release [IR] and extended‐release [XR] formulations) has proven efficacy as monotherapy for treating acute depressive episodes of BD I or BD II (Table 3 ; Calabrese et al., 2005 ; Suppes et al., 2010 ; Thase et al., 2006 ). A fixed‐dose combination of olanzapine and fluoxetine has demonstrated efficacy for treating acute depressive episodes of BD I (Tohen et al., 2003 ) and lurasidone has recently received FDA approval as monotherapy or adjunctive therapy (with either lithium or valproate) in BD I but not BD II (Loebel et al., 2014a , 2014b ).

For the maintenance treatment of BD I, FDA‐approved atypical antipsychotics include aripiprazole, olanzapine, quetiapine (IR and XR), risperidone long‐acting injection (LAI), and ziprasidone; these agents are approved either as monotherapy or as adjunctive therapy in combination with a mood stabilizer. A recent meta‐analysis of trials of the atypical antipsychotics in maintenance treatment concluded that aripiprazole, olanzapine, quetiapine (IR or XR), and risperidone LAI monotherapy were statistically superior to placebo for treating manic or mixed episodes, while quetiapine alone was also significantly effective against recurrence of depressive episodes (Vieta et al., 2011 ).

The safety and tolerability profiles of the atypical antipsychotics have been well characterized in patients with BD. A number of safety issues are associated with these drugs as a class, including sedation/somnolence, metabolic effects (e.g., weight gain, hyperglycemia, and dyslipidemia), and extrapyramidal side effects (EPS). The relative risk of these effects differs between individual atypical antipsychotics. For example, the risk of adverse metabolic effects is reported to be greatest with olanzapine and lowest with ziprasidone, and intermediate with quetiapine and risperidone (Perlis, 2007 ). Adjunctive therapies that include atypical antipsychotics in combination with other agents (usually mood stabilizers) are also associated with a greater risk of adverse events than monotherapies (Smith, Cornelius, Warnock, Tacchi, & Taylor, 2007 ). Given the propensity of atypical antipsychotics to adversely affect weight, lipid levels, and other metabolic parameters, it is important to monitor patients regularly (Hirschfeld et al., 2002 ; The Management of Bipolar Disorder Working Group, 2010 ).

Conventional antidepressants

The proper use of conventional antidepressants is an area of controversy in the treatment of BD (Pacchiarotti et al., 2013 ). The main concern in using antidepressants as monotherapy in patients with bipolar depression is the risk of precipitating a switch to mania/hypomania, which is estimated to occur in between 3% and 15% of cases (Pacchiarotti et al., 2013 ; Tondo, Baldessarini, Vazquez, Lepri, & Visioli, 2013 ; Vazquez, Tondo, & Baldessarini, 2011 ). Another unresolved issue is whether maintenance treatment that includes antidepressants is effective for the prevention of recurrence (Pacchiarotti et al., 2013 ; Vazquez et al., 2011 ). If conventional antidepressants are used, it is recommended to combine them with a mood stabilizer or an atypical antipsychotic, and to taper the antidepressant dose following remission of the episode (Amit & Weizman, 2012 ; Connolly & Thase, 2011 ; Hirschfeld et al., 2002 ; Yatham et al., 2013 ). Contemporary guidelines recommend selective serotonin reuptake inhibitors (SSRIs) or bupropion rather than selective serotonin‐norepinephrine reuptake inhibitors (SNRIs) or tricyclics, as SSRIs and bupropion are less likely to cause manic switch. While full consensus is currently absent, there is wide agreement that antidepressant monotherapy should be avoided in patients with BD I and patients with BD II with two or more concomitant core manic symptoms, while antidepressants should be avoided entirely in patients with rapid cycling or those being treated for a mixed episode (Pacchiarotti et al., 2013 ).

Psychosocial treatments

Psychosocial treatments, including individual psychotherapies as well as educational and supportive group therapies, are increasingly considered an integral part of the treatment of BD (Connolly & Thase, 2011 ; Geddes & Miklowitz, 2013 ). Common components of psychosocial treatments are education about the disease and a focus on treatment adherence and self‐care. Interestingly, among the psychosocial treatments, the strongest evidence for effectiveness is for group psychoeducation of patients and caregivers (Colom et al., 2009 ; Reinares et al., 2008 ). Long‐term benefits of this approach include a reduction in days with symptoms and in days hospitalized (Colom et al., 2009 ).

Two other psychotherapies with evidence to support their effectiveness are BD‐specific cognitive behavioral psychotherapy (Jones et al., 2012 ) and interpersonal and social rhythm therapy (Frank et al., 2005 ). Interpersonal and social rhythm therapy is an intervention designed to increase the regularity of patients’ daily routines, based on the concept that disruption of circadian rhythms is a underlying feature of mood disorders (Frank, Swartz, & Boland, 2007 ). These therapies can help patients improve adherence to their medication, enhance their ability to recognize triggers to mood episodes, and develop strategies for early intervention. Combining BD‐specific adjunctive psychotherapies with pharmacological therapy has been shown to significantly reduce relapse rates (Scott, Colom, & Vieta, 2007 ).

Peer support

BD impacts all aspects of a person's life, causing severe disruption to relationships, employment, and education. Peer support can be very helpful in dealing with the consequences of these effects through sharing of experiences, where patients can discover that others have had similar experiences and can have hope for recovery, stability, and a satisfying life. Support groups, sponsored by national organizations, may be available locally or regionally. There is also a wealth of resources available online (Table 4 ).

Web resources for BD

Major challenges in the management of patients with BD

A number of commonly encountered challenges can contribute to suboptimal outcomes in BD. An awareness of these challenges and the implementation of proactive strategies can help to maximize adherence to care and the benefits of treatment.

Nonadherence

Medication nonadherence is a significant problem in primary care medicine generally, and in patients with BD in particular. Experience from other areas of medicine suggests that nonadherence may be widely unrecognized (Ho, Bryson, & Rumsfeld, 2009 ). Validated scales for gauging nonadherence include the Morisky Adherence Scale, although this is not widely adopted in clinical practice (Morisky, Ang, Krousel‐Wood, & Ward, 2008 ). Reasons for nonadherence among patients with BD include the following: a denial of the diagnosis, especially in those with predominant mania; a lack of belief that the medications being offered are necessary or effective; and a wish to avoid the real or imagined adverse effects of medications (Devulapalli et al., 2010 ). Additional practical factors, including poor access to health care and limited resources to support treatment costs, can also affect adherence (Kardas, Lewek, & Matyjaszczyk, 2013 ).

Nonadherence is probably the most significant factor contributing to poor treatment outcome in BD (Hassan & Lage, 2009 ; Lew, Chang, Rajagopalan, & Knoth, 2006 ), which leads to increased emergency room visits and hospitalization (Hassan & Lage, 2009 ; Lage & Hassan, 2009 ; Lew et al., 2006 ; Rascati et al., 2011 ). Investing more time and resources to work with patients during symptom‐free periods is likely to be cost saving by reducing the utilization of these high‐cost resources (Zeber et al., 2008 ).

Comorbid psychiatric disorders

The complexity in treating patients with BD is increased by the high rates of cooccurring psychiatric disorders, in particular anxiety disorders and substance use disorders (Grant et al., 2005 ; Krishnan, 2005 ). The importance of these cooccurring conditions cannot be overstated; they are associated with both exacerbations of BD and poor treatment outcomes (Grant et al., 2005 ; Kessler et al., 1996 ). Although it may be prudent to refer such patients to specialist care, the first critical step is to make a correct diagnosis and to help these patients to accept the problem and the need for treatment.

Comorbid medical disorders

Patients with BD have an elevated prevalence of medical morbidities, including obesity, diabetes, cardiovascular disease, and hepatitis (Kilbourne et al., 2004 ; Krishnan, 2005 ). A comorbidity of increasingly recognized importance is obstructive sleep apnea (OSA), which causes sleep disturbance that can trigger mood episodes (Soreca, Levenson, Lotz, Frank, & Kupfer, 2012 ). A recent study reported OSA in over 20% of patients with BD, which the authors mention may be an underestimate of the true prevalence (Kelly, Douglas, Denmark, Brasuell, & Lieberman, 2013 ). The authors concluded that unrecognized OSA may play a major role in the mortality and morbidity of BDs. All patients diagnosed with a BD should be screened with an OSA questionnaire.

The burden of medical disorders may be increased by the adverse effects of BD treatment, by cooccurring substance misuse or by decrements in self‐care secondary to BD itself (McIntyre, 2009 ). For example, depression typically deprives patients of the motivation and energy to engage in treatment for chronic medical conditions. Early recognition and treatment of medical disorders in patients with BD has been shown to have a major beneficial effect on all‐cause mortality (Crump, Sundquist, Winkleby, & Sundquist, 2013 ).

Women of childbearing age

Women are at high risk of BD recurrence during pregnancy, especially if medications are discontinued, as well as during the postpartum period. Balancing the risk of medications against the need to prevent a mood episode requires active collaboration between the healthcare providers and the patient (McKenna et al., 2005 ). Teratogenicity is a potential risk with most of the mood stabilizers; lamotrigine may be an exception, but there are no well‐controlled studies in humans to confirm this. Atypical antipsychotics, with the exception of lurasidone, are rated FDA pregnancy category C, meaning that they have not been shown to be either safe or unsafe for use during pregnancy; lurasidone is classed in pregnancy category B based on current data.

Suicide rates in BD are the highest among the psychiatric disorders (Chen & Dilsaver, 1996 ; Tondo, Isacsson, & Baldessarini, 2003 ). The lifetime incidence of at least one suicide attempt was reported in one study to be 29% in patients with BD, compared to 16% for MDD (Chen & Dilsaver, 1996 ). Other studies have reported even higher rates of suicide attempts of 25%–60% during the course of BD, with suicide completion rates of 14%–60% (Sublette et al., 2009). The primary healthcare team should monitor all patients with BD for suicidality, especially those with persistent depressive or mixed‐mood symptoms, and immediately refer any patient at high‐risk for suicide to specialist care (Tondo et al., 2003 ).

Alcohol abuse in patients with BD is associated with further elevation in the risk of suicide, particularly in the presence of concurrent drug use disorders. A study that investigated this association concluded that higher suicide attempt rates in patients with BD I and alcoholism were mostly explained by higher aggression scores, while the higher rates of attempted suicide associated with other drug use disorders appeared to be the result of higher impulsiveness, hostility, and aggression (Sublette et al., 2009). This study, similar to previous reports, found that earlier age of bipolar onset increased the likelihood that alcohol use disorder would be associated with suicide attempts. Effective clinical management of substance use disorders has the potential to reduce the risk of suicidal behavior in these patients with BD.

BD continues to represent a substantial burden to patients, their care providers, and society. Management of BD poses a challenge to all healthcare providers, including the APNs. A suspicion of BD increases the likelihood of successful diagnosis. Emphasis should be placed on accurately identifying manic, hypomanic, and depressive episodes. A number of pharmacological and nonpharmacological treatments are available for acute and maintenance treatments. Healthcare providers should be aware of the efficacy and safety profiles of each of these agents, with the aim to achieve the most effective utilization of the approaches available in the management of patients with BD. An awareness of these aspects in BD—disease burden, diagnostic issues, and management choices—can enhance outcome in substantial proportions of patients. In summary, Table 5 provides a useful overview of the principles to consider when providing care for patients with BD.

Principles of providing care for patients with BD

Red flags indicating need for specialist involvement:

▪ Suicidality

▪ Pregnancy and postpartum

▪ Severe psychiatric comorbidity (e.g., substance dependence, anxiety)

▪ History of treatment resistance (e.g., multiple hospitalizations)

▪ Rapid‐cycling pattern.

Adapted from Culpepper ( 2010 ).

Funding Editorial support was provided by Bill Wolvey of PAREXEL, funded by AstraZeneca.

Disclosure Ursula McCormick has received personal fees from AstraZeneca and Sunovian. Bethany Murray and Brittany McNew report no conflicts of interest.

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