Psychopharmacology

Bipolar Disorder Without Medication

The young adult’s desire to leave bipolarity behind.

Posted Oct 05, 2019

For the late-age adolescent or young adult who has just received a diagnosis of bipolar disorder, psychiatric medication is usually a pivotal aspect of initial treatment recommendations.

No one wants bipolar and, certainly, no one wants to take one or more psychiatric medications. Medication is a daily reminder of the illness you don’t want. When effective, medication will mitigate mood elevation. It will limit your ups, your exuberance, your access to hyper-productivity as well as your belief that you can accomplish anything and everything. Medication also often comes with some experience of unwanted side effects.

Most young adults trying to figure out how to live with bipolarity find that medication is a hard pill to swallow. It’s both needed and hated.

Let’s fast forward a few years beyond the initial diagnosis. Imagine you’re a young adult, age 24. The initial sequence of mood cycling that led to your diagnosis during college years has been effectively stabilized. You’ve adjusted to the routine of taking your medication. You’ve been successful at establishing a stable sleep cycle. Perhaps you’ve even been motivated enough to substantially limit the frequency and quantity of your substance use. Essentially, the combination of medication, lifestyle modification and maturation has helped you progress into a period of sustained symptom remission. What a relief.

Sustained symptom remission can also create the illusion that your bipolarity is gone, or perhaps was never there in the first place. It’s not uncommon that this wishful thinking results in a decision to discontinue medication because mood is stable and overall functioning is good. 

Unfortunately, this decision often yields the unwanted outcome of relapse and a return to mood instability. The depression that accompanies the relapse is also worsened by the painful reality that bipolar illness isn’t gone. The initial mood episodes that led to the diagnosis weren’t just an anomalous sequence of reactions brought on by a unique set of situational stressors. They marked the onset of a chronic illness.   

In most instances where an individual wants to discontinue medication relatively early in the course of their bipolarity, I strongly recommend against it. In fact, the reality that they’ve entered a period of symptom remission is usually evidence that their medication is being effective.  

However, I also fully understand why young adults are drawn to the choice. They’re not yet ready to accept their bipolarity. This non-acceptance isn’t just their flawed thinking or their oppositional tenacity. It’s more reflective of their being in a period of development where everything is about preparing for their future, shaping their life resume and demonstrating their strengths and capabilities in the hope of accessing positive life-enhancing opportunities. Simply put, bipolarity doesn’t fit into this picture and the initial diagnosis is too painful a reality for young adults to easily wrap their heads around.

When a patient who is doing well tells me that she’s considering discontinuing medication treatment, I hear the desire as something that makes sense to her. My initial response is to want to explore and better understand where she’s coming from. I also usually try to extend the conversation over the course of several sessions to lessen the likelihood of an impulsive decision. But if the patient persists in her desire to see how she does without medication, I must accept that choice. In doing so, I also understand that the experiment of “seeing how she does” may be an essential component of the individual’s coming to terms with her bipolarity. 

With all these issues pertaining to medication I also strongly urge the patient to involve her prescribing physician or psychiatrist in the discussion. Even though I may be meeting with the patient more frequently than the prescribing physician, the medication choices really should be addressed within the patient-physician relationship. Furthermore, if the patient does elect to discontinue medication treatment, it’s important that the prescribing provider is monitoring the process since many psychiatric medications can cause uncomfortable withdrawal symptoms if they are abruptly discontinued. 

Additionally, if the experiment in remaining medication free is unsuccessful and the individual relapses with mood instability, it will be important for the individual to have rapid access to the prescribing provider to discuss resumption of medication treatment.

Bipolar relapse following medication discontinuation can be a strong disappointment in response to one’s wish that the diagnosis was inaccurate or that the “chronic” prognosis was false. But it’s also important learning. And while the relapse experience may be perceived as a painful setback, it may also be an essential piece that helps one develop enough motivation to accept the importance of medication treatment along with all the other adaptations one must make to live well with bipolarity. 

It’s likely there will be some that read this post who strongly hold to the position that that bipolar disorder doesn’t necessarily require medication treatment. I agree that sometimes that does occur. However, I also perceive that those who are successful in managing their disorder while remaining medication-free are usually individuals whose symptom acuity is relatively low. In those instances, if one can consistently utilize healthy lifestyle management and good self-care, then it may be possible to maintain mood stability without medication. I have found that’s usually just not the case for many with bipolar disorder.