Treatment
If you have bipolar disorder, you will need lifelong treatment. Regular monitoring and consultation with a health care professional is necessary to establish which medication or combination of drugs works best.
Medications called "mood stabilizers" are most often prescribed to help control bipolar disorder, and several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for an extended period of time to manage their illness, usually for years. Other medications such as antidepressants are combined with mood stabilizers when necessary, typically for shorter periods, to treat powerful episodes of mania or depression that may break through despite the mood stabilizer.
For more than 30 years, the mood stabilizer lithium has been one of the main treatments for people with bipolar disorder.
Lithium evens out moods so you don't feel as high or as low, but it's unclear exactly how the medication works in the brain. Lithium is not used just for manic attacks, but rather as an ongoing treatment to prevent all types of episodes. It can take up to 14 days to start reducing severe manic symptoms. It might take a few months of medication before the illness is under control.
When taken regularly, lithium can effectively control depression and mania and reduce the chances of recurrence. However, while it is effective treatment for many people, it doesn't work for everybody.
Regular blood tests are a must if you're taking lithium. Too small a dose might not be effective and too large might produce unwanted side effects, including weight gain, tremors, excessive thirst and urination, drowsiness, weakness, nausea, vomiting and fatigue.
Salt intake also affects the amount of lithium in your body. A dramatic reduction in salt intake, excessive exercise and sweating, fever, vomiting or diarrhea may cause lithium to build up in your body to toxic levels. An overdose of lithium can cause confusion, delirium, seizures, coma and may result, although rarely, in death.
In addition to lithium, other mood stabilizers used in the treatment of bipolar disorder include anticonvulsants. They may be combined with lithium or with each other for maximum effect. Specific ones used for bipolar syndrome include:
- Valproate (Depakote or Divalproex). Valproate is an anticonvulsive medication that can have a mood-stabilizing effect in people with bipolar disorder. It is especially useful for difficult-to-treat bipolar episodes. There is some evidence that valproate may result in hormonal changes in teenage girls and polycystic ovarian syndrome (PCOS) in women who began taking the medication before age 20, but this connection remains controversial. Nonetheless, young women should discuss this risk with their health care professional and those taking valproate should be monitored carefully for possible hormonal problems.
Anticonvulsants like valproate may interact with hormonal contraceptives to decrease their effectiveness.
The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) also have some effects as mood stabilizers although they are not yet approved for bipolar disorder by the U.S. Food and Drug Administration (FDA). Lamotrigine (Lamictal), the first FDA-approved medication for the long-term treatment of adults with bipolar I disorder since lithium was approved in 1970. It is specifically used to treat the depressive episodes involved with bipolar disorder.
Severely ill patients may require a combination treatment with mood stabilizers and other drugs, including:
Antidepressant medications. Several classes of antidepressant medications are available, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). Side effects and effectiveness differ for each class of medication, as well as for the individual brands.
In patients with bipolar disorder, use of antidepressants without mood stabilizers can trigger mania and possibly precipitate rapid cycling between mania an depression, particularly with TCAs and MAOIs. Make sure you tell your health care professional about any prior symptoms of hypomania (episodes that include increased energy, euphoria and irritability) before beginning antidepressants.
Antipsychotics. If you're experiencing psychotic or manic symptoms during an episode of bipolar disorder, health care practitioners will sometimes prescribe antipsychotic medicine alone or in combination with lithium to control symptoms. For example, the FDA approved the antipsychotic Zyprexa (olanzapine) to treat acute mania and for the long-term treatment of bipolar disorder in combination with lithium or valproate. Some studies find this combination works better than lithium or valproate alone. Olanzapine can also be used alone for the treatment of bipolar disorder.
Additionally, fluoxetine has been approved for treating the depressive phase of bipolar disorder.
Other drugs include the anti-psychotics ziprasidone (Geodon), quetiapine (Seroquel), aripiprazole (Abilify) and risperidone (Risperdal), all FDA-approved for the treatment of acute mania.
Be patient. It may take up to three weeks of regular use of a new drug before your symptoms improve or subside. However, if no changes are apparent within six weeks, talk to your health care professional about other options.
Electroconvulsive therapy (ECT) is another treatment option for bipolar disorder and other types of major depression. It is usually only used to treat bipolar disorder when medication, psychosocial treatment or the combination of these treatments are ineffective or work too slowly to relieve severe symptoms such as psychosis or thoughts of suicide. ECT may also be considered when certain medical conditions, such as pregnancy, make the use of medication too risky.
Just prior to ECT treatment, you're given a muscle relaxant and general anesthesia. Electrodes are then attached to your scalp. An electric current causes a brief convulsion. You won't remember the treatments and usually awake slightly confused. Acute treatments occur three times per week for two to three weeks. "Maintenance" ECT is also used; you may receive treatment once a week for several months.
ECT has been used for more than 70 years and has been refined since its early introduction as a treatment for depression. According to the National Mental Health Association, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. Researchers don't understand exactly how it works to improve symptoms of depression in some individuals, but the evidence is clear that it does work.
Although many myths and negative perceptions continue to be perpetuated about ECT, it is a very effective treatment for many people with severe depression, manic or mixed episodes who don't respond to other treatments. The National Mental Health Association reports that in some cases, the results of ECT are very favorable—some studies report that 80 percent of severely depressed patients improve after ECT treatment, although they still require medications. Other studies, however, indicate that the relapse rate is high in people who receive ECT. As with all other treatments, you should undergo a complete physical evaluation before beginning ECT therapy.
Side effects can include permanent memory loss and confusion. These side effects were more a concern of the past, and modern ECT techniques have reduced them significantly. However, the benefits and risks of ECT should still be carefully weighed before an individual or his or her family and friends decide to go with the treatment.
Psychotherapy. As with all mental illnesses and other serious conditions, bipolar disorder can devastate a person's self esteem and relationships with others, especially with spouses and family. Without treatment, people with the illness may jeopardize their finances, their careers, their families and their lives. Thus, in addition to treatment with medications, psychotherapy ("talk therapy") is also recommended for individuals with the disorder, as well as for their family members.
Bipolar Disorder and Pregnancy
Women with bipolar disorder who want to become pregnant need to consider several issues. Careful planning for pregnancy can help women with bipolar disease best manage their illness while avoiding risks to their babies. If you prefer not to use medication during pregnancy, a trial off medications (following a gradual taper) prior to pregnancy, possibly only stopping medications after conception, might be an option. Most health care professionals suggest avoiding sudden changes in medication during pregnancy, which can increase the risk of relapse.
Overall, studies show that taking only one mood stabilizer during pregnancy poses less of a risk to the developing fetus than does taking multiple medications. Lithium and other types of medications, such as benzodiazepines, certain antipsychotics, valproate, and carbamazepine may pose health risks for a developing fetus. Nevertheless, rates of problems vary widely based on the medication.
Haloperidol (Haldol), an older antipsychotic that has antimanic properties and no clear association with physical or cognitive defects in the developing fetus, can also be used for mania control during pregnancy. As with other medications, there is particular concern about physical birth defects resulting after exposing a fetus during the first trimester.
Later exposure to certain medications may also affect the developing brain. Some of these medications can be used while breastfeeding but all options should be discussed with your health care professional. Overall, if you are pregnant or planning to become pregnant and you have bipolar disorder, be sure to discuss safety of various treatment options during and after pregnancy with your health care professional.
ECT has also been used for decades (with appropriate adjustments) in pregnancy to treat severe mania or depression.
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Create Date: 1/10/02
Date Last Updated: 12/8/06
Review Date: 11/15/06
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