Bipolar disorder is characterized by alternating periods of major depression and mania. In rare case, mania—episodes of abnormally and persistently elevated, expansive, or irritable mood—can occur on its own.
For people with bipolar disorder, an accurate diagnosis is important to ensure appropriate treatment. But making an accurate diagnosis of bipolar disorder can be difficult. People seeking medical help during a depressive episode can be misdiagnosed with major (unipolar) depression; this mistake can be dangerous because giving patients of bipolar disorder an antidepressant medication alone may induce mania. Also, an acute episode of mania can be mistaken for schizophrenia, a condition that is treated differently from bipolar disorder and has a different course.
Bipolar disorder is a clinical syndrome, and as with many other syndromes, doctors use a number of medications to address the varied symptoms that patients experience. Symptoms of bipolar disorder include mania, depression, psychosis, and agitation. While some patients may require only one medication, those with severe bipolar disorder often require a combination of medications to treat their condition optimally.
Medications to Treat Acute Mania of Bipolar Disorder
Drugs known as mood stabilizers are used to bring mania under control. The mood stabilizer lithium (Eskalith, Lithobid) was the first medication to receive approval for the treatment of mania, and it remains the mainstay of treatment today. Because lithium can take up to a week to have an effect, a neuroleptic or a benzodiazepine (an antianxiety drug) may be added to help calm the person in the meantime.
Benzodiazepines should be used with caution, however, because some patients abuse them when these medications are prescribed for extended periods. Benzodiazepines may also disinhibit some manic patients.
Instead of lithium, psychiatrists may choose to use other mood-stabilizing medications—carbamazepine (Carbatrol, Epitol, and Tegretol) or valproate (Depakene and Depakote)—in combination with neuroleptics or benzodiazepines to treat acute mania. Valproate is also a good option for people with mixed states (simultaneous symptoms of mania and depression). The neuroleptic drug olanzapine (Zyprexa) has been approved for the treatment of manic episodes, as well.
If a manic episode is severe or involves psychosis, a neuroleptic medication is often used in addition to mood-stabilizing medication. Neuroleptics are usually given only for short periods because of their neurological side effects, which include tardive dyskinesia (repetitive, involuntary, purposeless movements). These side effects occur less often with the newer, atypical neuroleptics, such as olanzapine and risperidone (Risperdal).
Treating Acute Depression of Bipolar Disorder
Unlike major depression, a new episode of mild or moderate depression in people with bipolar disorder is usually first treated with a mood stabilizer such as lithium, which is often effective in preventing suicide as well. If depression is severe, an antidepressant drug may be added to the mood stabilizer. If the depression involves psychosis, the patient may need neuroleptic medication in addition to the mood stabilizer and antidepressant.
Antidepressant medications must be used with extreme caution in people with bipolar disorder. Use of any antidepressant medication—but particularly tricyclics—can cause a person with bipolar disorder to switch into a manic episode or cause rapid cycling between depression and mania. Patients with typical bipolar disorder must, therefore, always take mood-stabilizing medication along with their antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) and other relatively new antidepressant medications—such as bupropion (Wellbutrin), or venlafaxine (Effexor)—are the most likely to be used.
Long-Term Treatment Strategies for Bipolar Disorder
Because of the chronic and cyclic nature of bipolar disorder, psychiatrists often recommend that patients 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 take medication over the long term, even when they experience no symptoms. Treatment usually involves a mood stabilizer; other medications may be added in the short term if depression or mania worsens or if symptoms such as impulsivity, irritability, or poor concentration develop.
Patients on long-term treatment for bipolar disorder need periodic blood tests to check for adequate blood levels of the medication and to detect any toxic reactions, 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, certain neuroleptics, and increased doses of valproate may help promote sleep but should only be used for short periods. A sedative/hypnotic may also be a good option for people with difficulty sleeping.
If a depressive episode occurs despite adequate long-term treatment (so-called breakthrough depression), psychiatrists have a number of options. They may choose to increase the dosage of the mood stabilizer in people with mild to moderate depression. In some instances, the mood stabilizer may actually induce mild depression, and psychiatrists may therefore choose to decrease the dosage of the mood stabilizer.
If depression is severe, they may add an SSRI or a second mood stabilizer. If the patient experiences rapid cycling between mania and depression despite long-term treatment, antidepressants should be avoided altogether.
Nondrug Treatments for Bipolar Disorder
Psychotherapy also plays a role in bipolar depression—albeit a smaller one than for major depression. Environmental factors, such as stress, may trigger episodes of mania or depression, and counseling may help patients identify and deal with these triggers as well as gain insight into their condition. Psychotherapy also can help patients deal with the dysfunctional thinking often associated with bipolar disorder.
Counseling that involves the patient’s family can also help to educate relatives about the disorder and how best to cope with it. However, patients in an acute manic state will likely be unable to attend or benefit from therapy.
For those who do not respond to drug treatments or psychotherapy, electroconvulsive therapy may be needed to treat bipolar disorder.
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