Clinical Care Guideline: Bipolar Disorder (BD)

This article shares best practices for assessment and treatment of adults with bipolar spectrum disorders.

Bipolar disorder (which includes Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and related bipolar spectrum conditions) is a chronic mental health condition characterized by recurrent mood episodes of depression and elevated or irritable mood. An estimated 1 in 200 (or 37 million) people live with bipolar disorder worldwide. Bipolar disorder is associated with significant challenges in functioning, quality of life, and overall health outcomes. 

This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of bipolar disorder in adults.

Diagnostic Considerations for Bipolar Disorder in Adults

Note: Bipolar I and Bipolar II each have specific diagnostic criteria regarding symptom duration, severity, and episode history. The information below provides a general clinical guide and is not a substitute for reviewing the full diagnostic criteria. Please consult the DSM-5 for detailed distinctions.

Over the past several weeks to months (and historically across the client’s life), assess whether the client has experienced:

Distinct mood episodes, including:

  • Manic or hypomanic episodes: periods of elevated, expansive, or irritable mood with increased energy or activity, such as:
    • Decreased need for sleep (e.g., feeling rested after only a few hours)
    • Increased talkativeness or pressured speech
    • Racing thoughts or flight of ideas
    • Increased goal-directed activity or psychomotor agitation
    • Inflated self-esteem or grandiosity
    • Risky or impulsive behaviors (e.g., spending sprees, risky sex, reckless driving, substance use)
    • Increased distractibility or difficulty staying on task
  • Major depressive episodes: periods of depressed mood and/or loss of interest or pleasure, such as:
    • Persistent depressed mood and/or loss of interest or pleasure
    • Appetite or weight changes
    • Insomnia or hypersomnia
    • Fatigue or low energy
    • Psychomotor agitation or retardation
    • Difficulty concentrating or indecisiveness
    • Feelings of guilt or worthlessness
    • Recurrent thoughts of death, suicidal ideation, or suicidal behavior

Differential Diagnosis

It is important to note that mood symptoms may also be attributable to:

  • Unipolar depressive disorders
  • Substance/medication-induced mood symptoms
  • Mood disorders due to another medical condition
  • Personality disorders or trauma-related conditions that may include affective instability

As a clinical best practice, engage in a thorough longitudinal mood history, review of medical and substance-related factors, and differential diagnostic assessment before confirming a bipolar diagnosis.

For complete diagnostic criteria, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787

Documentation Tip: When documenting care, be sure to include the specific symptoms and distinct mood episodes (manic, hypomanic, depressive) the client experiences, including the duration, onset, and frequency of symptoms and episodes. This reflects diagnostic alignment and demonstrates medical necessity for services.

noun-lightbulb-1262995.png When documenting care, be sure to include the specific symptoms of GAD experienced by the client. This ensures your note reflects alignment with the diagnosis and demonstrates medical necessity for the service.

Symptom Screening and Monitoring

Measurement Informed Care (MIC) is foundational to effective treatment of bipolar disorder due to its episodic and fluctuating nature. Routine use of structured assessment tools supports diagnostic clarity, early detection of relapse, and treatment planning.

Consider using:

  • PHQ-9 – to assess depressive symptom severity
  • GAD-7 – to track anxiety symptoms commonly co-occurring with bipolar disorder
  • MDQ - to track mood changes over time
  • Daily or weekly mood charts including:
    • Mood state (depressed, neutral/euthymic, elevated/irritable)
    • Sleep duration and quality
    • Energy levels
    • Risk behaviors (e.g., spending, substance use, impulsivity)
    • Medications and adherence

Routine use of these tools helps clinicians:

  • Clarify mood episode patterns
  • Identify emerging warning signs of mania/hypomania or depression
  • Adjust treatment plans accordingly
  • Support accurate, ongoing assessment of clinical progress and medical necessity

Evidence-Based Approaches to Treatment

Research consistently demonstrates that bipolar disorder is most effectively treated through a combination of psychotherapy and psychiatric medication management, along with psychoeducation, lifestyle stabilization, and coordinated care.

Psychotherapy

Evidence-informed psychotherapy approaches include:

Psychoeducation

  • Understanding the nature of bipolar disorder
  • Recognizing typical relapse patterns
  • Identifying early warning signs and triggers
  • Supporting adherence to psychiatric treatment
  • Encouraging involvement of family or supports when appropriate

Cognitive-Behavioral Strategies

  • Challenging cognitive distortions related to mood states (e.g., grandiosity, hopelessness)
  • Addressing beliefs that interfere with sleep, routines, or medication adherence
  • Developing balanced thinking across mood fluctuations

Interpersonal and Relationship-Focused Interventions

  • Reducing interpersonal stressors that can precipitate episodes
  • Supporting communication skills, role transitions, and boundary-setting
  • Couples or family involvement as indicated

Behavioral and Routine-Focused Interventions

  • Establishing regular sleep-wake patterns
  • Maintaining consistent daily routines (meals, work, self-care)
  • Incorporating appropriate physical activity
  • Planning behavioral adjustments when early signs of elevation or depression appear
  • Engaging with a mood tracker for at least 30 days to understand patterns and triggers

Relapse Prevention and Safety Planning

  • Identifying individualized early warning signs
  • Creating a step-by-step action plan for responding to emerging symptoms
  • Maintaining an updated safety plan tailored to the client’s risk profile

Medication

Medication management is central to evidence-based care for bipolar disorder. First-line medications commonly prescribed by psychiatric providers include:

  • Mood stabilizers: e.g., lithium, valproate, lamotrigine
  • Atypical antipsychotics: e.g., quetiapine, olanzapine, lurasidone, cariprazine

While prescribing medication is outside of a psychotherapist’s scope, collaboration with the medical prescriber strengthens outcomes. Therapists play an essential role in:

  • Encouraging medication adherence and normalizing treatment
  • Supporting psychoeducation on the role of medication as one tool among many
  • Monitoring for clinical changes or concerns or reported side effects and coordinating with the prescriber

💡 Scope of Practice Reminder

It is beyond the scope of a psychotherapist to:

  • Recommend specific medications or doses
  • Advise starting, stopping, or adjusting medications
  • Recommend supplements or medical regimens

All medication related decisions must be made by a qualified prescribing clinician such as a Psychiatric Nurse Practitioner or Psychiatrist. 

noun-lightbulb-1262995.png As a reminder, it is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider.

When Should I Refer My Client for Psychiatric Medication Management?

Psychiatric involvement is generally recommended early and consistently in bipolar disorder. Strong indications for referral include:

  • Suspected bipolar disorder without current psychiatric care
  • History of manic, hypomanic, mixed, or severe depressive episodes
  • Psychiatric hospitalization or ED visits for mood or safety concerns 
  • Significant impairment in functioning due to mood instability
  • Recurrent depressive episodes with suspected bipolar features
  • Active or recent suicidal ideation, self-harm, or high-risk behaviors
  • Poor response to psychotherapy alone
  • Difficulty adhering to medication or experiencing adverse effects

Best practice steps:

  1. Discuss the need for psychiatric evaluation with the client in a collaborative, normalized manner.
  2. Submit a referral through Rula’s psychiatric referral workflows.

Clinical Resources to Support Treatment

To support your work with clients, Rula has developed a suite of evidence-based tools designed to complement your existing interventions. Feel free to download and share these worksheets that were selected specifically to address symptoms associated with Bipolar Disorder to help your clients deepen their progress:

  • Social Rhythm Metric: Using structured daily tracking of "social anchors" to stabilize the body’s internal biological clock (circadian rhythm), targeting the instability in sleep and activity that can trigger mood episodes for individuals with Bipolar Disorder.
  • Identifying Warning Signs/Symptoms: This technique involves helping the client identify the individual behavioral and biological shifts that are early indicators of a mood episode, which increases client awareness and allows for proactive intervention before symptoms escalate.
  • Urge Surfing: This mindfulness skill teaches clients to observe behavioral impulses as temporary "waves" that naturally peak and subside, allowing them to experience the sensation without acting on the urge. By shifting focus to physical sensations, clients learn to "ride out" the impulse until the neurochemical intensity diminishes.

To learn more about utilizing worksheets in your clinical practice, and to view the full library of resources, visit the Help Center article Utilizing Worksheets to Support Progress in Therapy. 

Assessing Risk and Higher Level of Care Needs

Bipolar disorder is associated with elevated risk for:

  • Suicidal ideation, attempts, or suicide
  • Impulsive or dangerous behaviors (e.g., reckless driving, risky sexual behavior, financial irresponsibility)
  • Substance use and co-occurring disorders
  • Psychotic features during severe mood episodes
  • Rapid decompensation during mania or severe depression

Clinicians should:

  • Conduct regular, documented assessments of suicide risk, self-harm, harm to others, psychosis, and impulsive behaviors
  • Collaboratively update a written safety plan, including:
    • Early warning signs
    • Internal coping strategies
    • Social supports
    • Crisis contacts and 988 
    • Clear criteria for seeking emergency care

Referral to Higher Levels of Care (HLOC)

Consider IOP, PHP, inpatient, or residential programs when:

  • There is acute risk of harm to self or others
  • Mania or depression severely impairs judgment or functioning
  • Outpatient therapy and routine psychiatry are insufficient for stabilization

Rula’s care coordination team can support clients in accessing HLOC services outside of Rula when needed.

noun-lightbulb-1262995.png Rula’s team of care coordinators is available to support your client in accessing additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC).

Cultural Considerations

The expression and understanding of bipolar symptoms are influenced by cultural contexts, including:

  • Beliefs about mood variability and mental illness
  • Explanatory models (e.g., spiritual, medical, relational)
  • Stigma around psychiatric diagnoses and medications
  • Norms related to emotional expression, sleep, and social behavior
  • Access to and trust in mental health or psychiatric services

Research shows that when clinicians incorporate cultural needs and values into assessment and care planning, outcomes significantly improve!

Disclaimer: Bipolar Disorder in Children and Adolescents

This care guide focuses on best practice guidelines for adults. Bipolar disorder in children and adolescents presents with developmental differences, overlapping symptoms with other conditions (e.g., ADHD, trauma responses), and unique treatment considerations.

When working with youth:

  • Use developmentally appropriate assessment tools
  • Involve caregivers in psychoeducation, adherence, and safety planning
  • Collaborate closely with child/adolescent psychiatric providers

Refer to child- and adolescent-specific bipolar resources and guidelines for more detailed pediatric best practices.

References

  1. American Academy of Family Physicians. 
    https://www.aafp.org/pubs/afp/issues/2021/0215/p227.html 
  2. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/bipolar-disorder 
  3. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787 
  4. Journal of Psychosocial Nursing & Mental Health Services, 2007, Vol 45, Issue 7, p32
    https://openurl.ebsco.com/EPDB%3Agcd%3A14%3A26583934/detailv2?sid=ebsco%3Aplink%3Ascholar&id=ebsco%3Agcd%3A106171235&crl=c&link_origin=scholar.google.com 

Updated

Was this article helpful?

0 out of 0 found this helpful