Clinical bibliography

Last reviewed: 23 September 2026.

The Bipolar Stability Program is 24 free lessons of education about bipolar disorder, created by René at Bipolar Clarity. This page exists so that anyone —a person with the diagnosis, a family member, an association, a professional— can check where what the program says comes from, without having to take our word for it.

What this page covers, and what it does not

• The 24 lessons: what is said in each video and what each workbook chapter teaches. This is the bulk of the page.
• The workbook frame —the opening and closing pages, including the evidence page—, which cites one work of its own. It is below, in its own section.
• The workbook glossary, its 34 clinical entries: 16 point back to the lesson where the word is taught and inherit its sources, and the other 18 carry a source of their own. It is below, entry by entry, separating what defines from what claims.

What does not enter either of the two: the website, videos that are not part of the Program, and standalone printables. This page belongs to the Bipolar Stability Program.

What citing a source does NOT mean

None of the organisations cited on this page has reviewed, approved or endorsed the Bipolar Stability Program, and none is affiliated with Bipolar Clarity. We cite their publications because they are public and because they are the best material available. Responsibility for how we have used them is entirely ours.

What this program does not claim

• It does not diagnose. No lesson, sheet or workbook can confirm, rule out or replace a diagnosis.
• It does not advise on medication. The program never tells anyone to start, stop, restart, reduce, change or combine a medicine. That conversation is with whoever prescribes.
• It does not replace treatment. It is asynchronous educational material. It is not therapy, it is not clinical follow-up, and nobody reads what you write in the workbook.
• It does not predict. What the sources describe are associations and group patterns. None of that predicts the course of one particular person.
• It is not an emergency service. If you are in immediate danger, local emergency services.

How to read this page

1. The source index is grouped by organisation. Each source appears once only, with the lessons that use it and one check:
   • Live link — that the address still works and still serves what it should serve. Where it says unchecked, the source is not in doubt: it only means we have not rechecked that link yet.
2. Source by lesson walks the 24 in order.
3. What appears between angle quotes is literally what is said in the video, word for word. If one of those sentences and the video do not match, that is our error and we want to know.
4. What appears under «What holds this lesson up» is a summary of what the lesson claims, not a word-for-word quotation.
5. Only claims that have a source appear here. What the program decides on its own terms —where it draws its limits, what it does not do— is further down, in its own section.

Source index — 99 works, cited 123 ways

The program rests on 99 distinct works. The index has 123 rows because some articles also appear under their identifier —PMID, PMC or doi:— so you can look them up whichever way suits you.

Each source appears with its author or organization, its title and its year.

NICE · National Institute for Health and Care Excellence (United Kingdom)

WHO · World Health Organization

NIMH · National Institute of Mental Health (USA)

VA/DoD · Department of Veterans Affairs and Department of Defense (USA)

SAMHSA · Substance Abuse and Mental Health Services Administration (USA)

NIDA · National Institute on Drug Abuse (USA)

NIAAA · National Institute on Alcohol Abuse and Alcoholism (USA)

NCCIH · National Center for Complementary and Integrative Health (USA)

FDA · Food and Drug Administration (USA)

NHS (United Kingdom)

APA · American Psychiatric Association

ACOG · American College of Obstetricians and Gynecologists

Cochrane

Peer-reviewed literature

Other public bodies

Books, manuals and articles without a link

No link does not mean no source. These are cited by edition and publisher, the way books are cited.

The workbook frame (outside the 24 lessons)

The complete workbook has pages of its own before and after the lessons. One of them —the evidence and limits page— cites a clinical trial with figures, and those figures come from no lesson. Here is the source, so it can be checked like any other.

What that trial says, and what the workbook says it says. One hundred and twenty people with stabilised bipolar disorder, randomly allocated between a six-month group psychoeducation program and an unstructured group; ninety-nine were still in follow-up five years later. Over those five years, those who did the psychoeducation had fewer relapses —3.9 against 8.4— and spent 154 days acutely ill instead of 586. The workbook prints those same figures and, on the same page, the three things the trial does not say: that education replaces medication, that a workbook produces that result, and anything at all about one particular person.

Article identifiers (PMID · PMC · DOI)

The limits repeated throughout the program

These sentences are repeated word for word in every lesson where they appear. They do not come from a clinical source: they are the limits the program sets for itself, which is why they are here and not in the source index.

The workbook glossary, entry by entry

The workbook closes with a glossary. Its clinical entries split in two, and both are referenced here:

• 16 entries point back to the lesson where the word is taught, and there they have that lesson’s sources, which are further up on this same page.
• The other 18 carry a source of their own, and those are the ones in the table that follows.

The middle column says what each entry claims beyond defining the word. Where it says definition only, the source is there to check how the term is used, not to back a claim. The main source comes first.

Source by lesson

L01 — Newly Diagnosed With Bipolar? Write This Page First

This lesson makes no clinical claims. It explains how the program works and what it does not do; those limits are further down, in their own section.

L02 — What Is Bipolar Disorder? (And What It Isn’t)

What holds this lesson up, and where it comes from

• Definition: Bipolar disorder is a mental health condition characterized by episodes involving meaningful changes in mood, energy, activity, and thinking or concentration.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Organizing heuristic: An episode is more than one feeling. A useful educational rule is to look for a cluster of changes across several areas, over time, with impact.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Diagnostic safety: Ordinary emotions and day-to-day variation are part of life. One mood, short night, productive day, or isolated symptom is not proof of bipolar disorder or a new episode.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Assessment process: Professional assessment considers course over time, symptoms between episodes, functioning, substances, medication effects, physical conditions, family history, development, coexisting conditions, and possible alternatives.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Diagnostic signposting: Mania, hypomania, bipolar depression, and mixed features name different episode patterns or combinations; detailed distinctions require later context.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Course: People may have periods closer to their usual baseline between episodes, while some symptoms or difficulties can persist between clearer episodes.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Identity/stigma: A diagnosis describes a health condition and a pattern relevant to care; it does not define personality or the whole person.
  ↳ Miklowitz, D. J. · The Bipolar Disorder Survival Guide, 3rd ed. · Guilford Press
• Recovery/hope: Recovery is possible, and people with bipolar disorder can live meaningful, connected, or self-defined lives, while course and support needs vary.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Terminology: Diagnostic wording may differ across frameworks, guidelines, records, and jurisdictions; record the wording already used in care and ask what it means.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• icd.who.int/en
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
• who.int/news-room/fact-sheets/detail/bipolar-disorder
• doi:10.1176/appi.books.9780890425787

L03 — Bipolar Sleep: 3 Short Nights That Mean Different Things

What holds this lesson up, and where it comes from

• Sleep and circadian disruption are common in bipolar disorder and may occur during episodes and between them.
  ↳ Tonon AC, Nexha A, Mendonça da Silva M, Gomes FA, Hidalgo MP, Frey BN · Sleep and circadian disruption in bipolar disorders: from psychopathology to digital phenotyping in clinical practice · Psychiatry Clin Neurosci, 2024 · Meyer N, Faulkner SM, McCutcheon RA, Pillinger T, Dijk DJ, MacCabe JH · Sleep and Circadian Rhythm Disturbance in Remitted Schizophrenia and Bipolar Disorder: A Systematic Review and Meta-analysis · Schizophrenia Bulletin, 2020
• Decreased need for sleep can occur with mania or hypomania, alongside increased energy/activity and other changes.
  ↳ VA/DoD · Management of Bipolar Disorder — Patient Summary, 2023
• Bipolar psychological care can include self-monitoring, identifying early warning signs, and relapse planning.
  ↳ NICE · Bipolar disorder in adults (QS95) — quality statement 2: personalised care plan
• Rhythm-focused psychological treatment may support bipolar care.
  ↳ Steardo L Jr et al. · Efficacy of the interpersonal and social rhythm therapy (IPSRT) in patients with bipolar disorder: results from a real-world, controlled trial · Annals of General Psychiatry, 2020
• Light-based and sleep-manipulation interventions require intervention-specific clinical judgment in bipolar disorder.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Prompt assessment is appropriate when reduced sleep need occurs with escalating activation, impaired judgment, psychosis, serious impairment, or danger.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• doi.org/10.1111/bdi.12847
• pmc.ncbi.nlm.nih.gov/articles/PMC11804932/
• pmc.ncbi.nlm.nih.gov/articles/PMC12646031/
• pmc.ncbi.nlm.nih.gov/articles/PMC7061484/
• healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Patient-SummaryFinal508.pdf
• nice.org.uk/guidance/cg185
• nice.org.uk/guidance/cg192/chapter/Context
• PMC11804932
• PMC12646031
• PMC7061484
• PMC7505194
• PMID 32165907
• PMID 39210713
• PMID 41131918

L04 — Bipolar Early Warning Signs: Pick 4 That Are Yours

What holds this lesson up, and where it comes from

• Early-warning work is individualized and concerns changes from a person’s usual pattern.
  ↳ NICE · Bipolar disorder in adults (QS95) — quality statement 2: personalised care plan · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Care planning may include early warning symptoms, triggers and preferred responses.
  ↳ NICE · Bipolar disorder in adults (QS95) — quality statement 2: personalised care plan
• A cluster, time course, context and impact are more informative than one isolated change.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Mania/hypomania and bipolar depression can involve changes in sleep, energy, activity, thinking and functioning.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Certain combinations of depressive distress and activation may be associated with elevated risk.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• A worksheet should not delay urgent professional or emergency help.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Medication changes require appropriate professional input.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nice.org.uk/guidance/qs95/chapter/quality-statement-2-personalised-care-plan
• nimh.nih.gov/health/publications/bipolar-disorder

L05 — What Is My Bipolar Medication Actually For?

What holds this lesson up, and where it comes from

• Medication is commonly part of bipolar care, with choices differing by phase and individual factors.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Acute treatment and longer-term maintenance can have different aims.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Benefits, adverse effects, preferences and practical burden belong in shared decisions.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Monitoring requirements differ by medicine and person.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · FDA · drugs portal
• Concerns should be reported and contemplated changes discussed with the appropriate professional.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Medication categories do not by themselves determine individual purpose.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• A worksheet cannot assess a severe reaction or replace urgent clinical care.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• doi.org/10.1176/appi.focus.20230009
• fda.gov/drugs
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• nimh.nih.gov/health/topics/mental-health-medications

L06 — Bipolar Life Chart: How to Map Your Mood History

What holds this lesson up, and where it comes from

• Bipolar assessment is longitudinal and uses history across time, functioning and context.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• What “a fuller assessment” looks at — changes in mood, energy, activity, thinking, sleep, judgment and functioning; symptoms between clearer episodes; family history; previous treatment response; physical health; medication effects; substance use; development; stressors; and coexisting conditions.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Records and trusted observations may add information when used lawfully and with consent.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Current severe change interrupts retrospective work.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder

L07 — Bipolar 1 vs Bipolar 2: What the Number Really Means

What holds this lesson up, and where it comes from

• Bipolar I: In mainstream current frameworks, a history of at least one manic episode is the central defining distinction for bipolar I; depressive episodes are common but are not what defines bipolar I.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Bipolar II: Bipolar II involves a history of hypomanic episodes and major depressive episodes, without a history of mania.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Non-hierarchy: Hypomania is less severe than mania by diagnostic definition, but bipolar II is not therefore a mild or harmless disorder. Overall burden depends on the whole course, especially depression, functioning, risk, and coexisting conditions.
  ↳ Berk M, Corrales A, Trisno R, Dodd S, Yatham LN, Vieta E, McIntyre RS, Suppes T, Agustini B · Bipolar II disorder: a state-of-the-art review · World Psychiatry, 2025 · Berk M, Corrales A, Trisno R, Dodd S, Yatham LN, Vieta E, McIntyre RS, Suppes T, Agustini B · Bipolar II disorder: a state-of-the-art review · World Psychiatry, 2025
• Mania versus hypomania: They share an activated family of changes, but mania reaches a level of severity, impairment, need for hospital care, or psychosis that changes the diagnostic category; hypomania is observable and clinically meaningful but does not reach mania’s defining severity.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Mixed features: Activated and depressive features can occur within the same episode or period; the experience is not necessarily a clean alternation between “high” and “low.”
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · American Psychiatric Association · «What Are Bipolar Disorders?»
• Mixed-feature safety: Severe distress or hopelessness combined with activation, agitation, impaired judgment, psychosis, or thoughts of harm deserves prompt professional attention; immediate danger supersedes the workbook.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Rapid cycling: In common DSM-oriented patient information, rapid cycling means four or more distinct mood episodes within twelve months. It describes episode frequency, not ordinary hour-to-hour emotion changes.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Course description: Rapid cycling is a course description/specifier, not a separate identity or a permanent forecast; whether distinct episodes occurred requires clinical interpretation of sequence and recovery/switching.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Framework difference: DSM, ICD, guidelines, local records, and clinicians may organize or name mixed presentations and course features differently. The useful action is to record the exact wording and ask what it means in that care context.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · World Health Organization · International Classification of Diseases, 11th Revision (ICD-11) · American Psychiatric Association · «What Are Bipolar Disorders?»
• Cyclothymic context: Cyclothymia refers to a longer-term pattern of recurring hypomanic and depressive symptoms that do not form the same episode history as bipolar I or II; it is context only in this lesson.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Treatment boundary: Diagnostic terminology can matter to clinical formulation, but a label alone does not determine one universal treatment plan. Current episode, history, response, safety, health, preferences, and local guidance also matter.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• doi.org/10.1176/appi.focus.20230009
• icd.who.int/browse/2025-01/mms/en
• pmc.ncbi.nlm.nih.gov/articles/PMC12079553/
• pubmed.ncbi.nlm.nih.gov/12622659/
• pubmed.ncbi.nlm.nih.gov/34599629/
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• psychiatry.org/patients-families/what-is-the-dsm
• PMC12079553
• PMID 12622659
• PMID 40371769

L08 — Hypomania Signs Others Often Notice Before You Do

What holds this lesson up, and where it comes from

• Manic episodes involve unusually elevated or irritable mood with increased activity compared with the person’s usual self.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Hypomania is less severe than mania and may interfere less with daily life.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Hypomania may feel good or productive and may be noticed as unusual by family or friends.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Candidate manic symptoms can include decreased need for sleep, faster thoughts or speech, increased activity, irritability, and changes in pleasurable or risky activity.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Bipolar assessment considers severity, duration, frequency, lifetime course, functioning, other health conditions, and substance or medication effects.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Psychosis can occur in severe manic or depressive episodes and requires urgent clinical attention.
  ↳ StatPearls · Bipolar Disorder · NCBI Bookshelf NBK558998
• Risk assessment in bipolar disorder may need to consider self-harm, harm to others, driving, spending, exploitation, and disinhibited behavior.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Immediate danger requires emergency action; rapid escalation, severe agitation, dangerous behavior, serious impairment, or inability to care for basic needs warrants urgent assessment.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Patient-SummaryFinal508.pdf
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• who.int/news-room/fact-sheets/detail/bipolar-disorder
• PMID 31956923
• PMID 32644424

L09 — Manic and Depressed at the Same Time? Mixed Features

What holds this lesson up, and where it comes from

• Bipolar disorder can include depressive episodes and presentations containing both depressive and manic symptoms.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Depressive episodes can involve low or anxious mood, loss of interest, slowing or restlessness, concentration/decision difficulty, sleep change, functional difficulty, hopelessness, worthlessness or thoughts of death/suicide.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Symptoms are interpreted as patterns over time, with changes in mood, energy, activity, behavior and impact.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Evidence-based treatment recommendations specifically for mixed features are limited.
  ↳ VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023
• Manic symptoms can accompany bipolar depressive episodes and may be overlooked when depressive symptoms dominate.
  ↳ Goldberg JF et al. · manic symptoms in bipolar depression · 2009
• Agitation can accompany bipolar depression and has been associated with a more severe illness history and suicidal behavior in observational samples.
  ↳ Serra F, Gordon-Smith K, Perry A et al. · Agitated depression in bipolar disorder · 2019
• Mixed presentations have been associated with greater illness burden and suicide risk in the literature.
  ↳ Swann AC · Mixed features: evolution of the concept, past and current definitions, and future prospects · CNS Spectrums, 2017 · Solé E et al. · review on mixed features · 2017
• Bipolar assessment includes direct safety assessment when there is risk of harm to self or others.
  ↳ VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023
• Early-warning observations and urgent/emergency procedures belong in collaborative maintenance planning.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023
• Psychosis can occur in severe mood episodes and needs urgent professional assessment.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025

Sources cited in this lesson

• pubmed.ncbi.nlm.nih.gov/19122008/
• pubmed.ncbi.nlm.nih.gov/28031070/
• pubmed.ncbi.nlm.nih.gov/28264741/
• pubmed.ncbi.nlm.nih.gov/31004555/
• healthquality.va.gov/guidelines/MH/bd/
• healthquality.va.gov/guidelines/MH/bd/VA-DOD-CPG-BD-Provider-SummaryFinal508.pdf
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• PMID 19122008
• PMID 28031070
• PMID 28264741
• PMID 31004555

L10 — Bipolar Disorder or Something Else? Thyroid, Trauma, ADHD

What holds this lesson up, and where it comes from

• Bipolar assessment is longitudinal and considers symptoms during and between episodes, functioning, family history, treatment response, physical health, medicines, substances, development, psychosocial context, comorbidities and differential diagnoses.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023
• Considering another explanation does not by itself reject the person’s account or existing diagnosis; another condition may also coexist.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Recurrent depression can prompt assessment for past mania/hypomania and the longer mood course.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• ADHD begins in childhood, often continues into adolescence and adulthood and appears across settings; similar symptoms can arise from sleep, anxiety, depression or physical conditions.
  ↳ NICE · Attention deficit hyperactivity disorder: diagnosis and management (NG87) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Psychotic symptoms can occur in severe bipolar episodes and other conditions; relationship to mood and course requires professional assessment.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Differential considerations in bipolar assessment include psychotic-spectrum, personality, substance/alcohol, ADHD and physical-health explanations.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• A general medical and medication review may include physical examination and laboratory work. VA/DoD Sidebar 3 lists, for everyone evaluated for suspected bipolar disorder: full medication reconciliation, mental-status and physical examination, and a basic laboratory set — TSH, complete blood count, comprehensive metabolic panel and urine drug screening. What is targeted is neuroimaging or EEG, …
  ↳ VA/DoD · Management of Bipolar Disorder — Provider Summary, 2023
• Medicines, non-prescribed substances and withdrawal/intoxication can affect mood, sleep, energy, perception or judgment and must be interpreted in context.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · SAMHSA · Co-Occurring Disorders and Other Health Conditions
• Co-occurring mental and substance-use disorders can exist together and complicate assessment and care.
  ↳ SAMHSA · Co-Occurring Disorders and Other Health Conditions
• Current psychosis, severe activation, serious loss of judgment/function, inability to meet basic needs, thoughts of harm or immediate danger requires an appropriate prompt or urgent route.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• medlineplus.gov/lab-tests/mental-health-screening/
• healthquality.va.gov/guidelines/MH/bd/
• healthquality.va.gov/guidelines/MH/bd/VA-DOD-CPG-BD-Provider-SummaryFinal508.pdf
• nice.org.uk/guidance/cg185
• nice.org.uk/guidance/ng87
• nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-what-you-need-to-know
• nimh.nih.gov/health/publications/bipolar-disorder
• ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp
• samhsa.gov/mental-health/trauma-violence/trauma-informed-approaches-programs
• samhsa.gov/substance-use/treatment/co-occurring-disorders
• doi:10.1176/appi.books.9780890425787

L11 — Alcohol, Cannabis, and Bipolar Disorder: What to Notice

What holds this lesson up, and where it comes from

• Mental-health and substance-use conditions can coexist and are appropriately considered together
  ↳ SAMHSA · Co-Occurring Disorders and Other Health Conditions · NIDA · Co-Occurring Disorders and Other Health Conditions
• Substance effects, underlying symptoms and withdrawal/after-effects can overlap; sequence and context help assessment
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIDA · Co-Occurring Disorders and Other Health Conditions
• Alcohol can alter sleep and can interact harmfully with medicines, especially sedating medicines
  ↳ Roehrs T and Roth T · Sleep, Sleepiness, and Alcohol Use · Alcohol Research & Health
• Sudden cessation after prolonged heavy drinking can produce potentially life-threatening withdrawal
  ↳ NIAAA · Core Resource on Alcohol — Alcohol-Medication Interactions: Potentially Dangerous Mixes
• THC-containing cannabis can change mood, thinking and perception; risk varies and individual response cannot be predicted here
  ↳ NIDA · Cannabis (Marijuana)
• Some stimulant effects overlap with activated states: wakefulness, increased confidence, energy, reduced appetite/sleep, anxiety or paranoia
  ↳ NIDA · Methamphetamine
• Stimulant after-effects or withdrawal can include low mood, anxiety, irritability, sleep problems and concentration difficulty
  ↳ NIDA · Methamphetamine
• Co-use can change risk, and alcohol plus some medicines can intensify sedation or other harms
  ↳ NIDA · Co-Occurring Disorders and Other Health Conditions · NIAAA · Core Resource on Alcohol — Alcohol-Medication Interactions: Potentially Dangerous Mixes
• Current severe confusion, psychosis, chest pain, seizure, difficulty breathing, collapse, serious loss of judgment or immediate danger needs urgent local help
  ↳ NIDA · Co-Occurring Disorders and Other Health Conditions · NIAAA · Core Resource on Alcohol — Alcohol-Medication Interactions: Potentially Dangerous Mixes
• Stigmatizing language can make someone less willing to seek treatment, and changing the words used can reduce that stigma
  ↳ NIDA · Words Matter: Preferred Language for Talking About Addiction, updated 19 March 2026

Sources cited in this lesson

• nida.nih.gov/research-topics/addiction-science/words-matter-preferred-language-talking-about-addiction
• nida.nih.gov/research-topics/cannabis-marijuana
• nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
• nida.nih.gov/research-topics/cocaine
• nida.nih.gov/research-topics/methamphetamine
• healthquality.va.gov/guidelines/MH/bd/VA-DOD-CPG-BD-Provider-SummaryFinal508.pdf
• niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-medication-interactions-potentially-dangerous-mixes
• niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/mental-health-issues-alcohol-use-disorder-and-common-co-occurring-conditions
• niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
• nice.org.uk/guidance/cg185
• samhsa.gov/substance-use/treatment/co-occurring-disorders
• PMC6707127

L12 — Bipolar Triggers: What Adds Pressure—and What Protects You

What holds this lesson up, and where it comes from

• Bipolar course reflects multiple biological, psychological, social and structural influences; no single factor reliably predicts an individual’s outcome
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Sleep and circadian disruption are associated with bipolar symptoms and recurrence; regular rhythms are a practical prevention target
  ↳ Gold AK and Sylvia LG · The role of sleep in bipolar disorder · Nature and Science of Sleep, 2016 · Tonon AC, Nexha A, Mendonça da Silva M, Gomes FA, Hidalgo MP, Frey BN · Sleep and circadian disruption in bipolar disorders: from psychopathology to digital phenotyping in clinical practice · Psychiatry Clin Neurosci, 2024
• Stressful life events can be associated with episode onset/recurrence, with substantial individual variation
  ↳ Lex C, Bäzner E and Meyer TD · Does stress play a significant role in bipolar disorder? A meta-analysis · Journal of Affective Disorders, 2017
• Positive goal-attainment events can accompany increased activation in some people with bipolar vulnerability
  ↳ Johnson SL, Sandrow D, Meyer B et al. · Increases in manic symptoms after life events involving goal attainment · Journal of Abnormal Psychology, 2000
• Psychosocial care commonly includes monitoring, social support, early warning signs, sleep/insomnia, functioning and practical life problems
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Group psychoeducation reduces relapses and days of acute illness alongside appropriate clinical care — in the Barcelona trial, at five-year follow-up, 3.9 relapses vs 8.4 and 154 days acutely ill vs 586. Its effect on functioning is not demonstrated: functional gains come from interventions designed for functioning, and even there only partly.
  ↳ Bond K and Anderson IM · Psychoeducation for relapse prevention in bipolar disorder: a systematic review of efficacy in randomized controlled trials · Bipolar Disorders, 2015
• Interpersonal and social rhythm approaches link routine/rhythm regularity with bipolar management
  ↳ Frank E, Swartz HA and Boland E · Interpersonal and social rhythm therapy · Dialogues in Clinical Neuroscience, 2007
• Family or trusted-person involvement can help when collaborative and appropriate
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Housing, work, relationships, access to care and other practical conditions belong in bipolar recovery planning
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · World Health Organization · Bipolar disorder · fact sheet, 11 September 2026
• Current psychosis, severe activation, inability to meet basic needs, thoughts of harm or immediate danger require an urgent safety route rather than workbook completion
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Pregnancy, birth and the postnatal weeks belong among the pressures worth tracking: bipolar disorder shows an increased rate of relapse and of first presentation in the postnatal period.
  ↳ NICE · Antenatal and postnatal mental health: clinical management and service guidance (CG192)

Sources cited in this lesson

• PMC11804932
• PMC12685540
• PMC3137243
• PMC3202498
• PMC5922774
• PMID 11195996
• PMID 17969869
• PMID 18489203
• PMID 25594775
• PMID 27418862
• PMID 27794254
• PMID 39210713
• PMID 39582312

L13 — Bipolar Psychiatry Appointment: Make the Short Visit Count

What holds this lesson up, and where it comes from

• Shared decision making is a collaborative process that considers evidence alongside the person’s preferences, values and circumstances
  ↳ NICE · Shared decision making (NG197)
• Useful questions include the available options, likely benefits and risks or downsides, and how the decision is made together
  ↳ NICE · Shared decision making (NG197)
• Writing down two or three important questions, bringing a medicine list and noting symptom details can help appointment preparation
  ↳ NHS · What to ask your doctor or other healthcare professional
• Before leaving, it is useful to check understanding, what happens next, when and who to contact if things worsen
  ↳ NHS · What to ask your doctor or other healthcare professional
• Bipolar maintenance planning should use shared decision making with the patient, treatment team and social supports where appropriate
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Care planning may include appointment/contact arrangements, urgent procedures, monitoring and timeframes for reevaluation
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• A complete medication reconciliation includes prescribed and nonprescribed medicines, supplements and vitamins
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Prior records and a longitudinal history can supplement the clinical interview
  ↳ Miklowitz, D. J. · The Bipolar Disorder Survival Guide, 3rd ed. · Guilford Press
• Interpreters, communication support, note-taking and an optional support person can improve access to the conversation
  ↳ NHS · What to ask your doctor or other healthcare professional

Sources cited in this lesson

• ahrq.gov/patient-safety/patients-families/index.html
• healthquality.va.gov/guidelines/MH/bd/Bipolar-pocket-card-508.pdf
• nhs.uk/nhs-services/gps/what-to-ask-your-doctor/
• nice.org.uk/guidance/ng197
• nice.org.uk/guidance/ng197/chapter/recommendations

L14 — I Feel Fine. Why Am I Still on Bipolar Medication?

What holds this lesson up, and where it comes from

• Bipolar guidelines organize treatment differently for acute mania/hypomania, acute bipolar depression and maintenance planning.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Maintenance planning follows stabilization or occurs between episodes and includes shared decisions, recurrence prevention and planned reevaluation.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Medication reconciliation should include prescribed and nonprescribed medicines, supplements and vitamins.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• People respond differently and medication purposes must be understood in individual context.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Psychoeducation has long distinguished acute and preventive purposes.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006
• Drug-family names carry broad meaning that helps a person follow a conversation, and none of them states the job a medicine has in one person’s plan.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/topics/mental-health-medications

L15 — Bipolar Side Effects: What to Track and When to Call

What holds this lesson up, and where it comes from

• Side effects should be discussed and managed within a medication plan.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Monitoring varies by medication, person, treatment stage and clinical context.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Breathing difficulty, airway swelling, collapse and loss of consciousness are emergency signs.
  ↳ NHS · Anaphylaxis
• Widespread painful, blistering or peeling rash and mucosal sores require immediate assessment.
  ↳ NHS · Stevens–Johnson syndrome
• Fever, severe muscle stiffness and altered mental state can signal a rare medical emergency.
  ↳ Simon LV, Hashmi MF, Callahan AL · Neuroleptic Malignant Syndrome · StatPearls, NCBI Bookshelf NBK482282
• Serious adverse-event reporting systems exist, but clinical help comes first.
  ↳ FDA · MedWatch · adverse event reporting program
• New or worsening thoughts of suicide or self-harm can begin when a medicine is started or a dose is increased, and are reportable straight away whatever the suspected cause.
  ↳ NHS · Antidepressants, reviewed 12 June 2025
• Akathisia — inner restlessness with an urge to move, usually in the legs — can begin in the first weeks of an antipsychotic or after a dose increase, and is readily mistaken for anxiety, agitation or the illness worsening.
  ↳ StatPearls · Bipolar Disorder · NCBI Bookshelf NBK558998
• For a small number of medicines, a blood test measures how much of the medicine is in the blood. Testing is anchored to starting the medicine and to any change in dose, then repeated on a rhythm once things are steady, because there is a range the level is meant to sit inside.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• A level describes the day it was taken. A normal result does not rule out a problem developing later.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · NHS Specialist Pharmacy Service · Advising on missed or delayed doses of medicines

Sources cited in this lesson

• psychiatryonline.org/doi/full/10.1176/appi.focus.20230009
• fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program
• healthquality.va.gov/guidelines/MH/bd/
• ncbi.nlm.nih.gov/books/NBK482282/
• ncbi.nlm.nih.gov/books/NBK519543/
• nhs.uk/conditions/anaphylaxis/
• nhs.uk/conditions/stevens-johnson-syndrome/
• nhs.uk/medicines/antidepressants/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/topics/mental-health-medications

L16 — Thinking About Stopping Bipolar Medication? Start Here

What holds this lesson up, and where it comes from

• Medication decisions should use shared decision-making and include the learner’s priorities and concerns.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Stopping long-term treatment can require planning and monitoring for relapse.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Stopping a prescribed medicine without professional help can cause unpleasant or harmful effects.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Advice after a missed or delayed dose varies by medicine and circumstance.
  ↳ NHS Specialist Pharmacy Service · Advising on missed or delayed doses of medicines
• Bipolar relapse prevention is part of long-term treatment planning.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/topics/mental-health-medications
• sps.nhs.uk/articles/advising-on-missed-or-delayed-doses-of-medicines/

L17 — Bipolar Disorder and Pregnancy: Questions to Ask Early

What holds this lesson up, and where it comes from

• Preconception planning should consider mental-health history, treatment benefits and reproductive context.
  ↳ NICE · Antenatal and postnatal mental health: clinical management and service guidance (CG192)
• Pregnancy or lactation status alone does not settle a medication decision: it opens one, and the answer is medicine-specific. For some medicines a guideline does give a direct instruction in pregnancy.
  ↳ NICE · Antenatal and postnatal mental health: clinical management and service guidance (CG192) · ACOG · Assessment and Treatment of Perinatal Mental Health Conditions
• Contraceptive interactions can operate in either direction.
  ↳ FSRH/CoSRH · Drug Interactions with Hormonal Contraception
• Combined hormonal contraception containing estrogen can reduce lamotrigine exposure.
  ↳ Costa L and Esteves-Sousa D et al. · Lamotrigine, Contraceptives, and Psychiatry: A Narrative Review

Sources cited in this lesson

• acog.org/programs/perinatal-mental-health/assessment-and-treatment-of-perinatal-mental-health-conditions
• cosrh.org/Public/Public/Documents/ceu-clinical-guidance-drug-interactions-with-hormonal.aspx
• gov.uk/guidance/valproate-reproductive-risks
• nhs.uk/mental-health/conditions/post-partum-psychosis/
• nice.org.uk/guidance/cg185
• nice.org.uk/guidance/cg192
• nimh.nih.gov/health/publications/bipolar-disorder
• PMC12853207

L18 — Does Therapy Help Bipolar Disorder? What the Evidence Says

What holds this lesson up, and where it comes from

• Structured, skills-based psychotherapies may be used alongside pharmacological treatment outside acute mania, with goals such as relapse prevention, self-management, depressive symptoms, relationships and rhythms.
  ↳ Miklowitz DJ et al. · Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysis · JAMA Psychiatry, 2021
• Candidate approaches include structured psychoeducation, CBT adapted for bipolar disorder, family or conjoint interventions, and interpersonal and social rhythm therapy.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006 · NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Therapy may address a defined coexisting problem or consequence, and evidence for that target is not evidence about bipolar recurrence.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Wellbeing and complementary practices are not one single evidence category.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · NCCIH · How Herbs Can Interact With Medicines
• Supplements are exposures with ingredients, dose, product variability and interaction potential.
  ↳ NCCIH · How Herbs Can Interact With Medicines

Sources cited in this lesson

• doi.org/10.1001/jamapsychiatry.2020.2993
• healthquality.va.gov/guidelines/MH/bd/
• nccih.nih.gov/health/tips/tips-how-herbs-can-interact-with-medicines
• nccih.nih.gov/health/using-dietary-supplements-wisely
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• doi:10.1001/jamapsychiatry.2020.2993

L19 — Bipolar Warning Signs: Subtle, Clear, and Urgent

What holds this lesson up, and where it comes from

• Early-warning-sign work added to usual care has been associated with a longer time to recurrence and fewer hospitalisations.
  ↳ Morriss R, Faizal MA, Jones AP, Williamson PR, Bolton CA, McCarthy JP · Interventions for helping people recognise early signs of recurrence in bipolar disorder · Cochrane Database of Systematic Reviews, 2007
• Neither depressive nor manic symptom levels differed between groups in that review.
  ↳ Morriss R, Faizal MA, Jones AP, Williamson PR, Bolton CA, McCarthy JP · Interventions for helping people recognise early signs of recurrence in bipolar disorder · Cochrane Database of Systematic Reviews, 2007
• Self-monitoring carries its own risks, and a lesson that hands someone a ladder has to say so.
  ↳ Morriss R, Faizal MA, Jones AP, Williamson PR, Bolton CA, McCarthy JP · Interventions for helping people recognise early signs of recurrence in bipolar disorder · Cochrane Database of Systematic Reviews, 2007
• The completed evidence base is Morriss 2007; the picture after 2005 is uneven.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006 · Morriss R, Faizal MA, Jones AP, Williamson PR, Bolton CA, McCarthy JP · Interventions for helping people recognise early signs of recurrence in bipolar disorder · Cochrane Database of Systematic Reviews, 2007
• A personalised plan can include early warning signs, triggers, preferred responses and liaison arrangements.
  ↳ NICE · Bipolar disorder in adults (QS95) — quality statement 2: personalised care plan
• Recurrence signs are worth identifying and reporting to the care team.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Episodes are described through changes in mood, energy, activity, cognition, sleep and behaviour.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Structured psychoeducation has long taught relapse-signature work.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006
• A warning sign is more useful when it has recurred before episodes of that type, when another person could observe it, when it can be raised without provoking conflict, and when its lead time is known.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006

Sources cited in this lesson

• cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004854.pub2/full
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nice.org.uk/guidance/qs95/chapter/quality-statement-2-personalised-care-plan
• nimh.nih.gov/health/publications/bipolar-disorder

L20 — How to Draft a Bipolar Crisis Plan—Before You Need It

What holds this lesson up, and where it comes from

• A jointly developed risk-management plan can include personal triggers, early warning signs, preferred responses and liaison arrangements.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Crisis-response tools exist and are used in clinical practice.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Safety-planning-type interventions can be considered.
  ↳ World Health Organization · mhGAP · Safety planning interventions, 2023
• Psychiatric advance directives are a recognised tool for self-directed care.
  ↳ SAMHSA · A Practical Guide to Psychiatric Advance Directives

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/srb/
• nice.org.uk/guidance/cg185
• samhsa.gov/resource/ebp/practical-guide-psychiatric-advance-directives
• who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre/self-harm-and-suicide/safety-planning-interventions

L21 — I Think a Bipolar Episode Is Starting—What Should I Do?

What holds this lesson up, and where it comes from

• A jointly developed plan can contain early warning signs, personal triggers, preferred responses and liaison arrangements.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Possible recurrence signs are worth identifying and reporting to providers.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Episodes involve changes in mood, energy, activity, cognition, sleep and behaviour, and professional treatment is central.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Regular routine and sleep support stability, and medication is not stopped without medical direction.
  ↳ NHS · Bipolar disorder

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nhs.uk/mental-health/conditions/bipolar-disorder/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder

L22 — How to Build a Routine That Helps With Bipolar Disorder

What holds this lesson up, and where it comes from

• Disrupted sleep and irregular daily timing are associated with mood episodes in bipolar disorder.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025 · NHS · Bipolar disorder
• Structuring activities and keeping a routine for eating, sleeping and exercising is recommended.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Regular sleep and daily routines are commonly encouraged as part of broader bipolar care.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NHS · Bipolar disorder
• IPSRT attends to regularity in social routines and interpersonal stress, as an adjunctive psychosocial treatment.
  ↳ Frank, E. · Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy · Guilford Press
• Routine timing is individual and culturally situated; the model emphasises regularity, not one universal clock time.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006
• Structured problem-solving can turn one broad pressure into a bounded next experiment.
  ↳ Colom, F. & Vieta, E. · Psychoeducation Manual for Bipolar Disorder · Cambridge University Press, 2006

Sources cited in this lesson

• healthquality.va.gov/guidelines/MH/bd/
• nhs.uk/mental-health/conditions/bipolar-disorder/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder

L23 — Life After a Bipolar Episode: Work, Money, and Relationships

What holds this lesson up, and where it comes from

• Bipolar disorder affects daily functioning and relationships, and treatment can improve functioning and quality of life.
  ↳ NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Occupational, educational, housing and relationship problems belong inside assessment and management.
  ↳ VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023
• Occupational and educational recovery belong within care, with individualized assessment retained.
  ↳ NICE · Bipolar disorder: assessment and management (CG185)
• Functional recovery can lag or diverge from symptom change.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025

Sources cited in this lesson

• op.europa.eu/webpub/empl/reasonable-accommodation-at-work/en/
• acas.org.uk/reasonable-adjustments/mental-health-adjustments
• eeoc.gov/laws/guidance/depression-ptsd-other-mental-health-conditions-workplace-your-legal-rights
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder

L24 — Grieving the Person You Were: Bipolar and Identity

What holds this lesson up, and where it comes from

• Personal recovery is not the same thing as symptom reduction.
  ↳ Chirio-Espitalier M, Schreck B, Duval M, Hardouin JB, Moret L, Grall-Bronnec M · Exploring the Personal Recovery Construct in Bipolar Disorders: Definition, Usage and Measurement. A Systematic Review · Frontiers in Psychiatry, 2022
• Identity after a bipolar diagnosis is ambivalent: positive and negative consequences at the same time.
  ↳ Mansell W, Powell S, Pedley R, Thomas N, Jones SA · The process of recovery from bipolar I disorder: A qualitative analysis of personal accounts in relation to an integrative cognitive model · British Journal of Clinical Psychology, 2010
• The recurring recovery domains are connectedness, hope, identity, meaning and empowerment.
  ↳ Leamy M, Bird V, Le Boutillier C, Williams J, Slade M · Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis · British Journal of Psychiatry, 2011 — the CHIME framework
• There is bipolar-specific work that proposes a different framework.
  ↳ Jagfeld G, Lobban F, Humphreys C, Rayson P, Jones SH · How People With a Bipolar Disorder Diagnosis Talk About Personal Recovery in Peer Online Support Forums · JMIR Medical Informatics, 2023 — the POETIC framework
• Individualized, collaborative care and attention to functioning and quality of life are supported.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025
• Grief and depressive symptoms can overlap.
  ↳ NICE · Bipolar disorder: assessment and management (CG185) · VA/DoD · Clinical Practice Guideline for Management of Bipolar Disorder in Adults, 2023 · NIMH · Bipolar Disorder · booklet, NIH Publication No. 25-MH-8088, revised 2025

Sources cited in this lesson

• medinform.jmir.org/2023/1/e46544
• pmc.ncbi.nlm.nih.gov/articles/PMC6679801/
• pmc.ncbi.nlm.nih.gov/articles/PMC9263970/
• healthquality.va.gov/guidelines/MH/bd/
• nice.org.uk/guidance/cg185
• nimh.nih.gov/health/publications/bipolar-disorder
• PMC6679801
• PMC9263970
• doi:10.1111/jopy.12461
• doi:10.1192/bjp.bp.110.083733
• doi:10.1348/014466509X451447
• doi:10.2196/46544
• doi:10.3389/fpsyt.2022.876761

How we keep this page up to date

Clinical guidelines get updated: NICE revised CG185 on 2 September 2025, and the NIMH booklet dates from 2025. We review this page whenever a source or a lesson changes.

If you find a source that does not say what we say it says, write to us and we will correct it.

Program created by René · Bipolar Clarity.