Treatment Approach

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There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications. Some people with bipolar disorder supplement or replace their prescribed medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms or relapses of depression or mania.

Nearly all bipolar treatment studies have involved treating patients in the acute (initial) mania stage, where use of medication may be justified in removing a patient from danger. Less is known, however, about long-term treatment, where relapse prevention and full remission are the main treatment goals.

Until recently, depression was largely overlooked in bipolar disorder. The anticonvulsant medication, lamotrigine (Lamictal) is often used for treating bipolar depression, particularly where other drugs have failed and the patient's disorder has a strong depressive component. New clinical trials are finding that certain new-generation antipsychotics such as olanzapine (Zyprexa) and quetiapine (Seroquel) show some beneficial effect in treating bipolar depression. Eli Lilly also offers Symbyax, a combination of olanzapine (Zyprexa) and fluoxetine (Prozac). Lithium also has a mild antidepressant effect.

Because there is a danger of antidepressant medications, such as SSRIs, switching bipolar patients into mania, these medications are used with caution and nearly always with a mood stabilizer.

Cognitive therapy may work to lessen the severity of mood swings by recognizing and managing triggering symptoms or events. Interpersonal and Social Rhythm Therapy (ISPRT) emphasizes the regulation of sleep, diet and exercise to prevent episodes, along with teaching coping skills; it is well-documented that sleep disruptions can trigger manic episodes.

Bipolar Medications

Medications called mood stabilizers are used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants. However, as stated above, antidepressants carry the risk of inducing mania, especially in bipolar patients who are not taking a mood stabilizer.

In severe cases where the mania or the depression is severe enough to cause psychosis (and sometimes in less severe cases as well), antipsychotic drugs may also be used. A new class of "atypical" antipsychotics has also become more widely used for bipolar episodes. The FDA has only approved them for the treatment of acute manic episodes associated with bipolar I disorder. (with the exception of olanzapine (Zyprexa), which is approved as a mood stabilizer). Like most doctors, psychiatrists use medication for "off-label" uses, even when such uses are not supported by available research. It is becoming accepted practice to use atypical antipsychotics as mood stabilizers at this point, and there is support in the literature for their effectiveness in mood stabilization.

Side Effects of Antipsychotic Medications

A rare, but serious, side effect that has been reported with this kind of medicine is known as NMS or neuroleptic malignant syndrome. NMS is characterized by muscle rigidity and fever. Other serious side effects, which have been reported, include tardive dyskinesia (uncontrollable movements). Tardive dyskinesia is a potentially disfiguring and sometimes irreversible movement disorder that may case the arms, legs, face or head to jerk or twitch. If you experience these side effects, it's important to notify your doctor immediately.

There have also been reports of elevated blood sugar and diabetes associated with the use of atypical antipsychotic medications. If you have diabetes, or possible risk factors like obesity, or if diabetes runs in your family, you should talk to your doctor about checking your blood sugar before starting an atypical antipsychotic and throughout treatment. If you develop symptoms of elevated blood sugar or diabetes, including excessive thirst, increased urination, overeating, or weakness, contact your doctor. Complications from elevated blood sugar or diabetes can be serious and even life-threatening.

Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is by nature episodic, and patients may experience remissions whether or not they receive treatment. For this reason, patients should expect immediate relief, although psychosis with mania can respond quickly to antipsychotics, and bipolar depression can be alleviated quickly with electroconvulsive therapy (ECT). Many doctors emphasize that patients should not expect full stabilization for at least 3-4 weeks (some antidepressants, for example, take 4-6 weeks to take effect), and should not “give up” on a medication prematurely nor should they discontinue medication with the disappearance of symptoms as the mania or depression may return.

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Reviewed: 03/2006