For those with bipolar disorder, the symptoms leading to the diagnosis typically emerge sometime between the mid-teens and the mid-twenties (see blog dated 2/10/10). It seems like a cruel joke that the behavioral norms of late adolescence and early adulthood are antithetic to the requirements for successful management of the disorder.

With bipolar disorder, the neurochemical processes which regulate mood, energy and cognition intermittently go awry. Broadly speaking, the treatment objective is one of restoring and maintaining stability. To capture this through more common experience, let's consider two analogous metaphors. The first is a faulty automotive idle control where the engine's RPM's either speed up or slow down without the accelerator being pressed. Sometimes the engine revs much too fast and at other times it's sputtering or stalling. In other words, you're not able to control how fast the engine is turning, just as bipolar individuals may not be able to control their shifts towards elevated mood or depression. Next consider an undisturbed can of soda. While sitting still, there's nothing unstable about it. But pick it up, shake it, pry open the tab and you have a mess on your hands, as does the bipolar individual who lives with a low threshold for emotional activation.

These two metaphors don't represent an either/or reality. It's more like the individual with bipolar disorder is faced with both challenges: minimizing stresses which can be destabilizing while also establishing a lifestyle that helps their energy, mood and cognition to flow at a fairly even pace.

Some of this can be facilitated through the use of appropriate medications such as mood stabilizers (anti-seizure drugs) and low-dose antipsychotics. However, the reality is that each person reacts uniquely to psychotropic medication. And if we take five people with the same bipolar symptoms and prescribe the same medications, we may end up with five very different responses to the drugs. What's needed is a skilled psychiatrist who strives towards use of the fewest medications with the lowest profile of side effects. This endeavor can take time and numerous medication trials before you and your psychiatrist find the right combination of effective drugs. The one outcome you don't want is to substitute your struggle with bipolar symptoms for your struggle with medication side effects. All too frequently, that is the young adult's experience and they conclude that effects of psychiatric medication aren't worth the effort. If that's where things are left, then psychiatric treatment has not been successful.

It would also be nice if there were clear-cut prescribing algorithms (i.e. - if symptom 1 then medication A, if symptom 2 then medication B, if symptom 1 and 2 then A and B, etc.). But more often than not, psychiatric prescription doesn't follow such linear equations. Granted, there are specific indications and guidelines for use of different medicines, but that's simply where psychiatrists start. The successful end result is more akin to something between art and a crapshoot. And I don't, in any way, mean to minimize psychiatric competency or sophistication. Over the last 20 years I've observed many excellent psychiatrists treating bipolar disorder and I've come to appreciate that it's rarely an easy or straightforward process.

If you're somewhere in your mid-teens to mid-twenties and you're trying to effectively control your bipolar symptoms, beyond the complexities of finding the right medication(s), you're also faced with the need to adopt a lifestyle which minimizes your experience of stress and emotional upheaval. In other words, you've got to work at keeping the soda can relatively still. But for the individual in high school or college this is much easier said than done. Even for those without bipolar disorder, late adolescence and young adulthood is stressful and the extent of developmental change during this period of time is rarely without emotional intensity. Add bipolar disorder to the mix and you've got a complex concoction of developmental and neurochemical instability.

So how do you keep both the engine idling at a steady rate and the soda can stable enough that it can be opened without the mess? The answer is multi-layered and involves healthy functioning and behavioral control applied to five key areas: 1) getting adequate and consistent sleep, 2) becoming highly effective at stress management, 3) developing a lifestyle that employs an effective balance of scheduling and predictable structure, 4) learning to self-monitor or self-observe so that you can perceive and appropriately adjust to changes in mood and energy, and 5) staying away from the destabilizing effects of psychoactive substances such as alcohol, pot, amphetamines and the like.

So it's simple. Just follow the plan. Oh, if it were only so simple!

You see, the reality of high school and university lifestyles is a far cry from the achievement of the five areas outlined above. Teens and twenty-somethings usually don't get adequate and consistent sleep. They just don't. If they do eventually become good at stress management, such probably isn't achieved until a point well beyond their adolescent and young adult years. As for structure and predictability, that too doesn't arrive on the scene until the accrual of significant life experience (typically the middle 30s or beyond). And with regard to refraining from psychoactive substance use, the adolescent or young adult is faced with peer group norms where alcohol and other substances are often an integral part of their social scene.

In effect, what we're really saying is that the young individual with bipolar disorder should strive to live with considerably more maturity and stability than is developmentally appropriate for them! And apart from the fact that this is very difficult to do, it's also something that many DO NOT WANT TO DO. It's like having to relinquish the pleasure and excitement involved in coming-of-age. Yes, it's far from a simple request. In fact it's quite a stretch.

The consequent reality of bipolar disorder during the teens and 20s often entails a strong degree of denial and treatment noncompliance. Who wants to accept a prognosis of continued mood instability? And if the diagnosis is not accepted (as is often the case), then why go through the extent of lifestyle modification that most professionals will recommend? Beyond that, even if medication is accepted with some measure of success, once bipolar symptoms have resolved and instability has smoothed out, then it usually feels like medication is no longer required and, of course, it's prematurely discontinued.

So why is bipolar disorder so difficult to treat? Because effective psychiatric and psychosocial adjustments are truly difficult to put into practice.

We should all have enormous respect for the challenges faced by young individuals trying their best to live with bipolar disorder. It's certainly no cake walk. And for those who are successful in managing their disorder without experiencing recurrent relapses, they've obviously learned much about acceptance, resilience and personal discipline.

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