Bipolar disorder is a significant mental health condition that can have serious emotional, financial, legal, and health related complications.  The more severe forms of this condition may require aggressive intervention and treatment when the patient is in an acute episode.

Many patients with bipolar disorder also have a drug or alcohol problem.  Problems such as cardiac illness, thyroid disease, diabetes, and other medical conditions are also more common in patients with bipolar disorder than in the general population.  When stabilizing a patient in an acute bipolar episode, these co-occurring conditions must also be a focus of treatment.

There are three stages in stabilizing an acute episode of bipolar illness.  Each is described below.

Provide for Safety of Patient and Others
The first and most important step is to make sure that the patient is safe, and that those around the patient are also safe.  When a patient is in an acute bipolar episode, the following must be evaluated and addressed:

  • Is the patient suicidal or homicidal? Is the patient psychotic or otherwise unable to take care of themselves due to their condition?  If so, the patient may require hospitalization, at times against their will.
  • If the patient abuses substances, is he or she at risk of dangerous complications from drug or alcohol withdrawal?  If so, the patient may require hospitalization to complete a drug detox.  This is particularly of concern is the patient is addicted to alcohol or benzodiazepines (Xanax, Valium, Klonopin).
  • Is the patient experiencing acute medical symptoms such as a cardiac emergency or dangerous blood sugar levels?  If so, the patient may require a visit to the hospital Emergency Room to get co-occurring medical disorders stabilized.

Stabilize the Bipolar Symptoms before Treating Other Psychiatric Disorders
Patients with bipolar disorder often have other co-occurring psychiatric disorders such as anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and trauma-based disorders.  It is essential to treat these other conditions as well, or the patient with bipolar disorder is at a greater risk of relapse.  However, most commonly the acute bipolar symptoms will be treated first, and the co-occurring psychiatric disorders will be treated once the bipolar disorder has stabilized and is no longer acute.

Initial stabilization of a bipolar episode involves at least three steps:  treatment for acute mania, treatment for acute depression, and treatment for acute psychosis.  Patients with bipolar disorder are more likely to be depressed than manic when having an episode, so often the focus of treatment is on bipolar depression.  However, bipolar mania is a common reason for acute treatment requiring hospitalization.  Sometimes patients may present with both depression and mania in what is known as a mixed state.  Finally, some patients can become delusional (express odd ideas), or hallucinate (hear things or have other unusual sensory experiences that others are not also experiencing).

Stabilizing an acute manic episode requires active monitoring of medications for depression, mania, and psychosis, in addition to any other treatment that is required for other medical conditions or drug detox.  This process could take several weeks or longer to complete.  Bipolar-specific psychotherapy should also be initiated at this point to help the patient and his or her family to recover more quickly from this crisis.

Treat Co-occurring Psychiatric Disorders when the Bipolar Symptoms are Stable
When the patient’s bipolar symptoms are reasonably stable, other psychiatric conditions that the patient may have such as an anxiety disorder or ADHD can now be a focus of treatment.  Some conditions such as anxiety may improve as a result of the primary treatment for bipolar disorder.  Other conditions such as ADHD may require medications that could make a bipolar episode worse if it has not already been stabilized.  Moreover, some medications used to treat anxiety disorders and ADHD can be addictive, so careful consideration must be taken with patients who are addicts or who are at risk for a substance abuse problem.