Bipolar Disorder Treatment Overview

The exact causes of bipolar disorder are unknown. While genes and life stress may contribute to it, experts believe that symptoms may arise from a problem with nerve circuits and areas in the brain that control emotion, thinking, and behavior.

The best treatment for bipolar disorder is often a combination of medication and counseling. Other treatments such as electroconvulsive therapy (ECT) are often successful for people with very severe symptoms who don't respond to traditional therapy or who can't take the medications.

Doctors sometimes treat the mania symptoms of bipolar disorder with one set of drugs and the depression symptoms with another, although some mood-stabilizing drugs are effective at treating both kinds of symptoms. Certain drugs are also used for "maintenance" to maintain a steady mood. Antidepressants are usually not used alone because they sometimes cause manic attacks in depressed patients, and they may be less effective for treating bipolar than unipolar depression.

Many people respond well to medications for bipolar disorder. For many others, the symptoms do not completely disappear despite therapy. The mood symptoms may become less intense and more manageable, however.

Remember, getting your diagnosis should come as a relief. Now you know what the problem has been and you're on the road to getting the right treatment.

Mania in Bipolar Disorder

If you are suffering from bipolar mania, your doctor at first may treat you with an anti-manic mood stabilizer and sometimes also an antipsychotic drug and/or a benzodiazepine to quickly control hyperactivity, sleeplessness, hostility, and irritability.

Mood stabilizers treat manias or depressions without causing symptoms to swing the other way. Some also may help to reduce the risk of suicide. They are usually taken for a long time, commonly for many years. Examples include lithium and certain anticonvulsant drugs such as carbamazepine (Tegretol), lamotrigine (Lamictal) or valproate (Depakote).  Atypical antipsychotics used to treat mania include aripiprazole (Abilify), asenapine(Saphris), cariprazine (Vryalar), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) .

Treating bipolar mania often requires hospitalization because there is high risk for unpredictable, reckless behavior and noncompliance with treatment. For people with extreme mania, pregnant women with mania, or those people whose mania can't be controlled with mood stabilizers, doctors sometimes also recommend electroconvulsive therapy (ECT).

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If mania occurs while you are on maintenance therapy, your doctor may simply change your medication dose. Or you may start taking an antipsychotic drug or a second mood stabilizer to lessen symptoms. Also antidepressants should usually be discontinued while someone is manic, because they can worsen the symptoms of mania.

Non-drug treatments, such as psychotherapy and establishing a well-ordered routine, may help patients in their maintenance phase. This is often suggested along with medication, but non-drug treatments are usually not effective alone.

Depression in Bipolar Disorder

Treating bipolar depression is controversial and challenging. Studies have shown that antidepressants may be less effective in treating bipolar depression than they are in treating unipolar depression (that is, major depressive episodes in someone who has never had a previous manic or hypomanic episode). Also using antidepressants alone may trigger a manic or hypomanic episode in some people with bipolar disorder.

Antidepressants alone also may lead to or prolong rapid cycling. In rapid cycling, a person may recover more quickly from depression but then experience mania followed by another episode of depression. And antidepressants can increase the risk of suicidal thoughts and attempts in children and adolescents with any form of depression.

Three drugs are FDA-approved for the treatment of bipolar depression: quetiapine (Seroquel) by itself, olanzapine (Zyprexa) when used with fluoxetine (Prozac) (which also comes as a combination pill called Symbyax), and lurasidone (Latuda) used alone or with lithium or valproate (Depakote). The atypical antipsychotic drug caripirazine (Vraylar) has also shown promise in initial studies to treat bipolar depression.

There are also a number of treatments that have begun to show promise in research studies for treating bipolar depression, including the Parkinson's disease drug pramipexole dihydrpcholoride ( Mirapex), the wakefulness drugs modafinil (Provigil) and armodinifinil (Nuvigil), the nutritional supplement n-acetylcysteine, and the intravenous anesthetic drug ketamine. 

In April 2002, the American Psychiatric Association suggested using lithium or the anticonvulsant drug lamotrigine(Lamictal) as an initial treatment for people in the acute depressive phase of bipolar disorder who were not already taking a mood-stabilizing drug. Since then, research has shown that Lamictal seems to be more effective at preventing future depression rather than treating current depression in bipolar disorder. Recent studies have shown that Lamictal added to lithium may be a potent treatment for acute bipolar depression.

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For depressed bipolar patients who don't respond to mood stabilizers alone, or to FDA-approved medications for bipolar depression, doctors sometimes prescribe a mood stabilizer plus  a traditional  antidepressant -- often  either buproprion (Wellbutrin) or an SSRI (selective serotonin reuptake inhibitor) such as fluoxetine(Prozac) or sertraline (Zoloft), although the effectiveness of antidepressants has not been proven for bipolar depression. 

If all else fails, or if symptoms are especially severe, doctors may recommend electroconvulsive therapy (ECT). It helps nearly 75% of the patients who are given this treatment. Two treatments called vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS) are also being studied as a treatment for bipolar depression.

In addition, psychotherapy may be beneficial when added to drug treatment. Once depression has resolved, mood stabilizers are the best-proven treatments to prevent either future depression or manias. If psychotic symptoms occur during an acute depressive episode, the doctor may recommend antipsychotic medicine.

Nondrug treatments -- such as psychotherapy and establishing a well-ordered routine -- may help patients in their maintenance phase. They are often suggested along with medication. Psychotherapy alone is typically not enough to treat bipolar depression unless symptoms are mild.

WebMD Medical Reference Reviewed by Joseph Goldberg, MD on November 21, 2015

Sources

SOURCES:

National Institute of Mental Health: "Step-BD Womens Studies." 

Massachusetts General Hospital Bipolar Clinic & Research Program. 

MedicineNet: "Bipolar Disorder (Mania)." 

American Psychiatric Association: "Practice Guideline for the Treatment of Patients With Bipolar Disorder."

Sonovion Pharmaceuticals, Inc.

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