Bipolar Disorder

What is Bipolar Disorder?

Bipolar disorder is a chronic mood disorder with repeated episodes of mania, hypomania and depression, often with periods of relatively stable mood between them. It affects about 40 million people worldwide and usually begins between ages 15 and 25.^{[1, 2]}

This is a condition that needs treatment from a psychiatrist or other qualified physician. The clinic's role is supportive and limited.

Common symptoms

Mania or hypomania is a distinct period of changed mood and behavior. Depression is the most frequent presentation, and about three quarters of the time with symptoms is spent in depressive episodes or symptoms.^[2]

• High: unusually elevated or irritable mood, racing thoughts, less need for sleep, talkativeness and risky or impulsive behavior
• Low: sadness or hopelessness, loss of interest, fatigue, sleep or appetite changes, trouble concentrating and thoughts of death or suicide
• Mixed features, where symptoms of both poles occur together, in roughly a third of episodes^[1]

Bipolar I disorder involves full mania. Bipolar II disorder involves depression and hypomania without full mania, and it is often mistaken for major depression.^[3]

Causes and risk factors

The exact cause is not known. Risk comes from many genes working together with environmental factors.^[4] Triggers for episodes include some medicines, especially antidepressants for mania, as well as seasonal changes, viral infections, reduced sleep and stressful life events.^[5]

How it is diagnosed and treated conventionally

A psychiatrist or physician diagnoses bipolar disorder from a detailed history and symptom review. Diagnosis is often delayed by about 9 years because early episodes look like ordinary depression or other conditions.^{[2, 4]}

Long-term treatment uses mood stabilizers such as lithium, valproate and lamotrigine, and some antipsychotic medicines. Antidepressants are not recommended alone. Psychotherapy and lifestyle changes support medicines.^{[2, 4]} More than half of people do not take treatment as prescribed, so staying in regular contact with the treating team matters.^[2]

Why Bipolar Disorder calls for a whole-person approach

Mood episodes are shaped by biology, sleep, stress and physical health together. Medicines are the foundation of treatment, but these other factors affect how stable a person stays.

Supportive care can address some of these factors, but only as an addition to psychiatric treatment.

Sleep and daily rhythms

Bipolar disorder is strongly linked to disrupted sleep and body-clock rhythms. Changes to the sleep and wake cycle can set off episodes.^[6] Reduced sleep is also among the reported triggers for mood episodes.^[5]

Stress

Stressful life events are among the possible triggers for depressive relapse.^[5] Steady routines and stress care are therefore part of long-term management.

Physical health

People with bipolar disorder have higher rates of metabolic syndrome, obesity, diabetes and smoking, and life expectancy is shortened by about 12 to 14 years, with higher rates of heart disease and suicide. Some antipsychotic medicines are linked to weight gain.^[2]

Anxiety and substance use

Anxiety and substance use disorders are common alongside bipolar disorder and complicate treatment.^[1]

Acupuncture as supportive care in Bipolar Disorder

What the research shows

Evidence for acupuncture in bipolar disorder itself is very limited. A review of complementary treatments for bipolar disorder found only one acupuncture study, which showed favorable but not statistically significant effects on mania and depression.^[7] A 2022 single-arm study of 36 people with treatment-resistant depression or bipolar disorder (21 had bipolar disorder) gave weekly acupuncture for 12 weeks alongside regular treatment. Depression, anxiety, pain and sleep scores improved. With no comparison group, it cannot show that acupuncture caused the change.^[8]

Case reports show that responses differ. In three people with bipolar disorder given 12 weekly sessions, depression improved in one, neither depression nor anxiety improved in another, and a person with rapid-cycling disorder had repeated episodes during treatment.^[9]

For sleep, a review of 24 trials in people with insomnia (not specifically bipolar disorder) included a meta-analysis of 15 trials that found acupuncture improved sleep scores compared with medicines after three or more weeks, with large differences between trials.^[10] Whether this applies to bipolar disorder has not been tested.

How acupuncture may work

The reviewed studies do not establish how acupuncture might affect mood episodes, so we do not offer a mechanism.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. The one small study used weekly sessions for 12 weeks.^[8] Acupuncture here is meant only to support sleep, stress and physical symptoms alongside psychiatric care. If signs of a mood episode appear, contact your psychiatrist.

In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker, which matters for electroacupuncture.

Ayurvedic medicine as supportive care in Bipolar Disorder

The Ayurvedic view

Ayurveda describes disorders of the mind in its own terms, including states of excitement and states of low mood, and links them to imbalance of the doshas and the mental qualities. This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Care is individual and may include:

• Regular meal times, a steady daily routine and consistent sleep and wake hours
• Warm oil massage and relaxation practices for stress and sleep
• Individually prescribed herbs, only after review of your psychiatric medicines

Panchakarma and fasting-based cleansing are not appropriate for people with bipolar disorder who are in a mood episode, are acutely ill, are pregnant or are frail. Fasting and reduced sleep have been reported as possible triggers of mood relapse.^[5]

What the research shows

No clinical trials of Ayurvedic treatment for bipolar disorder turned up in a PubMed search, so there is no evidence about whether it helps or harms. A review of herbal medicines in psychiatric disorders described ashwagandha as having only preliminary evidence in affective disorders in general.^[12] That is not evidence for bipolar disorder.

Herbal medicine as supportive care in Bipolar Disorder

Herbs and formulas that have been studied

No herb has been established as a treatment for bipolar disorder. Herbs with some evidence in other conditions include St John's wort and saffron for unipolar depression, and ashwagandha and lavender for anxiety.^[13]

What the research shows

We found no trials of herbal medicine for the core problems of bipolar disorder. Clinical guidelines on herbal and nutrient-based treatments recommend that they be used only as an addition within standard medical care, especially in more severe mental illness.^[13] The guideline found weak support for omega-3 fatty acids in bipolar depression, and it did not recommend N-acetylcysteine at this time. Those are nutrients, not herbs.^[13]

Safety and herb-drug interactions

Some herbs are risky for bipolar disorder. St John's wort has been linked in case reports to mania and psychosis, including 12 cases of mania or hypomania in one review, and it is listed among triggers of mania.^{[5, 14, 15]} People with bipolar disorder are generally advised to avoid it. Ginseng has caused mania when combined with an MAO-inhibitor antidepressant.^[16]

Lithium has a narrow safe range, and small changes in blood levels can cause toxicity. Its clearance is affected by kidney-active drugs such as diuretics, anti-inflammatory painkillers, ACE inhibitors and angiotensin receptor blockers.^{[17, 18]} Tell us about every medicine and supplement, and ask your prescriber before starting any herb. About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[19]

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes mood swings as imbalance among the liver, heart and kidney, with excess heat in the high phase and depletion in the low phase. Ayurveda describes excitation and low mood in terms of the doshas. Researchers study related ideas in biological terms, such as disrupted circadian rhythms, sleep loss and stress responses.^{[5, 6]}

No study has shown that a dosha or a TCM pattern corresponds to a specific biological process in bipolar disorder.

How this care fits with your medical care

Supportive care for bipolar disorder sits alongside your psychiatrist's or physician's care. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Do not stop or change lithium or any other prescribed medicine without your prescriber, because changing treatment can trigger an episode. We do not diagnose or manage bipolar disorder. Please bring your diagnosis, a full list of medicines and supplements, the name of your psychiatrist, and recent blood test results, including lithium levels if relevant.

When to seek urgent medical care

Bipolar disorder carries a high risk of suicide, and mood episodes can become dangerous quickly.^[2]

• Thoughts of suicide or self-harm; call or text 988 (Suicide and Crisis Lifeline)
• Mania with little or no sleep for days, risky or dangerous behavior, or being unable to care for yourself
• Hallucinations, delusions or severe confusion
• Signs of lithium toxicity if you take it, such as vomiting, diarrhea, severe tremor, unsteady walking or confusion
• Severe agitation or threats to harm yourself or another person

For an emergency, call 911 or go to the nearest emergency department.