Bipolar disorder is treated with three main classes of medication: mood stabilizers, antipsychotics, and — while their safety and effectiveness for the condition are sometimes controversial — antidepressants.
Typically, treatment uses a combination of at least one mood-stabilizing drug and/or atypical antipsychotic, plus therapy. The most widely used drugs for bipolar include lithium carbonate and valproic acid (also known as Depakote or generically as divalproex). Lithium carbonate can be remarkably effective in reducing mania, although doctors still don’t know precisely how it works. Lithium (Eskalith, Lithobid) may also prevent the recurrence of depression, but its value seems greater against mania than depression. It’s often given with other medicines known to have greater value for depression symptoms, sometimes including antidepressants.
Valproic acid (Depakote) is a mood stabilizer that’s helpful in treating the manic or mixed phases of bipolar disorder, along with carbamazepine (Equetro, Tegretol), another antiepileptic drug. These drugs may be used alone or in combination with lithium to control symptoms. In addition, newer drugs are coming into the picture when traditional medications are insufficient. Lamotrigine (Lamictal), another antiepileptic drug, has been shown to have value in preventing depression and, to a lesser degree, mania or hypomania.
Other antiepileptic drugs — such as gabapentin (Neurontin), oxcarbazepine (Trileptal), or topiramate (Topamax) — are regarded as experimental treatments that sometimes have value for symptoms of bipolar disorder or other conditions.
Haloperidol (Haldol Decanoate) or newer antipsychotic medications are often given as an alternative to lithium or divalproex, including options such as:
- Aripiprazole (Abilify)
- Asenapine (Saphris)
- Cariprazine (Vraylar)
- Olanzapine (Zyprexa, Zyprexa Relprevv, and Zyprexa Zydis)
- Milsaperidone (Bysanti)
- Risperidone (Risperdal)
They also may be given to treat acute symptoms of mania — particularly psychosis — before lithium or divalproex (Depakote) can take full effect, which may be from one to several weeks. Another antipsychotic, lurasidone (Latuda), is approved for use in bipolar 1, as is the combination of olanzapine plus fluoxetine (called Symbyax). The antipsychotic medications lumateperone (Caplyta) and quetiapine (Seroquel) are approved to treat bipolar 1 and 2.
Some of these drugs can potentially become toxic if doses get too high. They need to be monitored periodically with blood tests and clinical assessments by the prescriber. Because it’s often difficult to predict how someone will react to what drug or what the dosage should ultimately be, your psychiatrist may need to experiment with several different medications when beginning treatment.
While antidepressants are widely prescribed for bipolar, most antidepressants haven’t been adequately studied in people with bipolar.
In general, your doctor may try to keep the use of antidepressants limited and brief. Long-term treatment with antidepressants in bipolar tends to be recommended only when the initial response is clear-cut and there are no current or emerging signs of mania or hypomania. Some antidepressants — given alone or in combination with other drugs — may trigger a manic episode or cause cycles between depression and mania to be more rapid. If an antidepressant is not clearly having a beneficial effect on bipolar depression, there is usually little reason to continue it.
Your family or spouse can also be involved with treatment. Having full information about the condition and its manifestations is important for you and your loved ones.
Nondrug Treatments of Depression
While medications are usually the cornerstone of treatment for bipolar disorder, ongoing therapy is important to help you better understand and accept the personal and social disruptions of past episodes. It can also help you better cope with future episodes. Several specific forms of therapy have been shown to help speed up recovery and improve functioning people with in bipolar disorder, including:
- Cognitive-behavioral therapy
- Interpersonal/social rhythm therapy
- Family therapy
- Group therapy
Sticking with medications can be especially tricky in adolescence. But routine therapy helps you stay on your medication.
Electroconvulsive therapy (ECT) is sometimes used for people who don't respond to medication or for women who, while pregnant, experience symptoms. Because it can act quickly, it may be especially helpful for people who are at high risk for attempting suicide. ECT fell out of favor in the 1960s, but modern procedures have been shown to be both safe and highly effective.
If you do ECT, you'll get anesthetized and a muscle relaxant. Then, while you're asleep, a small electric current passes through electrodes placed on your scalp to create a seizure for a short time — less than one minute. A course of treatment usually involves six to 12 sessions, typically three times per week. During the course of ECT treatments— usually two to four weeks — lithium and other mood stabilizers are sometimes discontinued to minimize side effects. You'll start taking them again once the treatment is over.
The newer types of non-pharmocological treatments of depression are:
- VNS (vagus or vagal nerve stimulation), which involves the implantation of a device that sends electrical signals to the vagus nerve in order to treat depression
- TMS (transcranial magnetic stimulation), a procedure that involves the use of an electromagnetic coil to create electrical currents and stimulate nerve cells in the mood centers of the brain as a treatment for depression
- Light therapy, which has proved effective as an additional treatment when bipolar disorder has a connection to seasonal affective disorder (For those people who usually become depressed in winter, sitting for 20 minutes to 30 minutes a day in front of a special light box with a full-spectrum light can help treat depression)
Home Environment and Bipolar Disorder
If someone you live with has bipolar, make sure your home is a calm environment, particularly when that person is in a manic phase. Keep to regular routines for daily activities: sleeping, eating, and exercise. Adequate sleep is very important in preventing the onset of episodes. Avoid excessive stimulation. Parties, animated conversations, and long periods of watching television or videos can exacerbate manic symptoms. Alcohol or drug use can cause or worsen mood symptoms and make prescription medicines work less effectively.
Help and Support
In the manic phase of bipolar disorder, you may take part in risky activities, such as fast driving. You should be monitored and prevented from taking chances, especially in a car. Drinks and foods containing caffeine — tea, coffee, and soda — should be allowed in moderation. Avoid alcohol at all times. It’s very important for a someone experiencing manic symptoms to get a psychiatric assessment as soon as possible. Family members may need to contact the doctor, because oftentimes, people in a manic or hypomanic episode have little insight into their condition and may refuse treatment. But prompt intervention, including possible medication adjustments at an early point in an episode, may prevent further problems and the need for hospitalization.
