Can Bipolar Disorder Be Treated Without Medication?

While medication is central to bipolar disorder treatment, lifestyle changes, therapy (CBT, family-focused, etc.), and self-management strategies can offer significant support. Research highlights the effectiveness of psychotherapy in relapse prevention and improved quality of life alongside pharmacological interventions like lithium and antipsychotics for acute episodes.

Bipolar disorder, characterised by extreme mood swings from highs (mania or hypomania) to lows (depression), affects many individuals globally. While medication is a mainstream solution, many often wonder if it's possible to manage this condition without pharmaceuticals and psychotherapy. Let's explore alternative approaches and understand the broader spectrum of managing bipolar disorder.

What is Bipolar disorder?

According to International Classification of Diseases( ICD 11) A disorder consisting of two or more episodes in which an individual's mood and activity levels are significantly disturbed, alongside some episodes resulting in an elevation of mood and increased energy and activity (hypomania or mania) and others in a decrease of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania are described as bipolar.

What is Mania?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Mania is marked by high energy, restlessness, and rapid speech and thoughts. One may exhibit impulsivity, decreased sleep, inflated self-esteem, and distractibility. Emotional states can range from euphoria to irritability, and individuals may engage in reckless or high-risk behaviours, which can significantly impact functioning and decision-making.

What is Hypomania?

Some of the key features of Hypomania consist of mild mood elevation, increased energy and activity, and typically noticeable sensations of well-being and mental and physical efficiency. Although they are frequently present, enhanced sociability, talkativeness, over-familiarity, sexual energy, and a decreased need for sleep are not to a degree where they seriously disturb work or cause social rejection. Hallucinations or delusions do not accompany the mood and conduct abnormalities.

What is Bipolar Depression?

On the other hand, Bipolar Depression consists of low mood, decreased energy, and decreased activity, which are common symptoms of mild, moderate, or severe depressive episodes. Reduced capacity for enjoyment, interest, and concentration occurs, and noticeable fatigue following even minimal effort is typical. Usually, appetite is reduced and sleep is disrupted. Self-confidence and self-esteem are nearly always decreased, and even in the mildest cases, feelings of guilt or inadequacy are frequently expressed. Somatic symptoms such as loss of interest and pleasure, psychomotor retardation, agitation, loss of appetite, weight loss etc can also occur with the key features. 

Can bipolar disorder be treated without medications?

There is not enough significant evidence to conclude that bipolar disorder can be treated without medications

In a study conducted by Cappleman et al. (2014) on how individuals manage bipolar disorder (BD) without medications by developing tailored strategies aligned with their understanding of themselves and their moods. Key methods included:

• Lifestyle Adjustments: Managing diet, exercise, stress, and environmental factors to maintain mood stability.
• Personalised Support: Therapy, support groups, or practices that resonated with personal beliefs.
• Mood Regulation: Engaging in activities to stabilise or channel energy positively, such as creative tasks or systematic planning.
• Selective Engagement: Reducing contact with triggers or prioritising calming activities during high or low moods.

The strategies reflect a conscious effort to align behaviours with desired emotional states. Some other forms of strategies found in multiple research studies that have worked in the maintenance of bipolar disorder are exercise, yoga, light therapy, and acupuncture, which also help in coping with mood disturbances. (Ravindran & Da Silva, 2013) (Jean et al., 2022) (Tseng et al., 2016)

Additionally, the use of mood tracking apps and self-management apps can help in managing bipolar disorder by focusing on the ability to manage symptoms, objectively monitor symptoms, better treatment adherence, easy accessibility and better awareness regarding their condition. (Morton et al., 2022).

Treatment options for bipolar disorder

The role of lithium in treating bipolar disorder

Lithium, introduced by John Cade in 1949, is the most established long-term treatment for bipolar disorder. One of the most significant advantages of lithium treatment is its profound impact on reducing suicide risk among patients. Studies have shown that lithium can decrease the risk of suicide in individuals with bipolar disorder by more than 50%. This is a crucial finding, considering the increased vulnerability of these individuals to suicidal thoughts and actions.

Despite its benefits, lithium therapy comes with its share of challenges. Potential side effects include: 

• Pregnancy risks: Lithium may entail certain risks when prescribed during pregnancy, necessitating careful consideration and management.
• Thyroid dysfunction: Patients may experience alterations in thyroid function, which require monitoring and possible treatment adjustments.
• Renal effects: The impact on renal function is another area that requires attention, ensuring that patients receive comprehensive care to manage these side effects effectively.

Pharmacotherapy as treatment for bipolar disorder

The primary goal in treating bipolar disorder is to stabilise patients experiencing acute manic or depressive episodes. Effective pharmacotherapy brings them to a state of equilibrium, where their mood is steady and predictable. According to Geddes & Miklowitz (2013), typical treatments include:\

• Antipsychotics are primarily used during manic episodes.
• A mood stabiliser, such as lithium, helps in maintaining a balanced mood over time.
• Antidepressants and Cognitive Behavioural Therapy (CBT) are generally reserved for periods of bipolar depression.

Psychotherapy as a treatment for bipolar disorder

The role of psychotherapy for the treatment of bipolar disorder remains crucial. It goes beyond mere management of symptoms, fostering substantial, long-term wellness.

The primary objectives of adjunctive psychotherapy for bipolar disorder are psychoeducation, stress management techniques, how to recognise and address early recurrence indicators, and how to maintain regular lifestyle (e.g., sleep and exercise) habits. (Geddes & Miklowitz, 2013). Here is a glimpse of the therapies that can help with bipolar disorder management:

• Psychoeducation: Creating a rationale to help patients to reach out, continue and adhere to treatment.
• Cognitive behaviour therapy: Identifying and changing maladaptive thought patterns, beliefs and behaviours that can escalate the severity of the condition.
• Family-focused therapy: Decreasing the overall stress level for the patient through improving interpersonal relationships, which can lead to an individual feeling more supported.
• Interpersonal and social rhythm therapy: Improving mood and circadian stability, daily routine, regulating social rhythms, etc.
• Peer support: Enhancing self-efficacy, better awareness and decreasing social stigma and isolation. 

Benefits of psychotherapy

To better understand the benefits of psychotherapy for Bipolar Disorder, let’s take a look at some research studies: The findings from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), backed by the National Institute of Mental Health (NIMH), are particularly revealing. This comprehensive study demonstrates that intensive therapeutic approaches like family-focused therapy, interpersonal and social rhythm therapy, and cognitive-behavioural therapy not only speed up recovery but also help in maintaining clinical stability over the long term.

• Participants who engaged in intensive therapies reported not just clinical improvements, but also enhanced relationships, better functioning and increased overall life satisfaction.
• This suggests that intensive psychotherapy not only addresses the clinical symptoms of bipolar disorder but also improves the overall quality of life.
• Furthermore, a meta-analysis of various maintenance therapy trials shows that whether through family-based, individual, or group interventions, these strategies significantly reduce the risk of mood relapses. 
• The impact on social functioning varies widely, these therapies notably reduce the frequency of mood episodes when compared to standard care.

The substantial body of research confirming the effectiveness of psychotherapy in treating bipolar disorder highlights the necessity of this treatment approach. For anyone managing this condition, incorporating psychotherapy could be a key component in achieving not only stability but also an improved quality of life. 

Treating acute manic episodes

When an adult experiences an acute manic episode, immediate intervention is essential to reduce potential harm to both the individual and others around them. Researchers McIntyre et al. (2020) point out that medications such as carbamazepine, lithium, divalproex, and antipsychotics have shown significant antimanic properties. Lithium, in particular, is favoured not only for its effectiveness in acute scenarios but also for its mood-stabilising qualities that are beneficial in long-term treatment plans.

Treating bipolar depression

The treatment for bipolar depression integrates the use of several pharmacological options to manage symptoms effectively. Key medications include:

• Lithium and Lamotrigine: Well-known mood stabilisers.
• Second-Generation Antipsychotics: Offer additional support when used alongside traditional mood stabilisers.
• Cariprazine, Lurasidone, Quetiapine, and the Olanzapine–Fluoxetine Combination: Specifically geared towards treating symptoms of bipolar depression.

Navigating the complexities of bipolar disorder treatment requires a strategic and well-rounded approach, with pharmacotherapy playing a pivotal role. By understanding and applying the correct medication protocols, healthcare providers can significantly improve the stability and quality of life for individuals affected by this challenging disorder.