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Navigating Bipolar Disorder: Listen Closely, Treat the Whole Patient, and Don't Stop at “Better”

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Released: October 20, 2026

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Optimal management of bipolar disorder requires looking beyond the diagnosis to understand the patient’s full clinical presentation, treatment experience, and goals. Careful clinical interviewing can help distinguish bipolar from unipolar depression and uncover symptoms that may otherwise be missed, and ongoing assessment of residual symptoms, comorbidities, prior treatment response, tolerability, and substance use can guide individualized treatment decisions. Across the course of care, the clinical challenge is not simply achieving improvement, but determining what continues to limit meaningful recovery and adapting treatment accordingly.

Erin C. Crown
Erin C. Crown, PA-C, CAQ-Psychiatry
Navigating Bipolar Disorder

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I am genuinely excited to present at the upcoming Psychopharmacology Update conference because there are so many practical pearls in bipolar disorder that can change how we approach diagnosis, treatment selection, and long-term management.

I think one of the biggest themes is that good care starts with knowing the patient and not simply matching a diagnosis to a treatment indication. It is important to listen closely to how patients describe their symptoms, fully understand what is getting in the way of their goals, and make thoughtful treatment decisions based on their whole clinical picture.

Diagnosing Bipolar Disorder: Hear What the Patient Is Actually Telling You
When considering a diagnosis of bipolar depression vs unipolar depression, it is important to look beyond the standard psychiatric evaluation. Age of onset, hormonal changes, metabolic conditions, migraine, autoimmune disorders, hypothyroidism, PTSD, eating disorders, and other comorbidities can all contribute to the overall clinical picture. I am also very thorough with the general review of systems—for example, do they have asthma? Do they have a current or past history of a seizure disorder?—because those findings may ultimately affect the medications I can safely consider.

However, some of the most important information comes from how we listen. A patient experiencing a depressive episode might tell you, “I just don’t feel like doing anything.” If we stop there, we might interpret that as low energy or lack of motivation. But if you ask 1 more question: Why don’t you feel like doing anything? The answer may be, “It doesn’t seem like it would be any fun,” or “The last time I did it, I didn’t enjoy it.” That type of answer can provide a very different clinical signal, pointing to anhedonia instead of low energy or fatigue.

Similarly, if a patient says, “I don’t believe anything will ever be different,” that can sound like hopelessness, but it may also reflect an inability to anticipate pleasure. Our patients generally are not going to walk into the office and tell us that they have anhedonia, but they will tell us how they are experiencing their lives, and our job is to understand what those descriptions mean. Motivational interviewing techniques can be important for hearing our patients' responses and asking follow-up questions to dive a little bit deeper and more fully understand their lived experience.

Screening tools can help, particularly when time is limited, but they do not replace a comprehensive clinical evaluation. Tools such as the Rapid Mood Screener and Mood Disorder Questionnaire can help provide additional information when bipolar disorder is suspected, but their performance can vary across bipolar subtypes and clinical populations. The PHQ-9 is useful for identifying and following depressive symptoms, but depressive symptoms alone do not distinguish unipolar from bipolar depression. If we rely on depression screening alone, we may never uncover the hypomanic history that changes the diagnosis.

Hypomania can be especially easy to miss because patients do not necessarily experience it as a problem. Someone who has spent much of their symptomatic time depressed may interpret increased energy, productivity, and improved mood as simply feeling “normal.” That is why careful follow-up questions and thoughtful interviewing matter so much.

Treatment Selection Should Go Beyond the Indication
Once we have a working diagnosis, treatment selection should be individualized based on the patient’s treatment history, comorbidities, and preferences.

To determine the optimal treatment approach, it is important to know what the patient has taken before, how they responded, what they tolerated, what comorbidities they have, and what risks matter for that particular person. Metabolic status, anxiety, adverse event (AE) vulnerability, substance use disorders, and other aspects of the patient's presentation can change how I think about the available options.

Multiple evidence-based pharmacologic options are available for bipolar depression, with meaningful differences in efficacy across phases of illness, AE profiles, tolerability, and patient-specific considerations that can influence treatment selection. That requires understanding more than whether a medication has an indication for bipolar depression. We need to understand pharmacodynamics, receptor targets, and how those characteristics may intersect with the individual patient's symptoms and risks. “It is approved for bipolar depression” should not be the end of our clinical reasoning.

Optimal Dose Is Not the Same as Maximal Dose
When a patient has an incomplete response, I do not immediately jump to “switch or augment?” First, I reassess the clinical picture: Is the diagnosis still the right one? Is the patient taking the medication consistently? Has the treatment had an adequate trial, and is there room to optimize the dose? Are substance use, comorbidities, or other medications contributing to persistent symptoms?

It is important to remember that maximum dose and optimal dose are not the same thing. In addition, if a patient has had a meaningful partial response and tolerability is acceptable, I may consider augmentation. If there has been little to no response, I am more likely to consider a switch. The degree of benefit, the AE burden, and the patient's overall clinical situation can help determine whether optimization, augmentation, or switching makes the most sense.

A patient can be functioning better and still have important residual symptoms. In bipolar disorder, residual symptoms are clinically important because they are associated with an increased risk of recurrence, reinforcing the importance of assessing symptoms that persist even after a patient has meaningfully improved. Anhedonia, in particular, can persist even when a patient is no longer reporting obvious sadness or low mood. We need to keep asking about the patient's full experience rather than assuming that “better” means the work is finished.

Our goal should be to move toward remission whenever possible, using shared decision-making to determine whether optimization, augmentation, or switching makes the most sense.

Managing Tolerability Starts Before the First Dose
Tolerability is not simply something we deal with after an AE occurs. I think expectation setting is part of prescribing. Before a patient starts treatment, I discuss the AEs they are most likely to encounter and, when appropriate, whether they may be transient or potentially manageable. Sometimes a change in dosing time may help with somnolence (eg, taking the medication at bedtime instead of in the morning). With symptoms such as dizziness or nausea, the question may be whether the effect is manageable with supportive care and likely to improve or whether it creates a safety problem that warrants a different treatment strategy.

Other AEs, particularly those involving weight, metabolic health, or sexual function, can have a major impact on quality of life and treatment adherence. We need to be willing to discuss these issues with patients directly. Patients sometimes stop taking a medication and do not tell us why, particularly when they are uncomfortable discussing an AE. I want patients to understand that these conversations are normal and welcome. If something about treatment interferes with their quality of life, I want to know about it so we can decide together what to do next. I find that having a conversation to set these expectations appropriately before beginning therapy can help patients remain on a treatment long enough to determine whether it can benefit them.

Comorbid Substance Use Requires Parallel Attention
Active substance use can make mood stabilization much more difficult. When patients are using marijuana daily, opioids regularly, or excessive amounts of alcohol, I think we have to be direct about the fact that those substances are also affecting the brain and their clinical picture.

Understanding whether the mood disorder or the substance use disorder came first can help us understand the patient's story, but it does not eliminate the need to address both. Depending on the substance and the individual situation, that may include abstinence or reduction, appropriate medication treatment for substance use disorder, counseling, and other forms of dual care.

Long-term Management Is Bigger Than the Prescription
For bipolar disorder, I generally expect pharmacologic treatment to remain an important component of long-term management. However, ongoing psychotherapy, exercise, healthy nutrition, meditation, meaningful goals, and other healthy behaviors can all be part of supporting longer-term stability. It is important to emphasize to patients that a prescription is not the solution but is another tool in the toolbox.

This brings me back to what may be the most important point of all: get to know your patient. What are their goals? What is keeping them from getting there? Is it persistent depression? Poor tolerability? Lack of benefit from previous treatment? Substance use? Something else entirely?

Once we understand what the patient wants their life to look like, we can work with them to identify what is standing in the way and choose treatments and resources that actually address those barriers.

Join Us at the Live Session
At the upcoming Psychopharmacology Update conference on Friday, November 20 and Saturday, November 21, 2026, we will explore these issues in greater depth: recognizing bipolar disorder when the diagnosis is not obvious, individualizing treatment selection, deciding when to optimize, augment, or switch, managing safety and tolerability, and supporting patients over the long term.

Register now to hear more, and join us ready to ask questions, share your experiences, and think together about how we can make these decisions more thoughtful and more individualized.

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When a patient with bipolar depression has improved but has not achieved full symptomatic and functional recovery, what most often limits your ability to further optimize treatment?

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