Bipolar Disorder Treatment: Medication & Therapy

Getting an Accurate Bipolar Diagnosis

Many people seek treatment for their depressive episodes but do not realize that they have bipolar disorder. There are several reasons why a correct diagnosis is so important. Certain antidepressants that are effective for unipolar (major) depression can actually induce a manic episode in someone who has a bipolar disorder. Also, the standard antidepressants are not as effective for bipolar episodes of depression. Another concern is that family involvement in the therapy plan is more critical to the success of bipolar treatment, and its importance might be overlooked when the diagnosis is incorrect.

Treatment for bipolar disorder is distinctly different from treatment for unipolar (major) depression. If there is any history of manic or hypomanic episodes in addition to depressive episodes, bipolar treatment is critical. A primary care physician would refer to a psychiatrist, psychologist, or other qualified therapist to make the diagnosis, although we may see use of bipolar brain scans in the future to help with diagnosis and treatment planning.

The Importance of Comprehensive Treatment for Bipolar

Comprehensive treatment for bipolar is extremely important because of the complex nature of the disorder. The most effective treatment usually involves mood-stabilizing medications, therapy, education about the disorder, lifestyle adjustments, and support. While the medication helps lessen the intensity or frequency of mood swings, therapy helps the person adjust to their life without the extreme highs and lows.

• Medication: The most common types of medication for bipolar are mood-stabilizers and the antipsychotics. At times, antidepressants or antianxiety meds might be added to the med plan but would not replace the former.
• Therapy: Therapy helps the person with bipolar disorder to accept their current challenges and the likelihood of a different life experience once their mood swings are under control. Cognitive behavior therapy (CBT) is a common therapeutic treatment for bipolar disorder. It can be difficult to accept the need for long-term management of this disorder and to give up the creative and energetic aspects of manic episodes.
• Education: Both the person with bipolar disorder and their family need to become educated about the disorder. This education allows for distinguishing which behaviors are part of the person’s basic personality versus those that are related to the mood swings.
• Lifestyle: Having routines which maintain optimal functioning is critical to living well with bipolar disorder. These include routines of adequate sleep, a diet healthy for that individual, physical exercise, avoiding substance abuse, and stress management skills.
• Support: Social and emotional support is essential throughout the stages of bipolar treatment, including the assessment, pre-stabilization and post-stabilization stages. The support and caring of family or friends encourages better adherence to the treatment plan as well as hope for the future.

Bipolar Treatment Medications

The standard bipolar treatment medications are mood stabilizers. These work by decreasing abnormal activity in the brain so that manic and depressive episodes are prevented. Although these meds do not cure mood swings, they do provide much relief from the symptoms. It is not unusual to supplement this treatment with antipsychotics, antidepressants, and/or anti-anxiety meds.

There are three major effects that mood stabilizers have:

• Stop a manic episode or reduce the acute or severe symptoms of mania or depression to a level which is more manageable
• Reduce associated symptoms such as sleep problems, agitation, hallucinations and delusions
• Prevent relapse and rehospitalization in the future by maintaining more stable mood

Lithium

Lithium Carbonate, a mood stabilizer, has been one of the most used bipolar treatment medications for the past five decades. While lithium is a chemical element that occurs in nature, it is combined with oxygen and carbon to form lithium carbonate. It is believed to work by affecting the activity of the neurotransmitters serotonin and dopamine. Lithium treatment is used to reduce mania and relieve depression without triggering mania.¹

Side effects which can occur with lithium may be temporary and go away after a few weeks or months. Some of these side effects can include nausea, stomach cramps, thirst, fatigue, headache and mild tremor. More serious side effects should be reported to a physician immediately. These include vomiting, diarrhea, extreme thirst, muscle twitching, slurred speech, confusion, dizziness, or stupor.

Other Mood Stabilizers

Another type of effective mood stabilizer is an anticonvulsant (anti-seizure) medication. Anticonvulsants were originally developed to treat epilepsy, but have been effective in reducing symptoms of mania and controlling mood swings. They are believed to work by increasing the neurotransmitter GABA, which has a calming effect on the brain. Some of the anticonvulsants are better at reducing mania, while others treat the depressive episodes without triggering a manic episode.

Common side effects of the anticonvulsants are drowsiness, weight gain or loss, dizziness, tremor, diarrhea, and nausea. Additional side effects might include irritability, loss of balance, sedation and vomiting. Severe side effects may occur with these medications, particularly with carbamazepine and lamotrigine. The anticonvulsants may increase suicidal thinking and behaviors and require close monitoring for new or worsening symptoms.

• Divalproex/Valproic Acid (Depakote) Depakote is a good choice for those who have difficulty with the side effects of lithium. It is the first choice medication for those with rapid cycling of moods, mixed mania, or those having hallucinations or delusions.¹
• Carbamazepine (Tegretol) Carbamazepine is one of the meds used to treat bipolar mania, either alone or with other meds. It may cause serious side effects including changes in heartbeats, fever, chills, confusion, severe weakness, and increased seizures. Any of these symptoms should be reported immediately to a physician. Although rare, serious and sometimes fatal dermatologic reactions have been reported with Tegretol and should be carefully monitored.¹
• Lamotrigine (Lamictal) Lamotrigine has been found to delay bouts of depression, mania, hypomania, and mixed-mood episodes. A number of other lamotrigine side effects may occur; the most common among these are headaches, dizziness, blurred vision, double vision, and loss of coordination. One possible side effect of using Lamictal for bipolar is a serious skin rash that requires hospitalization and discontinuation of treatment.¹
• Topiramate (Topamax) Topiramate is sometimes useful for people who don’t respond well to other mood stabilizers. In particular, it has been used for rapid cycling or mixed bipolar states when the first-choice meds don’t work well. Common side effects of Topamax include drowsiness, dizziness, vision problems, unsteadiness, and speech problems.¹
• Gabapentin (Neurontin) Gabapentin is sometimes used off-label as a mood stabilizer for depression in bipolar disorder. However, research indicates that there is weak evidence that gabapentin is effective for bipolar disorder. Gabapentin can be addictive and stopping abruptly may result in gabapentin withdrawal symptoms. ¹
• Oxcarbazepine (Trileptal) Oxcarbazepine is similar to Carbamazepine in that it is directed at treating mania, but it has less frequent adverse effects. However, there is not enough data about its efficacy, making it less often prescribed than the other mood stabilizers.¹

Antipsychotics

The type of antipsychotics currently prescribed for bipolar are known as the second generation antipsychotics or the atypical antipsychotics. They act by blocking chemical receptors in the brain and affecting the levels of neurotransmitters, including serotonin and dopamine. They are particularly helpful for people who have psychotic symptoms as part of their manic or depressive episodes. These medications reduce agitation, delusions, hallucinations, paranoia, and confusion. They are often used in combination with a mood stabilizer.

Compared to the first generation antipsychotics, atypical antipsychotics are less likely to cause certain side effects, including Parkinson’s-like symptoms and tardive dyskinesia.  However, there are side effects associated with this group of medications. Most common among the possible side effects are: intestinal distress, drowsiness, dry mouth, weight gain, blurred vision, and sexual dysfunction.¹ If any of these side effects are severe or get worse, a physician should be contacted immediately due to the risk of toxicity.

The atypical antipsychotics used to treat bipolar are:²

• Aripiprazole (Abilify): Aripiprazole is used alone or with a mood stabilizer to treat symptoms of mania and depression in Bipolar I.
• Aripirazole (Aristada): Aristada is an injectible form of aripiprazole that can be used off-label to treat bipolar I and II.
• Asenapine (Saphris): Saphris is also used to treat Bipolar I, it may cause serious neurologic problems.
• Clozapine (Clozaril): Sometimes prescribed to reduce the risk of suicidal behavior, clozapine (Clozaril) has been shown to affect the immune system and make a person more vulnerable to serious infections.
• Olanzapine (Zyprexa): Used to treat psychotic symptoms of mania or depression in Bipolar, Zyprexa is sometimes prescribed along with other antipsychotics.
• Cariprazine (Vraylar) Used to improve clear thinking, decrease hallucinations and decrease agitation.
• Lumateperone (Caplyta): Used to improve clear thinking and lessen nervousness, Caplyta may also improve sleep, energy level and appetite.
• Lurasidone (Latuda): Used to treat the depressive episodes of bipolar disorder, Latuda may also improve sleep, appetite and energy levels.
• Quetiapine (Seroquel): Used to decrease hallucinations, improve concentration, reduce nervousness, and prevent severe mood swings. Seroquel may also improve sleep, appetite, and energy levels.
• Risperidone (Risperdal): Used to improve clear thinking and boost energy levels.
• Ziprasidone (Geodon): Used to decrease hallucinations, improve clear thinking, reduce agitation, and improve energy levels. Geodon carries a serious risk of a fatal skin reaction and must be carefully monitored.

Antidepressants

Although antidepressants have been used in the past for bipolar depression, their use is becoming more controversial. Evidence suggests that antidepressants aren’t effective in the treatment of bipolar I, and they may even trigger a manic episode.³ However, they are sometimes used for the short-term treatment of bipolar II. They work by altering the levels of certain neurotransmitters in order to improve mood. Common side effects of antidepressants include: agitation, headaches, nausea, sleepiness, and reduced sex drive.

Antidepressants used in the treatment of bipolar II include:³

• SSRIs: The Selective Serotonin Reuptake Inhibitors (SSRIs) effectively increase the levels of the neurotransmitter serotonin in the bloodstream. Common SSRIs are Paxil, Zoloft, Prozac, Celexa, Lexapro, and Wellbutrin.
• SNRIs: The Serotonin and Norepinephrine Reuptake Inhibitors have the effect of increasing levels of both serotonin and norepinephrine in the bloodstream. Common SNRIs include Pristiq, Cymbalta, and Effexor XR.
• Tricyclics: These medications increase the levels of serotonin and norepinephrine, and also affect other brain chemicals. Common tricyclic antidepressants include Elavil, Tofranil, and Pamelor.
• MAOIs: Monoamine oxidase inhibitors (MAOIs) may relieve depression when other treatments fail. However, they can interact with certain foods or medications, causing dangerous side effects. Common MAOIs are Marplan, Nardil, Emsam, and Parnate.

Antianxiety/Anxiolytics

Anti-anxiety medications are fast-acting sedatives that take effect within 30 minutes to one hour. They might be prescribed to relieve symptoms of anxiety, agitation, or insomnia. Due to the high risk of tolerance or addiction to these medications, they might be prescribed only for short-term treatment, until the mood stabilizers become effective. Possible side effects include drowsiness, light-headedness, confusion, slurred speech, muscle weakness, and memory problems.³

• Alprazolam (Xanax): One of the short-acting benzodiazepines, Xanax is used to treat anxiety and panic.
• Lorazepam (Ativan): Another short-acting benzodiazepine, Ativan produces a calming effect to relieve anxiety.
• Clonazepam (Klonopin):  One of the long-acting benzodiazepines, Klonopin has been effective in treating social anxiety, panic disorder, and generalized anxiety.
• Chlordiazepoxide (Librium): Another long-acting benzodiazepine, Librium works in a similar way to Ativan and produces a calming effect on the nervous system.
• Diazepam (Valium): Also long-acting benzodiazepine, Valium is used to treat anxiety, although it does have potentially serious side effects.
• Clorazepate (Tranxene):  One of the older anti-anxiety medications, Tranzene (clorazepate) may cause some serious side effects.

Pregnancy & Bipolar Medication

If you’re pregnant or planning a pregnancy, it’s important to learn about the effects of medications for bipolar disorder on your own health and that of the fetus/newborn. Communicate with your doctor as soon as you know you’re pregnant or planning to become pregnant. Many of the bipolar treatment medications are unsafe due to risks of birth defects or other serious health problems. In addition, many medications, including lithium and other mood stabilizers, antipsychotics, and benzodiazepines, are not safe when breastfeeding.⁵

It is best to consult with your doctor about the use of any medication during pregnancy. Simply going off meds without a physician’s guidance can cause problems with mood swings.

Therapy Options for Bipolar Disorder

Therapy is extremely important in all phases of bipolar treatment. Initially, it helps the person overcome any denial of the need to get treatment and make several life adjustments.  It’s also helpful in learning accountability for the behavioral problems associated with bipolar and in maintaining self-compassion rather than shame or self-blaming for those problems.

Symptoms cannot be managed by medication alone. Finding a therapist who specializes in bipolar disorder is critical for identifying and managing symptoms as well as gaining tools for coping with the difficulties of life with bipolar. A therapist often helps the person with bipolar clarify facts and myths about bipolar disorder so they can monitor their progress properly as treatment continues and moods stabilize.

Cognitive Behavioral Therapy

CBT is a therapy approach which is directed at changing thoughts and behaviors in order to improve mood and ability to function well. It is particularly helpful in the maintenance phase of treatment for bipolar. Cognitive and behavioral interventions are helpful in reducing symptoms of depression, reducing the severity of mania, and making relapse less frequent. CBT for bipolar is associated with better compliance in taking medication as well as fewer hospitalizations.

Interpersonal and Social Rhythm Therapy (IPSRT)

IPSRT is based on the theory that disruptions in daily schedules or routines lead to disturbances in circadian rhythm which then trigger episodes of mania or depression in bipolar disorder. It works by helping each person discover which routines of work, school, sleep, and recreation provide them with the best symptom control. Once those routines are figured out, the IPSRT therapist helps the person solve any problems that get in the way of maintaining those routines.

Family Therapy

Select family members are included in treatment so that they can learn what to expect as the person with bipolar goes through the challenges of becoming stabilized. The family may need help in coping with denial, particularly in the early phases of treatment. Once the person is stabilized, family members may need help in distinguishing between behaviors that are true to that person versus those that were part of the bipolar disorder. This type of learning and discussion is empowering for both the person and the family as it helps them move beyond fear and shame and toward acceptance and progress.

Group Therapy

The main purpose of group therapy for bipolar is psychoeducation. Individuals with bipolar along with select family members learn about the causes of the disorder, the early warning signs of manic or depressive episodes, and how to stick to their helpful lifestyle routines. There is evidence that education provided in a group (with other bipolar individuals or with family members) is more effective than education provided one on one.³

Medical Procedures

Medical procedures might be used for short-term treatment of severe bipolar symptoms, such as suicidal risk or psychosis. In ECT for bipolar, an electric current is passed through the scalp to the brain and prompts a seizure. It is only used when medications and other treatments are not yet effective and the person is having severe mood or psychotic symptoms, making it unsafe to wait for medication effectiveness. Short-term memory loss is the most common side effect and usually goes away within a few weeks after treatment has ended.⁴

A second medical procedure that has been used for severe bipolar symptoms is Repetitive Transcranial Magnetic Stimulation (rTMS). TMS for bipolar involves the use of magnetic fields to stimulate the brain’s electrical activity. Most experts agree that more research is needed to determine the best frequencies to use and the specific brain areas to target for treating bipolar.⁴ ECT and TMS should only be administered by trained health professionals along with a certified anesthesiologist.

Is Treatment for Bipolar I Different from Treatment for Bipolar II?

While Bipolar I and Bipolar II are different disorders, the types of medications and treatments are basically the same. The specific medications and dosages depend on the particular symptoms the person is having. Someone with Type I would require treatment specific to having manic episodes, while the person with Type II would have hypomanic episodes. A person with Type II is likely to need treatment for Major Depressive Episodes, while someone with Type I might not experience Major Depressive Episodes. The need for hospitalization could occur with either, depending upon the severity of symptoms.⁶

Is Treatment Different for Rapid Cycling Bipolar?

In rapid cycling bipolar, symptoms of depression usually dominate and become the focus of treatment. Mood stabilizing drugs are the core treatments for this form of bipolar, with one or more mood-stabilizers usually needed. Antidepressants are usually avoided due to the potential of actually increasing the frequency of new episodes over time.¹

How to Find Treatment

Treatment for Bipolar usually begins with speaking to your physician, who will then refer to a psychiatrist for evaluation and treatment. You can also start your search with this list of the best online psychiatrist options. A nearby mental health clinic is likely to have a psychiatrist on staff as well as other mental health professionals experienced in the treatment of bipolar. Another option is to search an online therapist directory to find a therapist experienced in treating bipolar. If needed, medical procedures such as ECT are usually done in a dedicated section of a hospital or medical clinic, and most often done on an outpatient basis.

How to Prepare for a First Appointment

During the first meeting with your health care professional, certain types of information will be very helpful to have available. Consider bringing a list of any current or previous illnesses, current medications, and past and current symptoms. If you have had any prior therapy, it is helpful to provide a diagnosis given to you in the past. You might also be prepared to talk about any major sources of stress in your life currently.

When preparing for your appointment with a psychiatrist or doctor, you might consider asking:

• What could possibly be causing these symptoms?
• What is my diagnosis?
• What kinds of tests will be necessary?
• What resources are available to me?
• What should I do next to begin treatment?

Final Thoughts

Although bipolar is a lifelong complex disorder, relief is possible with an accurate diagnosis and a thorough treatment plan. If you are suffering from any symptoms which suggest a bipolar disorder, you are encouraged to seek help from a qualified professional. Many mental health providers are experienced in working with people who have bipolar and they are eager to help you.