Bipolar Disorder Medication

The role of medication in bipolar disorder treatment

Bipolar disorder medication can be used during both the acute and maintenance phase of the illness. During manic or depressive episodes, mood stabilizers, antidepressants, and antipsychotics can bring severe symptoms under control. During the maintenance phase, mood stabilizers can be used to prevent your condition from deteriorating. Taken long-term, mood stabilizing drugs help prevent relapse into full-blown manic and depressive episodes.

But while bipolar disorder medications can reduce the symptoms of the disorder, they do not provide a cure. For long-term preventive treatment, bipolar disorder drugs are most effective when combined with therapy and other self-help coping techniques. Drug treatment may help reduce the severity of your mood swings, but therapy and education give you the tools to cope with life's difficulties, monitor your progress, and deal with problems bipolar disorder causes in your personal and professional life.

Finding the right bipolar disorder drug

Finding an effective medication regimen for bipolar disorder can be a difficult and drawn-out process. Everyone responds to medication differently, so you may have to try several prescriptions before you find the one that works for you. Once you've zeroed in on the right drug or drug cocktail, it may still take time to determine your optimal dosage. In the case of mood stabilizing medications such as lithium, the difference between a beneficial dose and a toxic one is small.

Because of the many adjustments that must be made based on your response to the bipolar disorder medication, you will need to work closely with your healthcare provider when starting treatment. Careful monitoring for adverse effects and frequent office visits are important. Once you find a bipolar disorder drug and dose that works for you, you can extend the length of time between check-ins with your doctor. However, because the course of bipolar disorder is unpredictable, self-monitoring is essential throughout your treatment.

Learning about your medication

When starting a new bipolar disorder medication, you should also educate yourself about how to take it safely. Questions to ask your doctor about any new prescription include:

• Are there any medical conditions that could be causing or exacerbating my mood swings?
• What are the side effects and risks of the medication you are recommending?
• When and how should I take this medication?
• Are there any foods or other substances I will need to avoid?
• How will this drug interact with my other prescriptions?
• How long will I have to take this medication?
• Will withdrawing from the drug be difficult if I decide to stop?
• Will my symptoms return when I stop taking medication?

Safety guidelines for medication use

All prescription drugs come with risks, but if you take your bipolar disorder medications responsibly, you can minimize them.

• Take your medication as instructed. You may be tempted to stop taking your bipolar disorder medication if you're experiencing side effects. Or conversely, you may want to stop taking your pills because you feel great and don't think you need them anymore. However, stopping maintenance medication comes with a high risk of relapse. Stopping cold-turkey is even more risky. Before you make any final decisions, talk to you doctor. If you don't like the way the drug makes you feel or if it's not working, there may be other options you can try. And if you decide that medication is not for you, your doctor can help you taper off your drugs safely.
• Keep track of side effects. Track any side effects you’re experiencing. Using a log, record what your symptoms are, when you’re experiencing them, and how bad they are. Bring the worksheet to your doctor. He or she may have suggestions for minimizing the side effects. If side effects are severe, your doctor may revise your bipolar disorder medication plan.
• Check for drug interactions - You should always check for drug interactions before taking another prescription medication, over-the-counter drug, or herbal supplement. Drug interactions can cause unexpected side effects or make your bipolar disorder medication less effective or even dangerous. Mixing certain foods and beverages with your bipolar medication can also cause problems. Talk to your doctor about special precautions for the medication or medications you’re taking. You can also learn about potential interactions by reading drug labels or talking to your pharmacist.

Mood s tabilizers for bipolar disorder

Mood stabilizers are medications that relieve both the symptoms of mania and depression. They are the cornerstone of bipolar disorder treatment, and are generally recommended for both the acute and preventive phase of the illness. Taken long-term, mood stabilizers can help prevent mood cycling and reduce the severity of episodes.

Lithium and valproic acid are the most widely prescribed mood stabilizers. Lithium is the treatment of choice for euphoric mania, while valproic acid is preferred for mixed episodes and rapid cycling.

• Lithium – Lithium is the oldest and most well-known mood stabilizer. It is highly effective for treating mania, and is usually the first line of treatment. Lithium is also effective for treating bipolar depression, particular when combined with another medication such as an antidepressant. It is not as effective for mixed episodes or rapid cycling forms of bipolar disorder. As a maintenance treatment, lithium can reduce the frequency and severity of manic and depressive episodes. Lithium takes from one to two weeks to reach its full effect.
• Valproic acid – Valproic acid, also known as divalproex or valproate, is an anticonvulsant medication originally used in the treatment of epilepsy. Commonly known by the brand name Depakote and Depakene, valproic acid is a highly-effective mood stabilizer. It is often the first choice for rapid-cycling bipolar disorder, mixed mania, or mania with hallucinations or delusions. People take from five to ten days to respond to valproic acid.
• Other anticonvulsant drugs – If lithium or valproic acid don’t work, there are a number of other anticonvulsants that can be used as mood stabilizers. The leading alternative for mania is carbamazepine. Lamotrigine has also been shown to be effective, particularly for depression and maintenance treatment..  

Major Mood Stabilizers for Bipolar Disorder
Drug	Brand Names	Common Side Effects	Special Precautions
Lithium	Eskalith, Lithobid	Weight gain, restlessness, tremor, nausea, stomach pain, excessive thirst, and increased urination.	Lithium can cause thyroid and kidney problems, so periodic blood tests are necessary to make sure they are functioning properly.
Valproic acid, (also known as valproate or   divalproex sodium)	Depakote, Depakene	Drowsiness, weight gain, dizziness, tremor, diarrhea, and constipation.	Valproic acid can cause liver damage and alter your body’s production of blood platelets. Periodic liver function tests and platelet counts are necessary.
Carbamazepine	Tegretol	Drowsiness, dizziness, upset stomach, vomiting, headache.	There is a rare but dangerous risk of liver inflammation and a decrease in your body’s production of blood cells. Blood tests are needed to monitor these functions.
Lamotrigine	Lamictal	Dizziness, loss of balance, headaches, and vision problems.	Lamotrigine can cause a serious rash. This risk can be reduced by increasing your dose very slowly and gradually.

In addition to the major mood stabilizers described in the table above, other mood-stabilizing options include:

• Gabapentin (Neurontin)
• Topiramate (Topamax)
• Oxcarbazepine (Trileptal)
• Levitiracetam (Keppra)
• Zonisamide (Zonegran)

Antidepressants for bipolar

Depression is the most pervasive feature of bipolar disorder. People with bipolar disorder typically spend far more time in the depressive phase than they do in the manic phase. Furthermore, bipolar depression is more disruptive than mania, frequently interfering with work, family life, and social functioning. Unfortunately, depressive episodes can be difficult to treat.

Concerns about antidepressants

Antidepressants have traditionally been used to treat episodes of bipolar depression. However, mounting evidence suggests that they aren’t effective. A major study funded by the National Institutes of Mental Health concluded that antidepressants don’t work any better than sugar pills in treating the symptoms of bipolar depression. If you are taking a mood stabilizer, there is no treatment benefit to adding an antidepressant during a depressive episode.

There are also serious safety concerns regarding the use of antidepressants for bipolar disorder treatment. First, antidepressants can trigger mania in people with bipolar disorder. Second, there is evidence that antidepressants may worsen the course of bipolar disorder over the long-term. Many experts believe that over time, antidepressant use in people with bipolar disorder has a mood destabilizing effect, increasing the frequency of manic and depressive episodes.

Because of the risks, antidepressant therapy for bipolar disorder should be limited. If an antidepressant is prescribed for a severe episode of depression, it should be discontinued once symptoms are under control. Antidepressants are not recommended for maintenance therapy.

Antidepressants for Bipolar Disorder
Generic and Brand Names
Bupropion (Wellbutrin) Venlafaxine (Effexor) Fluoxetine (Prozac) Fluvoxamine (Luvox)	Sertraline (Zoloft) Paroxetine (Paxil) Escitalopram (Lexapro) Citalopram (Celexa)
Special Precautions
Because antidepressants can trigger mania or hypomania in people with bipolar disorder, they must always be combined with a mood stabilizer such as lithium or valproate. Tricyclic antidepressants should be avoided, because they can bring on rapid cycling.

Antipsychotics for bipolar disorder

If you lose touch with reality during a manic or depressive episode, an antipsychotic drug may be prescribed. While older antipsychotics such as haloperidol (Haldol) and chlorpromazine (Thorazine) are approved for the treatment of bipolar disorder, long-term use can cause tardive dyskinesia, a permanent movement disorder characterized by involuntary tics. Other side effects of traditional antipsychotics include tremors, severe muscle stiffness, and restlessness. Because of these adverse motor effects, newer medications called atypical antipsychotics are preferred. 

Atypical antipsychotics are often used to control bipolar disorder when psychotic symptoms, such as delusions and hallucinations, are present. Typically, they are combined with a mood stabilizer such as lithium or valproic acid. In addition to their effectiveness in treating psychotic mania, the atypical antipsychotics have also been found to help with regular manic episodes. Because of this, this class of drugs is now considered to be a mood stabilizer as well as an antipsychotic. Atypical antipsychotics have also shown promise in the treatment of bipolar depression.

Atypical Antipsychotic Medications for Bipolar Disorder
Generic and Brand Drug Names
Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal)	Aripiprazole (Abilify) Ziprasidone (Geodon) Clozapine (Clozaril)
Common Side Effects
Drowsiness Weight gain Sexual dysfunction	Dry mouth Constipation Blurred vision
Special Precautions
The FDA requires all atypical antipsychotics to carry a warning about the risks of diabetes and hyperglycemia. These medications raise your risk of developing adult-onset diabetes. They also exacerbate preexisting Type 1 and 2 diabetes conditions.

Other medications for bipolar disorder

• Benzodiazepines – Mood stabilizers and antidepressants can take up to several weeks to reach their full effect. While you’re waiting for your medication to kick in, your doctor may prescribe a benzodiazepine to relieve any symptoms of anxiety, agitation, or insomnia you might be having. Benzodiazepines are fast-acting sedatives which work within 30 minutes to an hour. Common brand names include Xanax, Klonopin, and Ativan. Because of their high addictive potential, benzodiazepines should only be used until your mood stabilizer or antidepressant begins to work. Those with a history of substance abuse should be particularly cautious.

• Calcium Channel Blockers – Calcium channel blockers are sometimes prescribed for bipolar disorder. Traditionally used to treat heart problems and high blood pressure, they also have a mood stabilizing effect. They have less side effects than traditional mood stabilizers, but they are also less effective. However, they may be an option for people who can’t tolerate lithium or the anticonvulsants. Calcium channel blockers used for bipolar disorder include verapamil, nimodipine, isradipine, nifedipine, and diltiazem.

• Thyroid Medication – People with bipolar disorder often have abnormal levels of thyroid hormone. Thyroid dysfunction is particularly prevalent in rapid cyclers. Lithium treatment can also cause low thyroid levels. In these cases, thyroid medication is added to the drug treatment regimen. However, thyroid medication also shows promise

Related links for bipolar disorder medications

General information about bipolar disorder medications

What Are the Major Drugs Used For Bipolar Disorder? – Covers the primary medications used to treat manic depression. Includes dosage information, side effects, and drug interactions. (University of Maryland Medical Center)

Medication for Bipolar Disorder – In-depth look at bipolar disorder drugs, including the different types, special considerations and precautions, and questions to ask your doctor. (Psychology Information Online)

Mood Stabilizers and their side effects

Mood Stabilizers – Introduction to the mood stabilizers for manic depression and how to choose the right one. Includes the latest research on the effectiveness of different medications. (PsychEducation.org)

Bipolar Meds - The Mood Stabilizers – Describes mood stabilizers and their use in bipolar disorder. Includes research and usage guidelines for lithium and divalproex sodium. (McMan's Depression and Bipolar Web)

Antidepressants and their side effects

Antidepressants May Not Help Fight Bipolar Disorder – Report on a new study indicating that antidepressants do not provide a bipolar disorder treatment benefit. (Medline Plus)

Wrestling with Bipolar Disorder - Covers the negative effects of antidepressants on the course of bipolar disorder, and new drug options for the depressive phase. (Psychology Today)

Antidepressants in Bipolar Disorder: The Controversies – Summary of the research on antidepressants in the treatment of bipolar disorder. Includes information on their risks. (PsychEducation.org)

Antipsychotics and their side effects

Bipolar Meds - The Antipsychotics – Covers the history of antipsychotics and their use in treating mania and depression. (McMan's Depression and Bipolar Web)

Delving Deeper into Bipolar Disorder Diagnosis and Treatment

Management of Bipolar Disorder – Discusses the signs of bipolar disorder, co-occurring conditions, drug treatment recommendations, and drug interactions to watch for. (American Academy of Family Physicians)

Medication Treatment of Bipolar Disorder (PDF) – Part of The Expert Consensus Guideline Series, this reference tools offers a comprehensive look at drug treatment guidelines for manic depression. (Postgraduate Medicine Special Report

Melinda Smith, M.A., Jeanne Segal, Ph.D., Tina de Benedictis, Ph.D., and Robert Segal, M.A., contributed to this article. Last modified on October 10, 2007.