Can bipolar disorder be managed without medication? Experts weigh in

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Bipolar disorder is one of the most stigmatized and misunderstood mental health conditions in Western culture.

As a result, being diagnosed with bipolar disorder can be overwhelming. Stigma — and the shame and isolation that come with it — adds a layer of difficulty to a condition that in and of itself can be very painful.

The good news is that people with bipolar disorder can lead happy, fulfilling lives if they get the right support. Yet, the treatment of bipolar itself can also be a minefield of misinformation and stigma, particularly when it comes to the use of medications.

Two group therapy readers sent us questions about this:

“My 18-year-old daughter was recently diagnosed with bipolar 2. We have gotten her on meds … which have helped, but I don’t like the idea of a lifetime of medication. Is this all there is? I just feel there must be something more out there than medication for the rest of her life. Is anyone looking into psilocybin for bipolar? Are there any other therapies other than standard AMA-prescribed drugs?”

“is it possible to live with bipolar 1 without medication?”

In today’s newsletter, we’ll answer these questions and also explore what bipolar is, the standard ways of treating it, and ways of managing the disorder that are complementary to — but in most cases, not a substitution for — medication.

What is bipolar disorder?

Bipolar disorder can best be described as a “disorder of energy,” said Melvin McInnis, director of the Heinz C. Prechter Bipolar Research Program at the University of Michigan.

People living with bipolar cycle through manic or hypomanic (too much energy) and depressive (little to no energy) mood states, McInnis told me. The frequency, intensity, and length of manic and depressive states vary from person to person. Bipolar disorder is a spectrum.

“Every human has variations in their mood and how well they’re feeling on a day-to-day basis,” said Erin Michalak, professor of psychiatry at the University of British Columbia and the founder of Crest.BD, a multidisciplinary collaborative network of researchers, people living with bipolar disorder and their families, and healthcare providers.

“Bipolar is a bit different from that; it’s associated with more pronounced variations in mood. Some people will experience periods of psychosis — a disconnection from the reality that other people are seeing around them. People will go through phases where they’re doing really well and experiencing a great quality of life, and then other times they may need to be hospitalized or have real problems with work or relationships. It’s one of the most diverse and varied conditions we see in psychiatry.”

The DSM-5, the diagnostic handbook widely used by psychotherapists and psychiatrists in the United States, lists four major categories of bipolar spectrum disorders. You can read more about those here.

Because there are so many different ways bipolar can present, it’s often misdiagnosed as major depression, anxiety, psychosis, autism, ADHD, or personality disorders. When that happens, appropriate treatment is delayed, experts said — sometimes for many years.

As recently as the 1990s, bipolar was seen as a categorically severe and rare condition that affected only adults. Now, in addition to recognizing the condition as a spectrum, researchers believe that up to 4% of U.S. children and adults live with bipolar, according to the American Psychological Assn.

That’s a lot of people. But because of harmful portrayals of bipolar disorder in the media and a general lack of public education about the condition, it’s still heavily stigmatized, leading to restricted work opportunities and harassment. People with the disorder may unintentionally internalize these beliefs, which negatively affects how they see themselves and what they’re able to accomplish in this world.

Things are getting better, though, thanks to increased awareness of bipolar and all its nuances — largely because of the dogged advocacy of people who live with it.

Andrea Vassilev was diagnosed with bipolar when she was 14 years old. “I went from being the happiest girl on the block to suicidally depressed in a matter of weeks,” she said. “There was no ignoring it.”

Now a doctoral candidate and therapist specializing in the psychological treatment of bipolar disorder in L.A., Vassilev uses her platform to address stigma head-on.

“People can feel really awful about who they are because they have this condition,” Vassilev told me. “They think it defines them. Having lived with bipolar since I was a teen, I don’t see it that way.”

How is bipolar disorder treated?

As our readers alluded to in their questions, the front-line treatment for bipolar disorder is almost always medication. In particular, mood stabilizers can help balance out the highs and lows of mania and depression.

The most commonly prescribed mood stabilizer for bipolar disorder is lithium. While it can be highly effective for many people, the drug doesn’t work for everyone. About a third of people find a lot of relief from lithium, while another third find it somewhat effective. The final third isn’t helped at all by the medication. These efficacy rates are similar to those seen among antidepressants.

Lithium and other mood stabilizers are generally used long term when treating bipolar, and like other medications, they come with risks. Extended use of lithium can lead to chronic kidney or thyroid issues. There are side effects to all mood stabilizers in the short term, too, which may be one reason our readers are concerned about themselves or their loved ones taking these meds.

“Any medication comes with a balance of risks and benefits,” McInnis said. “How important is it for someone to take these medications and stay well, as opposed to the risks of taking them?”

Another big reason people feel uncomfortable with the idea of taking psychiatric medications long term is stigma, Vassilev said. If you’re prescribed insulin for diabetes, it’s a given that you’ll have to take it the rest of your life, and people are way less likely to resist that fact.

“Because mood stabilizers are treating our brains, though, it can feel like it’s about who we are,” Vassilev said. “People sometimes don’t want to take medication because they fear that it’ll change who they are. But in actuality, medication can bring you back to your baseline.”

Researchers are trying to find other pharmacological ways to manage the condition, especially for those whom medications like lithium don’t work. Studies into the use of psilocybin (otherwise known as magic mushrooms) and ketamine for the treatment of bipolar are promising, but more research needs to be done before those potential pathways to relief become mainstream, experts said.

Vassilev said she’s benefited greatly from regular intravenous ketamine infusions. “Over time, ketamine has changed the quality and frequency of my depressive episodes,” she said. “I don’t get as depressed.”

Vassilev urges caution, though, when pursuing ketamine treatment — which is available widely but quite expensive — as it can cause mania if not administered properly.

“It should only be done after careful consideration and review by the doctor, who should have knowledge of the person’s patterns and who they are,” McInnis said. “It’s not a panacea.”

Psychotherapy is also an integral part of the treatment of bipolar disorder. A UCLA review of 39 clinical trials found that pairing medication with therapy is more effective at preventing bipolar relapses than medication alone.

Therapy that’s tailored to the challenges of bipolar is especially helpful — most therapists aren’t rigorously trained in bipolar treatment, so that’s something to ask about when you’re speaking with potential clinicians.

Therapy can help people come to terms with the challenges of living with bipolar. “Many people have a hard time believing you can lead a successful, fulfilling life, but it’s completely possible. There are so many shining examples out there,” Vassilev said. “What a lot of those people have in common is self-acceptance.”

In therapy, people with bipolar can also learn how to spot the signs of an encroaching episode and ways to stabilize their sleep and exercise, both of which influence mood (irregular circadian rhythms are thought to contribute to episodes of mania and depression).

“Everyone should be able to receive psychoeducation about their condition because it’s unique from person to person,” Michalak said. “There’s so much people can do to really empower themselves to live well with this condition.”

Some research indicates that a ketogenic diet — which consists of primarily high-fat, low-carb foods — may also minimize symptoms of mood disorders, including bipolar. Studies have been small so far, though, so talk to your psychiatrist if you want to try it out. “Dietary manipulation is not a trivial thing,” McInnis said.

Can you manage bipolar without medication?

Our readers want to know whether it’s possible to manage bipolar without medication.

Experts told me that it’s possible, but also rare, especially for people with more severe forms of the condition.

“There’s very little research evidence for people successfully managing bipolar without medication,” Michalak said. “And it really depends on the type of bipolar you’re talking about. I know quite a few people with bipolar II who don’t take mood-stabilizing meds over the long term. That’s very different than bipolar I; most people who are really flourishing with type 1 are taking meds.”

The number of people who are able to manage the condition without medication is “probably very small,” Michalak said. “It’s extremely hard work in terms of the amount of monitoring and self-care that’s needed to manage mood and safety. It’s quite a herculean task.”

Part of the reason it’s so hard to manage bipolar without medication is that episodes occur out of the blue, even for folks who are doing everything they can to stabilize their mood — including not using drugs or alcohol, exercising regularly, sleeping well and going to therapy, McInnis said.

But regimented self-care can go a long way in minimizing the dosage of medications needed to manage bipolar, experts said. Vassilev said that at one point she was able to reduce her lithium dose by 30% because she was getting good aerobic exercise every single day.

Final thoughts

I asked our experts what they would tell our reader who’s concerned about her daughter taking medications for bipolar over the course of her life.

Vassilev said that if she were in a therapy session with our reader, she would ask, “What does your daughter being on medication bring up for you? How do you feel about it? Are you more concerned for her well-being and happiness, or the stigma of taking medication?”

“I feel your pain. I really do,” Vassilev said. “But if what you want is for your daughter to live a good life, she can, but she has to take care of herself, and her journey might look a little different than you imagined.”

Michalak said she knows that there are a lot of gloomy narratives out there about bipolar. “If you Google ‘bipolar,’ it can be quite terrifying, as are the prominent messages you get from media — that this will be a very severe condition, linked to higher rates of suicide. It’s really important to remember that with bipolar, people can and do live full lives with excellent health.”

And bipolar is a condition that can come with great assets, Michalak said. “People with bipolar can be so creative and have abilities for lateral thinking that really enrich them as human beings and their contributions to society.”

While our reader’s daughter might be struggling now, Michalak said, having a supportive family and access to treatment “is a solid place to be.”

“There’s a high probability that her daughter will do just fine in that environment,” she said. “You really have to hold on to that piece of hope at these early stages.”

. . .

I wish I could deliver a different answer than I did today. I wish I could say that people living with bipolar could find relief without working really hard. In this way, bipolar and mental illness writ large is an unfair card to be dealt.

But if you or someone you care about has the condition, I do hope you’ll walk away with more optimism, both for what can be done today to manage it and for promising treatments in the research pipeline.

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email [email protected] gets right to our team.

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More perspectives on today’s topic & other resources

California’s former acting surgeon general opens up about her experience living with bipolar disorder in this L.A. Times op-ed. “Today, I live with bipolar disorder as a chronic and manageable health condition,” Devika Bhushan wrote. “Having touched rock bottom and survived, I’m motivated to protect myself at all costs, to fiercely guard the boundaries and care strategies I need to stay healthy. With the right treatments and therapy in place, I hope to be well for the majority of my life.”

Mental health experts spoke with The Times earlier this year about how bipolar disorder is defined, the push to understand the condition on a spectrum, and the stigma that can come with a diagnosis. It’s a great primer on the evolution of bipolar as a diagnosis.

Other interesting stuff

Hanif Abdurraqib sees grief as its own kind of spiritual practice. The poet, author and music critic spoke with NPR about how he experiences loss. “I’m of the belief that one doesn’t move past loss. Or at least in my life, I don’t move past loss. Grief makes a home within us if we allow it to,” he said. “I believe that, at that point, I was learning to be something that I’m committed to now, I believe that I should be a generous steward to my grief. If I tend generously to my grief, then it treats me well in return.”

How boundaries became the rules for mental health — and explain everything. Lily Scherlis for Parapraxis Magazine explores the historic rise of “boundaries” dating back to the early 20th century. “I am not anti-boundaries,” Scherlis writes, “but they are so rarely questioned — they have a seductive moral authority as the dominant metaphor for how human relationships should work.”