Treatment of and Medications for Bipolar Disorder

To date, there are no known cures for Manic Depression, but there are a large number of medical and alternative treatments. Because this is a chronic and recurring illness, most people with the disorder are going to require long term, possibly lifetime treatment. Treatment typically consists of medication and psychotherapy or talk therapy. Most talk therapy is of the Cognitive Behavioral type which aims to change the patient’s way of thinking and behaviors. However, I would like to add that I believe a firm faith or spiritual grounding in a religion that suits you personally is equally as important as the medication and therapy. It has been my experience that practicing Nichiren Buddhism in addition to medication and psychotherapy has helped me to remain stable for a lot longer than previous to my becoming Buddhist about 3 1/2 years ago. 

Medication: Usually prescribed by a psychiatrist. Also very tricky to find the right combination of medications for each individual case. What works very well for me may turn out to be your worst nightmare, and vice versa. Medication is very individual and specific. It is important to find a psychiatrist that is good with medication, and is not into over-medicating.

“Mood Stabilizers” are usually the first drugs of choice. Patients will typically stay on mood stabilizers for years.

1. Lithium (also known as Eskalith or Lithobid) was the first of the mood stabilizers to be approved by the FDA in the 1970’s, and is still very common today as a first line medication for stabilizing mood. It is generally prescribed for preventing mania, but also works on depression. It is highly effective at preventing recurrences of manic and depressive episodes. The only drawback is the monthly blood level checks to make sure you are in between about a 0.6 and 0.9. Any higher than 1.0, and your body will become toxic, and any lower than 0.6, and you might as well take a sugar pill. It is also important to have renal system functioning tested monthly. Side effects of Lithium can include: Restlessness, Dry Mouth, Bloating/Indigestion, Acne, Unusual Discomfort to Cold Temperatures, Joint or muscle pain, Brittle hair and nails. If you have these or any other extremely bothersome side effects, contact your doctor immediately.
2. Depakote (Valproic Acid or divalproex sodium) is the other first line mood stabilizer. It was approved in 1995 for the treatment of mania. It is an alternative for those who cannot take Lithium. In my experience, Depakote just sucks as a mood stabilizer. I gained 40 pounds in the two months I was on it, and I slept all day, lost two jobs to being late constantly. No wonder my mood was stable: I was comatose.
3. Anti-convulsants: Although designed to treat seizure disorders, many in this class of medication are used as mood stabilizers. They include gabapentin (Neurotin), topiramate (Topamax), oxcarbazepine (Trileptal). Most recently, the FDA approved lamotrigine (Lamictal) for the treatment of Bipolar Disorder.

Depakote, Lamictal and other anticonvulsant medications tend to increase suicidal ideation in some patients so it is important to closely monitor people on these medications for any changes in thought or behavior, new or worsening symptoms of depression, suicidal thoughts or behavior,  or any unusual changes in mood or behavior. People taking Lamictal are also cautioned against the development of a rash that may become life threatening (Steven-Johnson’s Syndrome).

Lithium also can affect thyroid functioning especially in rapid cycling women. Both low and high levels af thyroid hormone can change energy and mood , it is important to monitor these levels as well. This may lead to taking Thyroid medication in addition to the bipolar medications.

“Atypical Antipsychotics” are also sometimes used in the treatment of Bipolar Disorder. They are often combined with other medications. They are called “Atypical” to set them apart from the earlier medications in this class which are called “first generation” or “conventional” antipsychotics.

1. Zyprexa when given with an anti-depressant medication can be effective in relieving symptoms of severe mania or psychosis. It is also available in injectable form which will put a quick stop to a manic episode or psychosis. People taking Zyprexa may gain weight and increase their risk of diabetes and heart disease. These side effects are more common than with the other “atypicals”.
2. Abilify is approved for the treatment of manic or mixed episodes. It is also used as a maintenance drug following a severe or sudden episode. It can also be injected to quickly control the symptoms of a manic or mixed episode.
3. Seroquel also relieves the symptoms of severe and sudden manic episodes. In 2006, the FDA approved its use for depressive episodes as well.

Risperidone and Geodon are examples of other “atypical ” antipsychotics that may be prescribed for a Bipolar patient.

“Anti-depressants” are sometimes used in combination with a mood stabilizer to control to treat symptoms of depression in bipolar disorder. Generally, this is because anti-depressants alone can often cause “switching” in which the patient becomes manic or hypomanic or rapid cycling.  A recent NIMH study found that adding an anti-depressant is sometimes no more effective than a mood stabilizer alone. Prozac, Paxil, and Wellbutrin are examples of anti-depressants that may be prescribed for Bipolar patients.

People taking medications for Bipolar Disorder should not suddenly stop taking their medication. This can lead to a worsening of symptoms and potentially uncomfortable or dangerous withdrawal effects. Patients taking anti-depressants should be monitored for the first few weeks of treatment. Potential side effects include worsening of depression, suicidal thoughts or behavior, trouble sleeping, agitation or withdrawal from normal activities. Generally, anti-depressants are not prescribed for people under the age of 18. 

Side-Effects

1. Mood Stabilizers: Drowsiness, Dizziness, Headache, Diarrhea, Constipation, Heartburn, Mood Swings, Stuffed or runny nose, other Cold-like symptoms
2. Antipsychotics: Drowsiness, Dizziness when changing position, Blurred Vision, Rapid Heart Beat, Sun Sensitivity, Skin Rashes, Menstrual Problems in women. People taking antipsychotics are prone to weight gain which may increase the chance of developing diabetes and high cholesterol. Patients on these medications should be monitored for lipid levels, weight and glucose levels. In rare cases, long term us is associated with a condition known as Tardive Dyskinesia which causes uncontrollable muscle movements most commonly affecting the mouth. These symptoms may be permanent, or they may improve once the patient is taken off the medication.
3. Anti-depressants : Headache, Nausea, Sleep problems, Agitation, Sexual problems (men and women) including decreased drive and enjoyment of sex. These side effects generally go away after a few weeks. Some of these medications cause more problems than others, however your doctor or pharmacist should be able to explain the differences in medications.

Psychotherapy in addition to medication can provide support, education, guidance, to people with bipolar and their families. Some therapies include:

1. “Cognitive Behavioral Therapy” helps patients to learn to change negative or harmful thinking and behaviors.
2. “Family-focused Therapy” includes family members. It helps with coping strategies, and can also improve communication and problem-solving
3. “Interpersonal and social rhythm Therapy” helps bipolar patients improve their relationships, and manage their daily routines. It is thought that regular daily routines may decrease the chance of episode recurrence.
4. “Psychoeducation” teaches patients about Bipolar Disorder and its treatments. This type of therapy helps people to recognize signs of relapse so than can act preemptively. This type of therapy is usually done in a group. It may also be of benefit to family members and caretakers.

The therapist often works closely with the psychiatrist to keep track of progress and regression. The number, type of therapy, and frequency of sessions should be tailored to fit the needs of each patient. Following the therapist’s suggestions is one key to success with psychotherapy as it is with medication. NIMH is supporting more research on which combination of psychotherapy and medication is the most effective at preventing relapses and helping to recover from episodes more quickly. 

Other Treatments

1. Electroconvulsive Therapy: Used when medication and talk therapy just do not work. This is considered one of the last resorts of treatment for Bipolar Disorder.
2. Sleep Medications: Used when sleep problems persist after medication therapy has begun. Usually once treatment has begun, the patient’s sleep improves. If is does not, then sleep medications may be prescribed.

People with Manic Depression should discuss all the medications they use including over the counter medications with their doctors to avoid possible interactions or lessening of efficacy of the psychoactive medications. There has not been much research done on herbal remedies or natural supplements so their effect on Bipolar Disorder is largely unknown. Once again, people with manic depressive disorder should discuss ALL medications used with their prescribing doctor.

That wraps up treatments and medications. This post is in no way meant to be exhaustive and you should continue to talk openly with your doctors about you medications, how they are working, side effects, etc. That is the only way to get maximum benefit from the medications. Also, do not stop and start medications just because you feel better. You won’t in a few weeks. The key to making medications work is to maintain continuous use, and not be sporadic about your treatment plan.