Bipolar Disorder (Treatments)

Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous rather than on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications

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While primary-care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Medications known as mood stabilizers are usually prescribed to help control bipolar disorder. Several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

Anticonvulsant medications such as valproate or carbamazepine also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine how well they work in stabilizing mood cycles. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who begin taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. Therefore, mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

Atypical antipsychotic medications, including clozapine and ziprasidone, are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval. Olanzapine may also help relieve psychotic depression.

If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead.

Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication. It is important to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.

To reduce the chance of relapse or developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

Thyroid Function

People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.

People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

Medication Side Effects

Before starting a new medication for bipolar disorder, always talk with your psychiatrist or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sexual drive, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects during treatment. She may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance.

Psychosocial Treatment

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or talk therapy)—are helpful in providing support, education, and guidance to patients and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique—interpersonal and social rhythm therapy. Researchers at the National Institute of Mental Health are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation may also be helpful for family members.

Family therapy uses strategies to reduce the level of family distress that may either contribute to or result from the ill person's symptoms.

Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regulate daily routines. Daily routines and sleep schedules may help protect against manic episodes.

As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Other Treatments

Electroconvulsive Therapy

In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective or work too slowly to relieve severe symptoms such as psychosis or suicidal thoughts, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, or mixed episodes. The possibility of long-lasting memory problems has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, when appropriate, with family or friends.

Herbal and Natural Supplements

Herbal or natural supplements, such as St. John's Wort, have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient.

Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's Wort can reduce the effectiveness of certain medications. In addition, like prescription antidepressants, St. John's Wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.

Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.

Even though episodes of mania and depression come and go, it is important to understand that bipolar disorder is a long-term illness that has no cure. Staying on treatment, even during periods without episodes, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

People with bipolar disorder may need help to get help:

  • Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
  • A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing a referral to a mental-health professional.
  • Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
  • A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
  • Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for the individual.
  • In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
  • Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
  • Family members of people with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
Bipolar Disorder. Last reviewed 01/10/2008

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