Understanding Bipolar Disorder: Psychological and Biological Perspectives in Treatment
Bipolar disorder is a complex condition. It encompasses a wide array of mood changes that are collected under a single diagnostic umbrella. The heterogeneity of bipolar disorder often makes it difficult for providers, patients, and their families to feel fully contained by any single explanatory model or treatment approach.
Interpretations of bipolar disorder often fall somewhere between two broad perspectives. On one end lies a psychological model, in which depression and mania are understood as responses of an individual’s mind to internal and external events. On the other end lies a biological model, which regards these mood extremes primarily as the result of neurobiological imbalance.
Similar distinctions emerge in treatment approaches for bipolar disorder. Someone who works primarily within a psychological framework will tend to understand mood changes in relation to events and dynamics in a person’s psychological life. In contrast, someone who operates within a biomedical framework may focus primarily on neurotransmitters and neurobiological mechanisms that can be modulated in order to stabilize mood.
These perspectives do not only influence the relationship between providers and patients. They often appear within families and friends as well. Patients who feel more comfortable within a psychological framework may struggle with others who believe their difficulties should be addressed primarily through medication.
On the other hand, patients who feel more comfortable within a biomedical framework may struggle with providers who emphasize psychological work and may instead request medication adjustments in the hope of restoring their sense of normality.
There Is Nothing Intrinsically Wrong With Viewing Bipolar Disorder From One Perspective or the Other
In the past, there was considerable debate about whether excessive reliance on psychological explanations deprived patients of effective medical treatment for bipolar disorder. This concern is not unreasonable. At the same time, it is also possible to argue that providers who rely exclusively on biological explanations may deprive patients of a deeper psychological understanding of mood changes.
Fortunately, these perspectives do not have to be mutually exclusive. In many cases, combining psychological and biological approaches provides a more comprehensive understanding and a more effective form of bipolar disorder treatment.
Treatment should be individualized and evolve over time, drawing on the best available evidence. This includes not only evidence from clinical research conducted at the group level, but also the practical evidence that emerges from observing what actually works for a particular individual.
The Goals of Bipolar Disorder Treatment
Bipolar disorder treatment presents particular challenges because acute mood episodes are often what bring individuals into treatment.
Someone experiencing depression may reach out for help because they are suffering and wish to feel better again. For individuals experiencing hypomania or early mania, however, the situation is often different. These states may feel subjectively positive, which can make it difficult to recognize the need for treatment. Nevertheless, elevated mood states often produce dysfunction in a person’s environment, and eventually the individual—or those around them—may seek help.
It can be tempting to disengage from treatment once mood returns to baseline. However, treatment in bipolar disorder is not only about managing acute mood episodes. A central aspect of treatment is prophylaxis — the prevention of future mood switches.
Avoiding Depriving Oneself of Helpful Treatments
Providers should not deprive patients of treatment approaches that may complement care or prove beneficial. At the same time, a patient cannot simply demand that a provider work outside the domains in which they feel professionally competent.
For this reason, it is entirely reasonable for a person to work with both a psychiatrist and a psychotherapist, particularly when the psychiatrist does not provide psychotherapy as part of their practice.
At the same time, patients should also be mindful not to deprive themselves of helpful treatments.
Many people have understandable concerns about psychiatric medication for bipolar disorder. Taking a medication every day may feel burdensome. Some worry that medication will change who they are, impair their functioning, or create a permanent dependency. Others feel uneasy with the idea that their subjective experiences might be reduced to something that can be addressed with a pill. They may want to feel understood and therefore reject medication treatment altogether.
Psychological treatment can raise its own concerns. Engaging in psychological work often requires examining oneself closely, reflecting on one’s experiences, and confronting difficult emotions. For some, this may create the impression that all responsibility for change falls entirely on their shoulders. Some may reject psychological treatment altogether and ignore that, despite having bipolar disorder, they are still people and are not immune to life stressors and challenges. They may instead insist on medication changes at every encounter, in pursuit of a hypothetical “perfect pill.”
Both concerns are understandable, and it is important to work through them with time and patience, clarifying what needs clarification and gradually working toward a treatment approach that adds to one’s life rather than allowing bipolar disorder to interfere with the pursuit of personal goals.
In Summary
Bipolar disorder treatment requires individualized psychiatric care.
An individualized treatment involves finding a balance that respects both the biological and psychological dimensions of human experience. It also requires time—time for careful assessment, time to observe how a person evolves over the course of treatment, and time to develop strategies that support long-term mood stability and well-being.
The goal of treatment is not to force an individual into a predetermined framework, but to gradually construct—together with the patient—an understanding of their bipolar disorder and a treatment approach that is both clinically useful and personally meaningful.
— Helder Araujo, MD, PhD
