The following is her perspective and does not represent the perspectives of all healthcare professionals. The information included is not a substitute for professional medical advice. Always talk to your healthcare provider. Intended for U.S. audiences only. Here, Ms. Holliday shares her perspective, including some of the fundamentals about bipolar 1 based on scientific and medical research, as well as her own clinical experience. Tarrah Holliday received compensation from Alkermes, Inc. for her contributions to this article.
What is Bipolar 1 and What Does it Look Like in Real Life?
Bipolar 1 is a serious mental health condition that typically causes intense shifts in mood, energy and activity levels, affecting an estimated 1% of adults in the United States.¹ What sets bipolar 1 apart from other types of bipolar disorders is the presence of at least one manic (abnormally happy) episode, which can be preceded or followed by a depressive (sad mood) episode.
A manic episode means someone might feel unusually “up”— for example, energized, talkative, restless or likely to engage in risky behavior— and it can last for days or even weeks. A depressive episode, on the other hand, can bring on sadness, fatigue, sleep changes, loss of interest in activities the person once enjoyed and difficulty concentrating. For some, these episodes may also include psychotic features, like delusions or hallucinations.² In my practice, most patients first come to see me while they are experiencing what’s called a “mixed episode,” where symptoms of mania and depression happen at the same time.³ In my experience, these episodes can be especially difficult to live with and treat because the emotional signals can be so conflicting.
It’s also important to know that someone can appear highly functional on the outside while still experiencing real and disruptive symptoms below the surface. Bipolar 1 doesn’t look the same for everyone. Some people cycle quickly between moods, while others may go years between episodes. Some feel more anxious or irritable than euphoric. That’s why it’s so important to talk to your healthcare provider about what you’re experiencing.
Why is Bipolar 1 Sometimes Misdiagnosed?
Bipolar 1 is a complex condition with a wide range of symptoms that can make it challenging to accurately diagnose. For example, patients with bipolar 1 often describe symptoms that could fit just as easily within a diagnosis of depression,⁴ anxiety or attention-deficit/hyperactivity disorder.1 This is why I don’t just talk to my patients; if possible, I try and talk with their close loved ones, to get a full picture of their experiences leading to this point. I ask questions that help build a timeline, such as what their last week looked like, whether they’ve been hospitalized or if they had sleep issues or emotional outbursts earlier in life. These details can reveal patterns that point to a bipolar 1 diagnosis, even if patients aren’t using clinical words like “manic.”
How Do I Guide Patients Through Their First Steps With Bipolar 1?
When someone is newly diagnosed with bipolar 1 there are often feelings of concern or uncertainty. Some may feel uneasy even hearing the term “bipolar 1,” while others express their relief at finally having a diagnosis for what they’re experiencing. My goal is to make sure they feel supported as we work together to develop a plan for what’s next. That starts with trust. I know that for many patients, opening up about mental health can feel vulnerable. What’s important for patients, I’ve learned, is for them to feel seen and heard, and to know that I am here not just to treat symptoms but to have a clinical relationship that supports their long-term wellbeing.
I usually start by asking: “What’s bothering you most right now?” Together, we review the symptoms they are experiencing and focus on what’s disrupting their daily life. What feels most urgent to me might not be the same for them, so we start with their concerns and priorities. Then, we talk about treatment options in straightforward language, including how medications may help and what they might expect, and also other psychosocial support that may be helpful in their journey. The goal is to help them feel empowered about their care plan, not overwhelmed.
Shared decision-making is the cornerstone of my practice. If someone doesn’t feel comfortable with a treatment plan, they may encounter difficulties in sticking with it, and that’s understandable. It’s their body and their experience. My job is to offer guidance and expertise, but ultimately the decision about how to move ahead is theirs.
What are the Biggest Challenges Patients Face When Starting Medication?
There’s no single path to treating bipolar 1 as every person’s experience is different; however, because it is a serious and chronic disease, people living with bipolar 1 often will require medication during their treatment journey.⁵ It can take time to find a treatment regimen that works for them because factors like side effects, personal preferences and past experiences with medication all play a role. That’s why it’s so important to understand that there may be some trial and error involved in building a plan that is effective and realistic.
Starting treatment can feel overwhelming. Many of my patients worry about things like side effects or how the medication is going to make them feel. I understand their concerns. That’s why I’m transparent from the beginning. We talk about what they might expect and how we may need to adjust if something doesn’t feel right. Every treatment plan is just a starting point. There’s no one-size-fits-all approach. What matters most is ongoing communication and trust.
In my practice, one treatment option I consider for my adult patients with bipolar 1 is LYBALVI® (olanzapine and samidorphan). This can include patients who are early in their treatment journey and looking for an effective antipsychotic medication that they can use alone as an ongoing treatment. It can also include patients who have tried medications and are interested in exploring an alternative option.
A note about LYBALVI: LYBALVI is an oral prescription medication used in adults to treat manic or mixed episodes that happen with bipolar 1 disorder, either alone for short-term (acute) or maintenance treatment or in combination with valproate or lithium. LYBALVI is also used in adults to treat schizophrenia. It is not known if LYBALVI is safe or effective in children. It’s important to note that LYBALVI may cause serious side effects, including increased risk of death in elderly people with dementia-related psychosis. LYBALVI increases the risk of death in elderly people who have lost touch with reality (psychosis) due to confusion and memory loss (dementia). LYBALVI is not approved for the treatment of people with dementia-related psychosis.⁶ Please read additional Important Safety Information below.
Another consideration is the overall complexity of a patient’s treatment regimen. In my practice, I frequently see individuals managing multiple medications to address different aspects of bipolar 1. This is especially true if they’ve had a long treatment history. I look for opportunities to personalize care in support of symptom control and treatment goals.4 In some cases, I may consider LYBALVI as one of several options, given its once-daily dosing and its approval as a medication that can be used alone for the treatment of bipolar 1.
How Do Education and Support Impact a Patient’s Experience?
Support systems, whether through family, friends or a care team, can be influential in a person’s treatment journey.3 I’ve often observed that when someone feels they can be open about their diagnosis and treatment, they may be more likely to follow a recommended treatment plan or speak up if symptoms begin to reemerge or other concerns arise. I always tell my patients that my role goes beyond just prescribing medication; I’m here as their partner through this process. That includes reinforcing information, checking in and making sure they know they can reach out at any time.
Education is just as important. When patients and their care partners understand the diagnosis and treatment plan—such as what their medication is intended to help with, how to take it and what to watch for—they feel informed and empowered. From my perspective, this opens the door to earlier conversations and helps us address concerns before they escalate. These kinds of conversations give people the awareness and tools to help identify sooner when there may be a concern, and additional clinical support may be helpful.
What is the Role of Stigma in Mental Health?
In recent years there has been a cultural shift toward more open conversation around mental health and acknowledgement that mental health is just as important as physical health. The brain is an organ, just like the heart and lungs, and deserves the same level of care, attention and compassion when unwell.
Despite this, there is still stigma around mental health, and serious mental illness in particular. In my practice, I have met patients who share that they have been told in the past that their symptoms are just a part of life. This stigma and misunderstanding can complicate the treatment journey and can prevent people from asking for the help they need.⁷
When we reframe the conversation to focus on “health” broadly and make a concerted effort to avoid negative labels for people living with these diseases, we have an opportunity to help break down stigma and shame while creating pathways to action so people can ask for the support they deserve. For people living with bipolar 1, it’s important to pursue the proper diagnosis, find a provider who truly listens, and work together on a thoughtful treatment plan to live life to their fullest potential.
Please read the Important Safety Information about LYBALVI below. See Prescribing Information and Medication Guide.
INDICATIONS AND IMPORTANT SAFETY INFORMATION
LYBALVI is a prescription medicine which contains 2 medicines (olanzapine and samidorphan) used in adults:
- alone for short-term (acute) or maintenance treatment of manic or mixed episodes that happen with bipolar I disorder
- in combination with valproate or lithium to treat manic or mixed episodes that happen with bipolar I disorder
- to treat schizophrenia
It is not known if LYBALVI is safe or effective in children.
LYBALVI may cause serious side effects, including increased risk of death in elderly people with dementia-related psychosis. LYBALVI increases the risk of death in elderly people who have lost touch with reality (psychosis) due to confusion and memory loss (dementia). LYBALVI is not approved for the treatment of people with dementia-related psychosis.
Do not take LYBALVI if you are taking opioids or are experiencing acute opioid withdrawal.
LYBALVI may cause serious side effects, including:
- Stroke (cerebrovascular problems) in elderly people with dementia-related psychosis that can lead to death.
- Opioid withdrawal. Do not take LYBALVI for at least 7 days after you stopped taking short-acting opioids and for at least 14 days after you stopped taking long-acting opioids. One of the medicines in LYBALVI (samidorphan) can cause opioid withdrawal that may be severe and cause hospitalization in people who are physically dependent on opioids. Talk to your healthcare provider if you have questions about the type of opioid you take.
- Risk of life-threatening opioid overdose. You should not start taking opioids for at least 5 days after you stop treatment with LYBALVI. One of the medicines in LYBALVI (samidorphan) can increase your chance of having an opioid overdose that can cause death if you take opioids during treatment or within 5 days after stopping treatment with LYBALVI.
You can accidentally overdose in 2 ways:
- LYBALVI blocks the effects of opioids, such as heroin, methadone, or opioid pain medicines. Do not take large amounts of opioids to try to overcome the opioid-blocking effects of LYBALVI. This can lead to serious injury, coma, or death.
- After you take LYBALVI, its blocking effect slowly decreases and completely goes away over time. You may be more sensitive to the effects of opioids. If you have used opioid street drugs or opioid-containing medicines in the past, using opioids in amounts that you used before treatment with LYBALVI can lead to overdose or death.
It is important that you tell your family and the people closest to you of this increased sensitivity to opioids and the risk of overdose.
You or someone close to you should get emergency medical help right away if you:
- have trouble breathing
- become very drowsy with slowed breathing
- have slow, shallow breathing (little chest movement with breathing)
- feel faint, very dizzy, confused, or have unusual symptoms
Tell your healthcare provider if you are taking LYBALVI before a medical procedure or surgery.
- Neuroleptic malignant syndrome (NMS), a serious condition that can lead to death. Call your healthcare provider or go to the nearest hospital emergency room right away if you have some or all of the following signs and symptoms of NMS:
- high fever
- sweating
- stiff muscles
- changes in your breathing, pulse, heart rate, and blood pressure
- confusion
- Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): One of the medicines in LYBALVI (olanzapine) can cause DRESS, which can cause death. Tell your healthcare provider right away if you develop any of the following symptoms of DRESS, including:
- rash
- fever
- swollen glands
- kidney problems
- liver problems
- lung problems
- heart problems
- Problems with your metabolism such as:
- high blood sugar (hyperglycemia) and diabetes. Increases in blood sugar can happen in some people who take LYBALVI. Extremely high blood sugar can lead to coma or death. Your healthcare provider should check your blood sugar before you start and regularly during treatment with LYBALVI.
Call your healthcare provider if you have any of these symptoms of high blood sugar during treatment with LYBALVI:
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- feel very thirsty
- need to urinate more than usual
- feel very hungry
- feel weak or tired
- feel sick to your stomach
- feel confused, or your breath smells fruity
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- increased fat levels (cholesterol and triglycerides) in your blood. Your healthcare provider should check the fat levels in your blood before you start and regularly during treatment with LYBALVI.
- weight gain. You and your healthcare provider should check your weight before you start and often during treatment with LYBALVI.
- Uncontrolled body movements (tardive dyskinesia). LYBALVI may cause movements that you cannot control in your face, tongue, or other body parts. Tardive dyskinesia may not go away, even if you stop taking LYBALVI. Tardive dyskinesia may also start after you stop taking LYBALVI.
- Decreased blood pressure (orthostatic hypotension) and fainting. You may feel lightheaded or faint when you rise too quickly from a sitting or lying position.
- LYBALVI may make you sleepy or dizzy, may cause a decrease in your blood pressure when changing position (orthostatic hypotension), and can slow your thinking and motor skills, which may lead to falls that can cause fractures or other injuries.
- Low white blood cell count. Your healthcare provider may do blood tests during the first few months of treatment with LYBALVI.
- Difficulty swallowing that can cause food or liquid to get into your lungs.
- Seizures (convulsions).
- Problems controlling your body temperature so that you feel too warm.
- Increased prolactin levels in your blood. Your healthcare provider may do blood tests to check your prolactin levels during treatment with LYBALVI.
The most common side effects of LYBALVI when used to treat people with schizophrenia include:
- weight gain
- sleepiness
- dry mouth
- headache
The most common side effects of LYBALVI when used alone to treat people with mixed or manic episodes that happen with bipolar I disorder include:
- weakness
- dry mouth
- constipation
- increased appetite
- sleepiness
- dizziness
- shaking
The most common side effects of LYBALVI when used in combination with lithium or valproate to treat people with mixed or manic episodes that happen with bipolar I disorder include:
- dry mouth
- weight gain
- increased appetite
- dizziness
- back pain
- constipation
- problems speaking
- mouth watering
- memory problems
- numbness and tingling in your arm and legs
Do not drive a car, operate machinery, or do other dangerous activities until you know how LYBALVI affects you. LYBALVI may make you feel drowsy.
Avoid drinking alcohol during treatment with LYBALVI.
Avoid getting over-heated or dehydrated.
- Do not exercise too much.
- In hot weather, stay inside in a cool place if possible.
- Stay out of the sun. Do not wear too much clothing or heavy clothing.
- Drink plenty of water.
Before taking LYBALVI, tell your healthcare provider about all of your medical conditions, including if you:
- have or had heart problems or a stroke
- use or abuse street (illegal) drugs
- have or had low or high blood pressure
- have kidney problems
- have diabetes or high blood sugar or a family history of diabetes or high blood sugar
- have or have had high levels of total cholesterol, LDL cholesterol, or triglycerides or low levels of HDL cholesterol
- have or had a low white blood cell count
- have problems swallowing
- have or had seizures (convulsions)
- have or had problems with urination or prostate problems
- have or had breast cancer
- have or had constipation or a bowel obstruction
- have or had high prolactin levels
- are pregnant or plan to become pregnant. Talk to your healthcare provider about the risks to you and your unborn or newborn baby if you take LYBALVI during pregnancy.
- Tell your healthcare provider right away if you become pregnant or think you are pregnant during treatment with LYBALVI.
- If you become pregnant during treatment with LYBALVI, talk to your healthcare provider about registering with the National Pregnancy Registry for Atypical Antipsychotics. You can register by calling 1-866-961-2388 or visit http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/
- are breastfeeding or plan to breastfeed. LYBALVI passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby during treatment with LYBALVI.
Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
LYBALVI and other medicines may affect each other causing possible serious side effects.
LYBALVI may affect the way other medicines work, and other medicines may affect how LYBALVI works.
Especially tell your healthcare provider if you:
- take opioids or have stopped taking opioids in the past 14 days
- take or plan to take other olanzapine containing medicines
Your healthcare provider can tell you if it is safe to take LYBALVI with your other medicines. Do not start or stop any medicines while taking LYBALVI without first talking to your healthcare provider.
Tell your healthcare provider if you take a urine drug screening test because LYBALVI may affect your test results. Tell those giving the drug screening test that you are taking LYBALVI.
These are not all the possible side effects of LYBALVI.
Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
Please see full Prescribing Information, including Boxed Warning, and Medication Guide.
LYBALVI® (olanzapine and samidorphan) is available as 5 mg/10mg, 10 mg/10 mg, 15 mg/10 mg, and 20 mg/10 mg tablets.
ALKERMES® is a registered trademark of Alkermes, Inc. LYBALVI® and logo are registered trademarks of Alkermes Pharma Ireland Limited, used by Alkermes, Inc., under license. ©2025 Alkermes, Inc. All rights reserved. LYB-003330
¹ Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication [published correction appears in Arch Gen Psychiatry. 2007 Sep;64(9):1039]. Arch Gen Psychiatry. 2007;64(5):543-552. doi:10.1001/archpsyc.64.5.543
² American Psychiatric Association. What Are Bipolar Disorders? American Psychiatric Association. https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
³ National Institute of Mental Health. Bipolar Disorder. National Institutes of Health; 2018.
⁴ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
⁵ American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159(4 Suppl):1-50.
⁶ LYBALVI [medication guide]. Waltham, MA: Alkermes, Inc.
⁷ Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the literature. J Affect Disord. 2013;150(2):181-191. doi:10.1016/j.jad.2013.05.030
