Bipolar Disorder

Proper treatment helps most people living with bipolar disorder control their mood swings and other symptoms. Because bipolar disorder is a chronic illness, treatment must be ongoing. If left untreated, the symptoms of bipolar disorder get worse, so diagnosing it and beginning treatment early is important.

Treating bipolar disorder may include medication, psychotherapy, education, self-management strategies and external supports such as family, friends and support groups. There is no one approach to treating bipolar disorder.

Psychotherapy

Psychotherapy, support groups and psychoeducation about the illness are essential to treating bipolar disorder:

  • Cognitive behavioral therapy (CBT) helps change the negative thinking and behavior associated with depression. The goal of this therapy is to recognize negative thoughts and to teach coping strategies.
  • Family-focused therapy helps people with bipolar disorder learn about the illness and carry out a treatment plan.
  • Psychotherapy focused on self-care and stress regulation, and helps a person improve self-care, recognize patterns of the onset of the symptoms and to manage stress.

An NIMH clinical trial, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive a combination of several intensive psychotherapy interventions. Individuals in the study received three types of psychotherapy, which focused on cognitive strategies, family involvement and stress regulation.

Medications

With the prescribing doctor, work together to review the options for medication. Different types of bipolar disorder may respond better to a particular type. The side effects can vary between medications and it may take time to discover the best medicine. 

Lithium

Lithium (Lithobid, Eskalith) is effective at stabilizing mood and preventing the extreme highs and lows of bipolar disorder. Periodic blood tests are required because lithium can cause thyroid and kidney problems. Common side effects include restlessness, dry mouth and digestive issues. Lithium levels should be monitored carefully to ensure the best dosage and watch for toxicity.

Lithium is used for continued treatment of bipolar depression and for preventing relapse. There is evidence that lithium can lower the risk of suicide but the FDA has not granted approval specifically for this purpose.

Anticonvulsants

Many medications used to treat seizures are also used as mood stabilizers. They are often recommended for treating bipolar disorder. Common side effects include weight gain, dizziness and drowsiness. But sometimes, certain anticonvulsants cause more serious problems, such as skin rashes, blood disorders or liver problems.

Valproic acid and carbamazepine are used to treat mania. These drugs, also used to treat epilepsy, were found to be as effective as lithium for treating acute mania. They may be better than lithium in treating the more complex bipolar subtypes of rapid cycling and dysphoric mania as well as co-morbid substance abuse.

Lamotrigine is used to delay occurrences of bipolar I disorder. Lamotrigine does not have FDA approval for treatment of the acute episodes of depression or mania. Studies of lamotrigine for treatment of acute bipolar depression have produced inconsistent results.

Second-Generation Antipsychotics (SGAs) 

SGAs are commonly used to treat the symptoms of bipolar disorder and are often paired with other medications, including mood stabilizers. They are generally used for treating manic or mixed episodes.

SGAs are often prescribed to help control acute episodes of mania or depression. Finding the right medication is not an exact science; it is specific to each person. Currently, only quetiapine and the combination of olanzepine and fluoxetine (Symbax) are approved for treating bipolar depression. Regularly check with your doctor and the FDA website, as side effects can change over time.

Standard Antidepressants

Antidepressants present special concerns when used in treating bipolar disorder, as they can trigger mania in some people. A National Institute of Mental Health study showed that taking an antidepressant also to a mood stabilizer is no more effective that using a mood stabilizer alone for bipolar I. This is an essential area to review treatment risks and benefits.

Other Treatments

Electroconvulsive Therapy (ECT)

In rare instances, ECT can be considered as an intervention for severe mania or depression. ECT involves transmitting short electrical impulses into the brain. Although ECT is a highly effective treatment for severe depression, mania or mixed episodes, it is reserved for specific situations and for symptoms that have not responded to other treatments.

Treatment Considerations for Women and for Children

Women. Women with bipolar disorder who are of childbearing age, or who are considering getting pregnant, need special attention. A complex risk-benefit discussion needs to occur to look at the treatment options available. Some medicines can have risk to the developing fetus and to children in breast milk. However, there is also evidence that being off of all medications increases the likelihood of bipolar symptoms, which itself creates risks to both mother and fetus or baby. Planning ahead and getting good information from your health care team based on your individual circumstances improves your chance of a best outcome.

Children. The diagnosis of bipolar disorder in children has been controversial. Before receiving any psychiatric diagnosis, children must have a comprehensive evaluation of their physical and mental health. Children with bipolar disorder may also have other conditions including attention-deficit hyperactivity disorder, early childhood psychosis, posttraumatic stress disorder, learning disabilities or substance abuse problems. Each of these co-occurring conditions requires a thoughtful and individualized treatment plan. Children with bipolar disorder usually receive psychotherapy and psychosocial interventions before medications are considered.

The identification of a new mental health condition, Disruptive Mood Dysregulation Disorder (DMDD), could affect how bipolar disorder is diagnosed in children. DMDD better describes children who are intensely irritable, have temper tantrums, but do not have classic symptoms of mania. Early evidence suggests children with DMDD do not have an increased risk of developing bipolar disorder as adults, but they may have other co-occurring illnesses like depression.