Lily Strachan serves as a chaplain to Robert Menzies College at Macquarie University. She was a fellow with Anglican Deaconess Ministries (ADM) in 2021 and is completing a book on living with bipolar and loving those who do. In this article, Lily discusses treatment for bipolar and shares how her Christian faith has been of profound benefit. In a previous article, Lily shares her experience and helps us to understand bipolar. In a later article, Lily will share how to care for someone living with bipolar.
Treatment
Complexity
In my first article on understanding bipolar disorder, I talked about complexity.
Bipolar can be difficult to diagnose, and the causes are not always clear. There are vulnerabilities and triggers, signs, and symptoms, but we cannot yet predict exactly who will develop this illness, or what it will look like from person to person.
It’s no surprise, then, that treating bipolar disorder is also complex. This is partly because there is a lot going on for the person living with this illness. Treatment must address a range of changing mood states – hypomania, mania, psychosis, depression, and sometimes suicidal thinking. Some people will face additional challenges such as anxiety, addiction, or a personality disorder.
Underpinning all this is the reality that we are complex beings. We have a genetic and chemical makeup, and minds and bodies that respond to exercise, food, medication, and sleep. We are also emotional, relational, and spiritual beings. Good treatment will seek to address a person in all their complexity.
If you live with bipolar, you will need help, but the good news is that there is help available.
Management
There is no cure for bipolar disorder – no single pill, brain surgery, or blood infusion. Researchers are on the case, but for now, the way to live and thrive as a person with bipolar is to manage this illness.
In most cases, effective management of bipolar will involve the following:
- Medical care – including medication prescribed and managed by a psychiatrist.
- Lifestyle management and physical care – including a good routine, sleep, diet, and exercise.
- Psychological care – including talk therapy with a psychologist or counsellor.
Some people will also benefit from:
- Hospitalisation
- Alternative treatments that act on the brain through controlled seizures (electro convulsive therapy – ECT), or deep brain stimulation (trans magnetic stimulation – TMS).
Bipolar is an illness where mood can be impacted day to day and year to year by a range of life’s circumstances and changing brain chemistry. Because of this, management of bipolar must also be dynamic. Treatment that may be effective one year can change the next. Bipolar is not an illness where treatment should remain stagnant and unexamined by either you or your doctor.
Medication
Medication is almost always necessary for the effective treatment of bipolar. Exactly what is happening in a bipolar person’s brain is in many ways unknown. Researchers have discovered several drugs that help regulate wayward moods, even if the precise ways in which they affect our brains (including our neurons, synapses, and neurotransmitters) are yet to be fully understood.
Medications that are available to help treat and manage bipolar include:
- Mood stabilisers to balance mood, such as the bipolar ‘gold standard’ drug lithium.[1]
- Antipsychotics to prevent and dampen high moods, such as olanzapine, lurasidone, and quetiapine.
- Antidepressants to lift low moods and lower anxiety, such as SSRIs (Selective Serotonin Reuptake Inhibitors) like escitalopram or SNRIs (Selective Serotonin and Norepinephrine Reuptake Inhibitors) that work to increase these two brain chemicals in the synapses between brain cells.
- Anticonvulsants that researchers think work on neuron cells to control mania, such as lamotrigine and valproate.
The regime that currently keeps me well comprises the mood stabiliser lithium, antipsychotics quetiapine and lurasidone, antidepressant escitalopram, and anticonvulsant lamotrigine. Most people won’t need this many drugs to manage their bipolar, but as my dear psychiatrist likes to tell me, “You’re complicated.”
Far from ‘changing your personality’ or indicating a character defect, the right medication/s will help you to be you, free from the damaging impacts of excessively high or low moods. Just like we wouldn’t suggest that a diabetic should try to live without managing their blood sugar levels with insulin, we need to stop thinking that medication for mental illnesses is somehow optional, or a sign of weakness.
we need to stop thinking that medication for mental illnesses is somehow optional, or a sign of weakness.
It is true that people diagnosed with bipolar and their doctors may have to endure a frustrating time experimenting with different drugs and dosages to find your goldilocks mood zone. This can leave you feeling defeated and inclined to give up on medication altogether. But in my experience – and that of many others – the refining process is worth the effort.
Side effects
Part of finding the right medication/s is assessing the impact of side effects on your life and wellbeing. Don’t hesitate to speak up to your doctor if you are finding the side effects of a particular drug to be contributing to poor health.
When I was first diagnosed, a psychiatrist put me on an anti-psychotic that resulted in me putting on a lot of weight, losing hair, and – most upsettingly – increasing my depression. It took me a year before I meekly asked if we could try something else. She immediately said of course and prescribed another anti-psychotic that was much better for me.
Some drugs come with side effects that can be managed relatively easily. For example, lithium requires regular blood tests to ensure that there is no impact on the kidneys. Your psychiatrist will be able to assess this potential side effect by checking the lithium levels in your blood, and adjust your dosage accordingly.
After wading through the wilderness of trialling different drugs, I am happy to live with the side effects that come with my current medications. The stability and wellness I enjoy drastically outweigh the downsides.
An important word about medication: Don’t stop taking a medication just because you are not feeling manic, hypomanic, or depressed. Quite possibly the reason you are well is because you are taking the medication prescribed to you. Sometimes it will be appropriate to taper off or change a particular medication, but this should be done under the care of your doctor to prevent unwanted impacts on your health and safety.
Psychiatrists
Sadly, not all psychiatrists are equally helpful. For me, it took two psychiatrists and four involuntary hospital admissions to find my current doctor. Under those first two psychiatrists, I faithfully took the medication prescribed and attended regular appointments, but it did not stop the extreme highs or desperate lows. I assumed this was all I could expect from life with bipolar.
Looking back, those psychiatrists failed to do a few key things that my current doctor does well.
First, previous doctors focused on preventing mania and psychosis but didn’t do much to treat the depression that characterised my life. They were not willing to prescribe an anti-depressant. This was not completely unreasonable, given that anti-depressants can trigger mania or hypomania.
In contrast, my current psychiatrist has been just as determined to treat my depression as my high moods. Under his care, I take an antidepressant each day, balanced with anti-psychotic and mood stabilising medication.
Second, my psychiatrist is readily available. I switched to my current doctor after he saw me in hospital for my last psychotic episode in 2012. At first, we met twice a week so he could closely monitor my wobbly moods and fragile state. It took time and close attention for him to work out what medications produced the most stable mood and acceptable side effects. As he refined the drugs and dosages to ensure greater balance, my appointments moved to weekly, monthly, and – now that my moods are stable – to twice a year.
Early warning signs and early intervention
Third, my psychiatrist has taught me how to manage bipolar by being aware of my early warning signs for mania.
For me, when I struggle to sleep, or when my thinking and speech speed up, I know that my mood is becoming elevated. Others may become easily irritable or have grandiose delusions. I am wary, for example, when I set out to write the great Australian novel.
Over the years my psychiatrist has taught me how to tweak my medication in response to those early warning signs. For example, when I notice signs of elevated mood, I know to increase the dosage of one of my anti-psychotics and halve my anti-depressant until my mood settles down.
Early intervention is key to ensuring you don’t become unwell. My doctor has taught me how to notice my triggers and act straight away.
Early intervention is key to ensuring you don’t become unwell. My doctor has taught me how to notice my triggers and act straight away.
Seek help from your doctor in adjusting your medication in response to early warning signs. My psychiatrist is quick to respond in between appointments because he knows that if symptoms go unchecked and untreated, they grow in intensity, leaving patients at greater risk of a runaway manic or hypomanic episode.
When it comes to psychiatrists, if you are not getting better – repeatedly unable to manage your moods or stay out of hospital – I think it’s worth getting a second opinion. It can be a difficult process trying to get the medications right, but a good doctor will not give up until you are as well as possible.
Lifestyle management and physical care
There are other things you can do alongside taking the right medication to help balance your mood. When your mood is edging up, think about how you can reduce stimuli in your life. For example, if things are speeding up for me, I will stay home or spend time with a friend, rather than go to the big, exciting party. If my mood is dipping, I do what I can to get out of the house, into the sunshine or a favourite cafe with a close friend or an easy-to-read book.
Research has found regular exercise to be as impactful as anti-depressants for cases of mild to moderate depression. Don’t underestimate the importance of your physical self and the impact of movement, healthy diet, and regular sleep on your mind and body.
Routine is also key. Humans thrive when there is regularity to sleep, work, rest, and play. For the person living with bipolar, a steady routine – particularly when it comes to sleeping and waking, exercise, and work hours – is helpful for managing moods.
You may notice that certain times of the year – such as seasonal changes or holidays – disrupt your routine and mood. It is important to be aware of what times of the year may trigger instability for you and to take steps to protect yourself.
Lifestyle adjustments like these are not enough to keep most people well – for that, medication is needed. But they can be effective ways to help flatten the ups and downs.
In all of this, it can be helpful to track your mood, routine, and sleep on a chart or with an app to help detect early warning signs and assess the impact of new or changing medication.
Psychological care
Most people with bipolar will spend more time depressed than manic or hypomanic. Sadly, bipolar depression is harder to treat than elevated moods – with mania and hypomania typically being more responsive to medication than depression.
Psychological care in the form of talk therapy with a psychologist or counsellor can be helpful. The person living with bipolar depression can be helped by a range of therapies. Cognitive Behavioural Therapy (CBT) is used to challenge unhelpful negative thinking and beliefs. Acceptance and Commitment Therapy (ACT) and family systems therapy can help you to process difficult emotions, whilst grieving loss and managing challenges.
Again, finding a psychologist that works for you can involve trial and error. In my experience it is key to find someone you respect, who listens well, and helps you to bring compassion, curiosity, and calm to your life. Getting a mental health care assessment with your GP may entitle you to subsidised visits with a registered psychologist.
Hospital when suicidal
If someone is severely depressed or suicidal, time in hospital can be a helpful part of their treatment. It could be an involuntary admission in the case of someone being in extreme danger and unwilling to seek safety, or it could be a voluntary admission – as was the case for me in 2010.
Early that year, the darkness of depression loomed over and swallowed me up. By September, I was so desperately sad that it felt like death was the only way out. I shared how I was feeling with my parents, and they suggested we call the local hospital’s Mental Health Care Team. The nurse I spoke with asked questions about my mood, my thoughts, and any plans I had to kill myself. As we discussed these details, a narrow sliver of relief broke through. My despair felt seen and validated. The nurse suggested I come into hospital for a few days to rest and stay safe. Unable to see how I could go on living or organise dying, I agreed.
It turned out to be a wonderful relief. I got to pause life and responsibilities, and I didn’t have to pretend that I was fine. After a few days resting in hospital, the sun peeked out from behind the clouds – enough that getting out of bed was not so unbearable and living felt possible.
Friends of mine have also found time in hospital beneficial in providing access to therapies such as ECT or TMS. These can be effective treatments for bipolar where symptoms of depression or mania have not shifted with medication and other therapies.
Hospital when manic or psychotic
As it should be, hospitals do not detain troubled minds readily. At each of my involuntary hospital admissions for severe mania/psychosis, I have vague memories of being given time and space to calm down and return to reality.
Perhaps others have managed to come down from such highs whilst staying out of hospital, but I never did. As painful and confusing as an involuntary admission is, the safety of a hospital bed, with carefully monitored medication and therapy was what I needed.
Faith
Throughout years of illness, I have benefited greatly from physical, medical, and psychological help. My wellbeing has improved through expert doctors, exercise, the right medication, and the occasional respite in the hospital.
But we are not just bodies and brains. We are not even just our moods and our thoughts. We are relational, and spiritual. For me, knowing that God is real and good is a game changer – especially for the depression that has been so stubbornly persistent in my life.
Since becoming a Christian in high school, I have long claimed that God is all-good and all-powerful. But my experience of suffering over the last twenty years led me to doubt this entirely. How could God be good and powerful when illness has darkened so many days? Perhaps God is good in a distant kind of way, but he certainly isn’t good to me.
Over the years, I have seen God answer my cries for help, reminding me through the Bible, through people, and in nature, that he is at work in my life. But sometimes this isn’t enough – if God is good, I can’t see it.
But we are not just bodies and brains. We are not even just our moods and our thoughts. We are relational, and spiritual.
How can I rely on a God who seems so ineffectual, uncaring, or missing in action?
What stands out to me, stark and bloody and real, is the crucifixion of Christ. Entering my mess, giving up all his relationships and comforts, being judged in my place, Jesus loved me to his dying breath.
Depression fits with the scene’s gritty bleakness, the sky turning black, and Jesus’ profound isolation and grief. With a broken heart, Jesus cried out to God, asking, ‘My God, my God! Why have you forsaken me?’ Mark 15:34
My feelings might scream ‘God is not good’. But I have realised that my experiences and emotions do not define what is true about life. Whilst they are valid and important, my feelings don’t trump the historical weight of Jesus’s life, death, and resurrection. This is how I remember that my life is safe in God’s hands. This is how I can echo the words of the Psalmist,
‘But I trust in your unfailing love; my heart rejoices in your salvation.
I will sing of the Lord’s praises, for he has been good to me.’ Psalm 13:5-6
When people speak the truth in love to me, it is remarkable. I’m always thankful for family, friends, and counsellors. But when I remember that Christ is himself truth and love for me, this is powerful beyond measure.
The Bible insists that the God who made and sustains me, will one day soon return to recreate all things, and end illness, pain, and death for good. Because of the cross, as we wait for that day, we can trust that God will work for our good – even through mess, suffering, and heartache.
This might sound strange – maybe even offensive. Certainly, our complexity means that we can’t say, “just pray, trust God, and you’ll be fine.” But equally so, I don’t think we can say, “just see your doctor, take medication, exercise, and you’ll be fine.”
We ignore our relational and spiritual selves at our peril. Secular authors, researchers, and doctors have long acknowledged the power of religion and spirituality for mental health.[2] I think it is always worth investigating where you find meaning, hope, and joy in life.
For me, knowing that God is at work in my life for good changes everything. It has had a profound impact on my depression, lifting it in a way that has been just as important as the medications I take.
It is also imperative that you don’t go it alone when seeking to treat and manage bipolar. My next article will focus on how you can care for someone who lives with bipolar.
If you or someone you know is in crisis, please call one of the following national helplines:
Lifeline 13 11 14, Suicide Call Back Service 1300 659 467
[1] It was Australian psychiatrist John Cade who discovered in 1948 that lithium worked as a mood stabiliser in the treatment of bipolar – then known as manic depression.
[2] For example, see Prof Ian Hickey and James O’Loghlin Minding Your Mind: Understanding Your Mind, Taking Control of your Mental Health (Penguin Random House) 2022, 255-262 and Hugh can Cuylenburg The Resilience Project: Finding Happiness through Gratitude, Empathy, and Mindfulness (Ebury Australia) 2019.
The Mayo Clinic found that “a majority of nearly 850 studies of mental health and 350 studies of physical health have found a direct relationship between religious involvement and spirituality and better health outcomes.” Paul Mueller, David Plevak, Teresa Rummans “Religious Involvement, Spirituality, and Medicine: Implications for Clinical Practice” Mayo Clin Proc. 2001;76:1225-1235.
