Medications for Bipolar Disorder

What Medications Are Used to Treat Bipolar Disorder?

The most commonly used medications for treating bipolar disorder are lithium, antipsychotics, and certain anti-seizure medications. These medications are used as mood stabilizers to prevent and treat cycles of manic and depressive mood. Antidepressants and benzodiazepines are also helpful for some people.

Some of these medications are FDA-approved and others are used off-label. An FDA-approved medication has been evaluated for safety by the FDA and has been proven to be effective in treating bipolar symptoms. An off-label use of a medication means that it is not formally recognized for treating bipolar disorder, but prescribers can decide to use a medication off-label when they believe it may offer a benefit to someone.

There are four main factors that prescribers consider when prescribing medication for bipolar disorder:

1. Their symptoms at the time of diagnosis
2. The effectiveness of a medication
3. How well the individual may tolerate that medication and its side effects
4. How safe that medication may be for the individual

Lithium

Lithium was the first medication developed specifically to treat bipolar disorder in 1949 and is used as a mood stabilizer.¹ Currently, it is one of the main FDA-approved treatments for bipolar disorders, especially for acute mania and long-term therapy after mania symptoms have been treated. The exact reason why lithium helps in bipolar disorders is still not fully understood. However, there are theories that explain how lithium can calm the brain and an overexcited central nervous system.²

Common Lithium Side Effects 

The biggest concern regarding lithium is that the amount of lithium to safely treat bipolar disorders without causing harm falls within a narrow range. Lithium is also the only long-term medication for bipolar disorders that has been shown to decrease the risk of suicide. So despite concerns about side effects, the benefits of taking lithium often outweigh the risks.

Continue taking lithium medication as prescribed. Do not stop taking lithium even after you start feeling better unless your doctor directs you to do so.

Common side effects of lithium include:*¹

• Tremor (usually in the hands)
• Increased urination and increased thirst
• Nausea
• General sense of unease/discomfort
• Weight gain
• Loose stool
• Cognitive impairment

*This is not a comprehensive list of side effects with lithium. There are serious and mild side effects possible with the medication. You should talk with your doctor about your health history and any possible side effects before starting the medication.

Side effects of lithium can usually be alleviated by reducing the dosage or changing the dosage schedule. If you feel any side effects due to lithium, talk to your doctor about what should be done next.

Anticonvulsants

Anticonvulsants are anti-seizure medications. However, some anti-seizure medications have been shown to be of great benefit in managing bipolar disorder. Anticonvulsants might be prescribed by itself or in combination with another medication based on an individual’s symptoms and the severity of symptoms.

Anticonvulsants commonly prescribed to treat bipolar disorder include:

• Depakote (divalproex sodium): Manic episodes
• Lamictal (lamotrigine): Depression, mania, hypomania, mixed episodes
• Carbamazepine: Manic episodes
• Oxtellar (Oxcarbazepine): Off-label treatment for bipolar symptoms

Common Anticonvulsant Side Effects 

Anticonvulsant medications are known to have some serious side effects. Due to this, when prescribed these medications, you will need to visit your physician every few months in order to properly monitor your progression on the medication and to keep an eye out for any harmful side effects. With these visits, your doctor will also ask you to get blood tests done to monitor the levels of medication in your body.

Common side effects of anticonvulsants prescribed for bipolar disorders can include:*

• Hair loss
• Weakness
• Nausea
• Appetite changes
• Dry mouth
• Tremors
• Mood changes
• Nervousness
• Back pain
• Trouble breathing
• Weight changes
• Dizziness
• Drowsiness
• Rash

*All medications, including anticonvulsants, can cause side effects which can be mild or serious. This is not a comprehensive list of all possible side effects. You should talk with your doctor about any questions you have and to understand the potential side effects and benefits of any medication.

Antipsychotics

Antipsychotics are a class of medications that are typically used to treat psychosis, a condition where the mind loses touch with reality. Psychosis has many potential causes, including psychiatric disorders such as bipolar disorder or schizophrenia, medical conditions, medications, or trauma. Atypical antipsychotics are used either alone or with a mood stabilizer to manage psychotic symptoms associated with bipolar disorders, such as mania with hallucinations and delusions.

They help to decrease the high levels of excitability and agitation in patients experiencing mood episodes, thereby reducing reckless behavior often associated with manic episodes. Additionally, research has supported the use of atypical antipsychotics as a treatment for other phases of bipolar disorder.⁶

Antipsychotics commonly prescribed to treat bipolar disorder and their FDA-approved treatment goals are:⁷

• Abilify (aripiprazole): Mania, mixed bipolar episodes, long-term therapy for bipolar disorders
• Saphris (asenapine): Mania, mixed bipolar episodes
• Latuda (lurasidone): Bipolar depression
• Zyprexa (olanzapine): Mania, mixed bipolar episodes, long-term therapy for bipolar disorders
• Seroquel (quetiapine): Mania, bipolar depression
• Risperdal (risperidone): Mania, mixed bipolar episodes
• Geodon (ziprasidone): Mania, mixed bipolar episodes
• Symbyax (olanzapine/fluoxetine): This is an antipsychotic combined with an SSRI antidepressant used to treat bipolar depression.
• Caplyta (lumateperone): Depressive episodes in bipolar disorders

Common Antipsychotic Side Effects

Serious side effects that can be caused by atypical antipsychotics are seizures, heart attacks, and suicidal thoughts. If you notice such symptoms, seek medical treatment immediately.

Common side effects of antipsychotics may include:*

• Dry mouth
• Dizziness
• Weight gain
• Sleep disruption (insomnia or drowsiness)
• Nausea
• Restlessness
• Fatigue

*All medications, including antipsychotics, can cause side effects which can be mild or serious. This is not a comprehensive list of all possible side effects. You should talk with your doctor about any questions you have and to understand the potential side effects and benefits of any medication.

Antidepressants

Antidepressants are a family of medications typically used to treat disorders involving depression, anxiety, and chronic pain. They include selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and others.*

While antidepressants may increase the risk of manic episodes for people with bipolar disorder, these medications may be beneficial for others.⁹ Some psychiatrists will use antidepressants as an adjunct to a patient’s mood stabilizer.

Antidepressants are not indicated as stand alone medications for bipolar disorder for two main reasons:

1. The risk of induction into mania
2. More importantly, they don’t seem to work that well—even for bipolar depression

*Antidepressants have a black box warning, the most serious kind of warning from the FDA for a risk of suicidal thoughts and behaviors in certain people. You should talk with your doctor about these risks before starting this medication.

Symbyax

The only FDA-approved use of an antidepressant in the treatment of bipolar disorders is Symbyax, which is a combination of olanzapine (an antipsychotic) and fluoxetine (an SSRI). It can be used to treat acute bipolar depression episodes for short periods, but if any signs or symptoms of mania or hypomania emerge when using Symbyax or any other antidepressant medication, you need to call your psychiatrist immediately.

Side Effects of Antidepressants

Some individuals may experience side effects when taking antidepressants. Many are mild and manageable, but some may require medical care because they are persistent, difficult to tolerate, or severe. Serotonin syndrome and increased suicidal thoughts and behavior are severe effects that require immediate medical attention.

Benzodiazepines

Benzodiazepines reduce stimulation and slow down messages in the central nervous system. When used under supervision and in combination with other bipolar medications, benzodiazepines can help with short-term treatment of manic symptoms. Benzodiazepines can also be used short-term during bipolar depressive episodes to alleviate anxiety, insomnia, and suicidal ideation and behavior.¹⁰

Benzodiazepines commonly prescribed for treating bipolar disorder include*:

• Klonopin (clonazepam)
• Ativan (lorazepam)
• Versed (midazolam)

*This medication has black box warnings, the most serious kind of warnings from the FDA for abuse or misuse, risk of physical dependence and risk of serious side effects, including death, when combined with an opioid.

Common Side Effects of Benzodiazepines 

Some people who take benzodiazepines experience side effects. Among the most common are:

• Drowsiness
• Low energy
• Low inhibition (acting without feeling worried or embarrassed)
• Slowed or shallow breathing

Many side effects can be managed and may be mild, but a person with persistent or severe side effects, such as slowed breathing or loss of consciousness, should get immediate medical attention.

What Is the Best Medication for Bipolar?

The best medication for bipolar disorder depends on the individual and their most prominent symptoms. The medication regimen that is the best for a single patient might evolve over time depending on how well-managed their symptoms are and if new symptoms develop. It may also change depending on how someone tolerates the medication, which may require an ongoing conversation with their prescriber about the benefits and risks.

How to Get Medication for Bipolar Disorder 

To get medication for bipolar disorder, you may begin by speaking with your primary care physician, a psychiatrist, or a mental health provider. If you are struggling to find a physician and have insurance, you can reach out to your insurance provider to find options near you or online. Online psychiatry services may also meet your needs better than an in-person prescriber depending on your needs and where you live.

Other Bipolar Disorder Management Tools

Medications are not the only treatment for bipolar disorders. A well-rounded treatment approach to bipolar disorder includes not only medications but therapy as well. Bipolar disorder is a chronic condition that requires treatment for a lifetime. Discuss all the necessary and available treatment options with your primary care physician and psychiatrist.

A well-rounded treatment plan for bipolar disorder could include:

• Therapy: Psychotherapy can help someone struggling with bipolar disorder to develop coping methods to recognize and avoid triggers of acute manic or depressive mood episodes. CBT for bipolar disorder may improve symptoms and help a person take their medication regularly.
• Education: Psychoeducation is how a therapist educates a patient and their loved ones about their condition, provides support, and teaches coping skills. Learning more about bipolar disorders can help a person and their loved ones stay with the treatment plan and understand symptoms.
• Lifestyle: Acute mood episodes can be triggered by poor sleep, use of alcohol and other substances, and stress. A person can help manage their symptoms by addressing stress in positive ways, planning relaxing activities, exercising regularly, and eating a healthy diet.
• Support: The treatment of bipolar disorders can be more successful with support from family, friends, and the community. Group psychoeducation sessions can help individuals with bipolar disorders connect with others sharing a similar struggle while learning how to best manage the condition together.
• Electroconvulsive therapy (ECT): ECT might be used as part of the treatment for patients who do not respond well to typical treatments, such as medications and psychotherapy. Those who have extremely severe symptoms or have severe immediate life-threatening suicidality may also benefit from ECT treatment.

Questions to Ask Your Health Team About Bipolar Medicine

Bipolar disorder is a complex syndrome that can manifest differently for each person. If you have been diagnosed with bipolar disorder, your symptoms and the factors affecting the condition can change over your lifetime. The communication between you and your medical and mental health providers is essential.

Come to your scheduled appointments prepared with any questions you might have about your condition, medications, or other factors affecting your life. These conversations can help your doctor recognize the need for changes in your treatment plan.

Questions to ask your prescriber about bipolar medication include:

• Is it safe to take bipolar medication with my other medications?
• Can my bipolar medications affect my other medications? If so, what can I expect?
• Will bipolar medications be covered by my insurance?
• Which medication has the best results as a treatment for depression symptoms?
• Which one has the best results as a treatment for mania symptoms?
• Does my medical history increase my risk of side effects?
• How long can I expect side effects to last?
• How often should I see you for checkups while taking bipolar medication?
• Will I need to complete lab work prior to our checkups? How often?
• Will my treatment/medication regimen change in the future? If so, what changes can I expect over time?
• Do you have recommendations for psychotherapists or psychoeducation groups I can attend to further help me in my treatment goals?
• Do I need to consider ECT if my medications do not work for me?

In My Experience

In my experience, each individual experiencing bipolar disorder and any other mental health disorder have unique experiences. Because of this, there is no one “best” treatment that will fit every diagnosis of bipolar disorder. The treatments prescribed will be tailored to the symptoms experienced by the patient and their response to initial treatments.

Many other factors also contribute to which treatment regimen is chosen for an individual patient and how this regimen might change over time. It is important to have open and honest conversations with your doctors and healthcare teams about your bipolar symptoms, medications, and treatment options.