The goal of treatment of bipolar disorder is to prevent both manic and depressive episodes, controlling the extreme highs and lows to create a stable mood. The core treatment is mood-stabilizing medications.
Lithium (Lithobid) was the first medication to be approved for treating mania, and it remains the mainstay of bipolar disorder treatment today. (Blood levels of lithium are measured regularly to ensure adequate doses and to avoid the dangerous effects of toxic levels.) Because lithium can take more than a week to have an effect, a neuroleptic (an antipsychotic drug) or a benzodiazepine (an antianxiety drug) may be added to treat symptoms of acute mania. Benzodiazepines should be used with caution, however, because of the risk of dependency and abuse. They can also disinhibit some manic patients, escalating inappropriate behavior.
Instead of lithium, doctors may choose to use other mood-stabilizing medications —carbamazepine (Equetro), valproic acid (Depakene, Depakote), or lamotrigine (Lamictal) —in combination with one another or with neuroleptics or benzodiazepines to treat acute mania. The neuroleptic drugs aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) have also been approved for treating manic episodes. Valproic acid and neuroleptics are also good options for people who have what’s known as mixed states —simultaneous symptoms of mania and depression.
A neuroleptic drug is prescribed in combination with a mood-stabilizing drug when manic episodes are severe or involve hallucinations or delusional ideas. Neuroleptics are usually taken only for short periods because of their neurological side effects, which include repetitive, involuntary, purposeless movements or twitches (known as tardive dyskinesia or tardive dystonia) that may not go away even if medication is stopped. These side effects occur less often with some newer (or atypical) neuroleptics, such as Zyprexa and Risperdal. These drugs are also linked with a condition called neuroleptic malignant syndrome, which includes symptoms such as muscle stiffness or spasms, high fever, and confusion or disorientation.
A new episode of mild or moderate depression in people with bipolar disorder is typically treated with a mood stabilizer such as lithium. If the depression is severe, only then would an antidepressant drug be added to the mood stabilizer. (Lithium has been shown to be effective in preventing suicide, and antidepressants must be used with caution in people with bipolar disorder.) If the depression involves psychotic symptoms, the person may need to take neuroleptic medication in addition to the mood stabilizer and antidepressant.
The reason antidepressants must be used with extreme care in people with bipolar disorder is that they can stimulate a manic episode or cause rapid cycling between depression and mania. This is particularly true for tricyclic antidepressants. A recent study in The New England Journal of Medicine suggests that they offered no clear benefit but were also associated with no significant increase in manic symptoms when prescribed in combination with a mood-stabilizing medication during the 26 weeks of the study. Despite the presumed risk and lack of proven benefit, it’s estimated that 50 to 70% of people with bipolar disorder are prescribed antidepressants. Each individual’s situation must be assessed, since some clinical situations —such as prominent coexisting anxiety symptoms —may be the reason for including an antidepressant in the treatment.
SSRIs and other relatively new antidepressants, such as Wellbutrin or Effexor, are the most likely drugs to be used. In addition, Symbyax —a combination of an atypical neuroleptic (olanzapine) and an SSRI (fluoxetine) —has been approved by the FDA to treat depressive episodes in people with bipolar disorder.
Despite the risk of mania, according to a study in The American Journal of Psychiatry, people with bipolar disorder whose depression responded to treatment with antidepressant medication (in addition to their other medications) had a low incidence of relapse into depression or mania during the first year after the depression eased if they remained on antidepressant medication during that time.
Long-term Treatment of Bipolar Disorder
People who have had at least two episodes in five years (that is, at least two manic episodes, two depressive episodes, or one manic and one depressive episode) or three serious lifetime episodes will need to take medication over the long term, even when they experience no symptoms. This can be difficult for people to accept once they stabilize and begin to feel well again. However, research clearly shows that bipolar disorder is a chronic, cyclic disease and that the consequences of going off medication can be tragic. Treatment usually involves a mood stabilizer; other medications may be added on a short-term basis if depression or mania worsens or if symptoms such as impulsivity, irritability, or poor concentration develop. A person on long-term treatment for bipolar disorder will need periodic blood tests to monitor blood levels of the medication and to check for any serious side effects, such as liver, kidney, or thyroid problems.
Sleeping problems are common in people with bipolar disorder because mania can cause a reduced need for sleep and depression can cause insomnia. Benzodiazepines and certain neuroleptics may help promote sleep but are given only for short periods.
Sometimes a depressive episode occurs in someone who has been doing well with long-term treatment (known as breakthrough depression). When this happens, there are a number of treatment options. Those who experience mild to moderate depression may be given a higher dosage of their mood stabilizer. (In some instances, however, the mood stabilizer may actually induce mild depression, and the doctor may choose to lower the drug dosage.) If depression is severe, the person may be given an SSRI or a second mood stabilizer. Rapid cycling between mania and depression despite long-term treatment precludes use of antidepressants.
