Understanding Bipolar Disorder -- Treatment

Bipolar disorder is treated with three main classes of medication: mood stabilizers, antipsychotics, and, while their safety and effectiveness for the condition are sometimes controversial, antidepressants.

Typically, treatment entails a combination of at least one mood-stabilizing drug and/or atypical antipsychotic, plus psychotherapy. The most widely used drugs for the treatment of bipolar disorder include lithium carbonate and valproic acid (also known as Depakote or generically as divalproex). Lithium carbonate can be remarkably effective in reducing mania, although doctors still do not know precisely how it works. Lithium (Eskalith, Lithobid) may also prevent recurrence of depression, but its value seems greater against mania than depression; therefore, it is often given in conjunction with other medicines known to have greater value for depression symptoms, sometimes including antidepressants.

Valproic acid (Depakote) is a mood stabilizer that is helpful in treating the manic or mixed phases of bipolar disorder, along with carbamazepine (Equetro, Tegretol), another antiepileptic drug. These drugs may be used alone or in combination with lithium to control symptoms. In addition, newer drugs are coming into the picture when traditional medications are insufficient. Lamotrigine (Lamictal), another antiepileptic drug, has been shown to have value for preventing depression and, to a lesser degree, manias or hypomanias.

Other antiepileptic drugs, such as gabapentin (Neurontin), oxcarbazepine (Trileptal), or topiramate (Topamax), are regarded as experimental treatments that sometimes have value for symptoms of bipolar disorder or other conditions that often occur with it.

Haloperidol (Haldol Decanoate) or other newer antipsychotic medications, such as aripiprazole (Abilify), asenapine (Saphris), olanzapine (Zyprexa, Zyprexa Relprevv, and Zyprexa Zydis) or risperidone(Risperdal), are often given to patients as an alternative to lithium or divalproex. They also may be given to treat acute symptoms of mania -- particularly psychosis -- before lithium or divalproex (Depakote) can take full effect, which may be from one to several weeks. Another antipsychotic, lurasidone (Latuda), is approved for use in bipolar I depression as is the combination of olanzapine plus fluoxetine (called Symbyax). The antipsychotic quetiapine (Seroquel) is approved to treat bipolar I or II depression. Preliminary studies also suggest that the atypical antipsychotic cariprazine (Vraylar) also may have value for treating bipolar depression

Some of these drugs can potentially become toxic if doses get too high. Therefore, they need to be monitored periodically with blood tests and clinical assessments by the prescriber. Because it is often difficult to predict which patient will react to what drug or what the dosage should ultimately be, the psychiatrist will often need to experiment with several different medications when beginning treatment.

While antidepressants remain widely prescribed for bipolar depression, most antidepressants have not been adequately studied in patients with bipolar depression.

In general, your doctor may try to keep the use of antidepressants limited and brief. Long-term treatment with antidepressants in bipolar disorder tends to be recommended only when the initial response is clear-cut and there are no current or emerging signs of mania or hypomania. Some antidepressants -- given alone or in combination with other drugs -- may trigger a manic episode or cause cycles between depression and mania to be more rapid. If an antidepressant is not clearly having a beneficial effect for bipolar depression, there is usually little reason to continue it.

The family or spouse of a patient should be involved with any treatment. Having full information about the disease and its manifestations is important for both the patient and loved ones.

Nondrug Treatments of Depression

Whilemedications are usually the cornerstone of treatment for bipolar disorder, ongoing psychotherapy is important to help patients understand and accept the personal and social disruptions of past episodes and better cope with future ones. Several specific forms of psychotherapy have been shown to help speed recovery and improve functioning in bipolar disorder, including cognitive- behavioral therapy, interpersonal/social rhythm therapy, family therapy, and group therapy. In addition, because denial is often a problem -- sticking with medications can be especially tricky in adolescence -- routine psychotherapy helps patients stay on their medications.

Electroconvulsive therapy (ECT) is sometimes used for severely manic or depressed patients and for those who don't respond to medication or for those women who, while pregnant, experience symptoms. Because it can act quickly, it may be especially helpful for severely ill patients who are at high risk for attempting suicide. ECT fell out of favor in the 1960s partly due to distorted, negative portrayals of its use in the media. But modern procedures have been shown to be both safe and highly effective. The patient is first anesthetized and a muscle relaxant is given. Then, while the patient is asleep, a small electric current is passed through electrodes placed on the scalp to produce a grand mal seizure of short duration -- less than one minute. A course of treatment usually involves 6-12 treatments, typically administered three times per week. During the course of ECT treatments -- usually two to four weeks -- lithium and other mood stabilizers are sometimes discontinued to minimize side effects.They are then resumed after completion of the treatment.

The newer types of nonpharmocological treatments of depression are:

• VNS (Vagus or Vagal Nerve Stimulation) involves implantation of a device that sends electrical signals to the vagus nerve in order to treat depression.
• TMS (Transcranial Magnetic Stimulation) is a procedure which involves the use of an electromagnetic coil to create electrical currents and stimulate nerve cells in the mood centers of the brain as a treatment for depression.
• Light therapy has proved effective as an additional treatment when bipolar disorder has a connection to seasonal affective disorder. For those people who usually become depressed in winter, sitting for 20 minutes to 30 minutes a day in front of a special light box with a full-spectrum light can help treat depression.

Home Environment and Bipolar Disorder

If someone you live with has bipolar disorder, maintain a calm environment, particularly when that person is in a manic phase. Keep to regular routines for daily activities -- sleeping, eating, and exercise. Adequate sleep is very important in preventing the onset of episodes. Avoid excessive stimulation. Parties, animated conversation, and long periods of watching television or videos can exacerbate manic symptoms. Alcohol or illicit drug use can cause or worsen mood symptoms and make prescription medicines work less effectively.

IMPORTANT! Help and Support

In the manic phase of bipolar disorder, patients may engage in risky activities, such as fast driving or certain risky sports. They should be monitored and prevented from taking chances, especially in a car. Drinks and foods containing caffeine -- tea, coffee, and cola-- should be allowed in moderation. Avoid alcohol at all times. It is very important for a patient experiencing manic symptoms to receive prompt psychiatric assessment. Family members may need to contact the doctor, because oftentimes patients in a manic or hypomanic episode have little insight into their illness and may refuse treatment. But prompt intervention, including possible medication adjustments at an early point in an episode, may prevent further problems and the need for hospitalization.

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