Medical and therapeutic treatments for bipolar disorder include antidepressants, mood stabilizers, antipsychotics, benzodiazepines, and psychotherapy. Treatment of bipolar disorder is usually lengthy, often lasting years, although most long-term treatment is limited to simply taking a daily medication to help keep the symptoms of bipolar disorder at bay.
Ideally, the best treatment for bipolar disorder is a combination of different medications, psychotherapy (or talking therapy), natural treatments and lifestyle choices. No single treatment, therapy, or lifestyle choice is likely to be the most effective. A number of them working as complements to each other ensures your best chance of success.
Medication Treatment for Bipolar Disorder
Medication treatment for bipolar disorder generally involves three classes of drugs:
- Antidepressants for depression
- Mood stabilizers for mania
- Anti-psychotics for mania
Some people may also be prescribed a benzodiazepine to help calm them. People with bipolar disorder are typically prescribed a combination of drugs referred to as a “drug cocktail.” The American Psychiatric Association, in its bipolar disorder treatment guideline, lists remission as the goal of medications treatment. Remission is defined as having virtually no symptoms and a return to full functioning. Unfortunately, you may have to settle for less, given the imperfect nature of these medications. However, you are entitled to a best effort from our psychiatrist. Equally as important, side effects that interfere with your ability to think and function should not be regarded as an acceptable trade-off for reducing your symptoms.
What you need to know about antidepressants from a bipolar perspective is that there is divided opinion in psychiatry concerning the safety of bipolar patients on antidepressants. This is because an antidepressant without a concomitant antimania medication is almost certain to switch a patient into mania. Some authorities contend that even with an antimania drug, the danger is there. Accordingly, the American Psychiatric Association, in its bipolar disorder guidelines issued in 2002, does not recommend an antidepressant-antimania combination as a first option. Another guideline recommends tapering and discontinuing soon after remission is achieved.
On the other hand, there is a smaller body of opinion that feels the risk is overstated. One study found that those who stayed on their antidepressants fared better over 12 months than those who quit them before six months. But the same study also found that antidepressants did not work for the large majority of those in the study.
Mood stabilizers mainly keep mania in check, though it’s not certain precisely how they function in the brain. Lithium, which is a common salt, was discovered as a treatment for bipolar disorder by accident. It’s the only mood stabilizer with proven efficacy for treating all phases of bipolar depression and mania.
The other mood stabilizers – Depakote (valproic acid), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Neurontin (gabapentin), Topamax (topiramate) and Lamictal (lamotrigine) – first came on the market as antiseizure medications. Depakote, Tegretol, and Trileptal are used to treat mania. Neurontin is useful for co-occurring anxiety, and Topamax is effective for weight loss. Lamictal is the current favorite for treating bipolar depression. Because we don’t know exactly how they work and what we should be targeting, it comes as no surprise that their clinical benefit leaves much to be desired, with burdensome side effects ranging from dry mouth to weight gain to tremors to sedation to skin rash. However, a lot of these effects go away as the body adjusts to the medication. Because of the side effects, noncompliance is common. What one needs to keep in mind is as imperfect as these medications are, they offer one a fighting chance at recovery, as well as a welcome alternative to what would have been a lifetime of institutionalization a generation ago.
Lithium and Lamictal have antidepressant properties. Although Lamictal is the current favorite for treating bipolar depression, its FDA indication is for relapse prevention.
Antipsychotics are yet another medication that first came on the market to treat another illness – schizophrenia. The drugs work by binding to dopamine receptors in the brain, preventing overstimulation from the neurotransmitter dopamine. The older antipsychotics bind tightly to these receptors, resulting in considerable side effects, including sexual dysfunction, increased lactation (which can result in loss of menses in women and lower testosterone in men), dulled cognition, sedation, and involuntary facial and muscular spasms. One of these, Haldol, is still in common use.
The newer “atypical” antipsychotics bind more loosely to the dopamine receptors, resulting in less risk of these side effects, though they still remain fairly common. Nevertheless, the APA and other guidelines recommend the atypicals as a first option for treating mania in the initial phase, often in combination with a mood stabilizer. The same guidelines and product labeling on these medications also recommend gradual tapering following remission, owing to the risk of tardive dyskinesia (involuntary spasms), unless needed. The atypicals include Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Geodon (ziprasidone), and Abilify (aripiprazole). Abilify, the newest, is thought to have the best side effects profile. Zyprexa and Seroquel also have significant antidepressant effects. Further studies are likely to find antidepressant effects in other atypicals. Combination Zyprexa-Prozac (Symbyax) is FDA-approved to treat bipolar depression.
There are medications to treat tremors and spasms, and wakefulness agents to handle sedation. Sometimes simply lowering the dose may solve the problem or changing to a different medication. Letting your psychiatrist know of any side effects, the two of you can work on a solution. Also keep in mind that good lifestyle choices can reduce side effects.
These include Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam). Their main purpose is to relieve anxiety and promote sleep, but they can be very effective in quickly bringing down a person from a manic state or as an additional medication in the “drug cocktail”. Their main drawback is they can be habit forming, with severe withdrawal symptoms, as well as having a depressive effect, so they are typically prescribed short-term or on an as-needed basis.
Pregnancy and breastfeeding
In general, antidepressants are considered safe through all phases of pregnancy and breastfeeding. However, check with your doctor or psychiatrist. As for mood stabilizers, lithium runs an outside risk of heart defect in the first trimester, while the risk of spina bifida is too great to be taking Depakote or Tegretol (and possibly the other mood stabilizers) during the first trimester. Of the antipsychotics, Haldol, the most studied, can be used safely during pregnancy. Frederick Goodwin MD, author of the definitive book on bipolar disorder, stated at a 2001 conference that because of the risk of postpartum mania, it is critical for expectant mothers to get back on their medications well before giving birth. Alternatives to medications include omega-3 and light therapy; and, as a last option, ECT. Drugs to avoid while breastfeeding: Lithium, Lamictal, antipsychotics.
Alcohol should not be consumed if you’re expecting your medications to work. If you find it hard to quit, bring this up with your psychiatrist. Caffeine and nicotine are other drugs you should seriously consider eliminating or cutting back on.
Which Medications are Right for Me?
Every individual is unique and no two cases of bipolar disorder are the same, so what works for one person in your support group may not work for you and vice versa. The American Psychiatric Association and other organizations implicitly recognize this in their treatment guidelines, which set out a number of first options for medications treatment, graduating to a stepped series of different options should those first options fail.
As a general rule, finding the right combination of medications takes time. Patience and persistence are required. You may have to persevere through a number of trials before you and your psychiatrist, as a team effort, hit upon a satisfactory solution.
This can be discouraging if you believe you can let your medications do all the work. Smart lifestyle choices and various coping techniques can make a substantial difference. Medication treatment can also be combined with talking therapy to great effect.
What Are My Choices in Psychotherapy?
Cognitive therapy – also called cognitive behavioral therapy – works to change erroneous thoughts (such as “My life will never be better.”) into more positive ones (such as, “Let’s find a solution.”) Once one is thinking and behaving in a positive way – such as working toward a solution rather than anticipating another day of unhappiness – one actually begins feeling better. The therapy applies equally well to depression and mania. The therapy typically lasts 10 to 20 sessions, involving active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone. Learn more about cognitive therapy.
Behavioral therapy and interpersonal therapy
These are also short-term, manual-based therapies that focus on coping skills. By changing destructive behaviors and dealing better with people, one can successfully negotiate the stressful situations that can trigger a mood episode. Learn more about behavioral therapy or interpersonal therapy now.
What about other types of talking therapy?
Before you engage in therapy that involves working on painful issues or suppressed memories, it’s important that your mood is stabilized. Otherwise these therapies may cause your condition to deteriorate. However, if your boss is making you unhappy and your family is causing you stress, simply taking medications only invites another episode. These situations represent very dangerous triggers that need to be addressed. Long-term talking therapy that can help you resolve these issues may literally save your life.
What about ECT?
Electroconvulsive therapy, also known as shock treatment, has been used successfully to treat both depression and mania. However, because of risk of short-term memory loss – and in rare cases long-term memory loss – it is regarded as a treatment of last resort, except if the patient’s condition puts him/her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on.
The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than candid over the memory loss element, and neglects to mention that relapses are common, which necessitates additional periodic “booster” treatments.
Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their bipolar in remission should do their research and make their decision accordingly, while they have their wits about them. You can state your wishes in the form of a psychiatric advance directive.