An Overview of Treatments for Bipolar Disorder
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.
Psych Central. (2020). An Overview of Treatments for Bipolar Disorder. Psych Central. Retrieved on April 8, 2020, from https://psychcentral.com/lib/an-overview-of-treatments-for-bipolar-disorder/