Bipolar disorder is a lifelong mental health condition characterized by extreme mood swings between manic (or hypomanic) highs and depressive lows. While the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) does not officially divide bipolar into “stages” like cancer, clinicians and researchers sometimes use a staging model (e.g., Berk et al., 2007; Kapczinski et al., 2014) to describe progression. Stage 4 represents the most severe, treatment-resistant phase.

In Stage 4 bipolar, episodes are frequent, prolonged, and poorly responsive to standard medications (lithium, valproate, antipsychotics). Rapid cycling (≥4 episodes/year) or mixed states are common. Cognitive deficits memory loss, executive dysfunction, and slowed thinking persist even between episodes, often due to repeated neuroinflammation and brain volume loss (seen on MRI). Functional impairment is profound: most patients cannot maintain employment, relationships, or independent living. Comorbidities like substance abuse, anxiety, or cardiovascular disease accelerate decline.

Symptoms include:

• Manic phase: Severe psychosis (delusions, hallucinations), dangerous impulsivity (financial ruin, hypersexuality), aggression.
• Depressive phase: Suicidal ideation, catatonia, total anhedonia.
• Inter-episode: Chronic irritability, cognitive fog, social withdrawal.

Treatment shifts from mood stabilization to palliative care:

• Clozapine or ECT (electroconvulsive therapy) for refractory cases.
• Ketamine/esketamine infusions for acute suicidality.
• Intensive case management, disability support, and family psychoeducation.

Prognosis: With early intervention, progression to Stage 4 can be delayed. However, once reached, full remission is rare; focus is on harm reduction and quality of life. If you or a loved one show worsening symptoms despite treatment, consult a psychiatrist specializing in treatment-resistant bipolar immediately.