Bipolar disorder is a mental illness in which the usual ups and downs of emotional states are extremely exaggerated. People with bipolar disorder can have manic episodes (with an elevated mood and increased activity) or depressive episodes (feeling sad and lower activity). Depending on the symptoms, it can often be treated with medication.

Types of medication used to treat bipolar disorder

Medication can be used to control the symptoms of bipolar disorder. These include:

  • Mood stabilizers (such as lithium or valproate), which help to reduce the severity of mood swings.
  • Antipsychotics (such as risperidone or olanzapine), which help treat acute mania.
  • Antidepressants (such as citalopram or fluoxetine), which are believed to boost production of serotonin in the brain and therefore improve mood.
  • Anticonvulsants (such as carbamazepine or lamotrigine), which help treat acute mania or depression.
  • Anti-anxiety medications (mostly benzodiazepines such as diazepam or clonazepam), which treat bipolar anxiety.

Mood stabilizers

Mood stabilizers are the main form of medical treatment for bipolar disorder, with the most widely available being lithium [1] 

They work by preventing mood swings or reducing their severity. Lithium has also been shown to have a role in prevention of suicide attempts among bipolar patients. [1]

Mood stabilizers are known to cause adverse effects. Lithium cause tremors, weight gain or lead to hypothyroidism. Valproate can cause weight gain, nausea and vomiting, as well as alopecia, tremors and easy bruising. Carbamazepine can cause nausea, vomiting, diarrhea, and hyponatremia (low blood sodium). Lamotrigine’s side effects include rashes, nausea, dizziness, and tremors. [2]

Antipsychotics

Atypical antipsychotic medications have been widely studied for their efficacy in treating acute mania. To date, the data suggests that the most effective of these are olanzapine, risperidone, quetiapine, aripiprazole, and ziprasidone. These antipsychotic drugs can be used as an alternative to or in conjunction with certain mood stabilizers such as lithium or divalproex. [3]

Antipsychotics help to prevent or suppress manic symptoms (euphoric/irritable mood and increased activity or energy). 

Antipsychotics have a range of side effects. They can be relatively minor (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, sexual disfunction).  

More severe side effects can be painful (e.g., involuntary muscle spasms), disfiguring (e.g., weight gain), or life threatening (e.g., heart attack). [4] Therefore, it is extremely important that you tell your doctor or health care provider immediately if you feel that something is wrong.

Antidepressants

Bipolar depression is often treated with antidepressant medication in conjunction with a mood stabilizer. An antidepressant taken alone can trigger an episode of mania or rapid cycling in someone who has bipolar disorder. Antidepressants work by increasing the function of nerve cells in the brain that release the neurotransmitter serotonin. This is the chemical in the body that regulates mood.

Antidepressants used to treat bipolar disorder include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. They can take several weeks to take effect.

Common side effects can include:

  • Weight loss or gain
  • Insomnia
  • Anxiety
  • Nausea
  • Rash
  • Agitation
  • Erectile dysfunction
  • Diarrhea 

It should be noted that these are off label medications for bipolar disorder, and the efficacy of antidepressants in bipolar depression remains unproven. [5]

Anticonvulsants

There is increasing evidence for the role of anticonvulsants in the effective treatment of bipolar disorder, including valproate, lamotrigine, carbamazepine/oxcarbazepine, and topiramate.. However, only valproate is currently approved by the FDA for treatment of acute mania. Other anticonvulsants include carbamazepine, lamotrigine, and gabapentin, all with varying degrees of efficacy in treating bipolar disorder. [6]

Anticonvulsants are primarily used as antiepileptic, or antiseizure, drugs in the treatment of epileptic seizures. They have become increasingly common in the treatment of bipolar disorder because of their mood-stabilizing qualities.

Side effects of anticonvulsants can include, dizziness, drowsiness, fatigue, nausea, tremors, reach and weight gain.

Anti-anxiety medications

The mainstay of anti-anxiety medications are benzodiazepines. These are prescribed for other medical conditions as well as anxiety, such as insomnia and alcohol withdrawal.

Benzodiazepines have sedative effects, which help to reduce anxiety and aide sleep. Common examples include diazepam, alprazolam, and clonazepam.

The most concerning side effect of benzodiazepines is dependence. Benzodiazepines can be extremely addictive, and doctors should be careful in prescribing them to people with a history of addiction. Other side effects include drowsiness, light-headedness, confusion, dizziness, and unsteadiness.

Other ways to treat bipolar disorder

Medication isn’t the only method used to treat bipolar disorder. Alternatives include a range of therapies, which can be used as a standalone treatment, but are more commonly used in conjunction with medication.

  • Psychotherapy – this is the umbrella term encompassing all the techniques of “talk therapy”, where a patient or group of patients meet with a trained mental health professional to identify troubling emotions, thoughts, and behavior. Psychotherapy falls into five categories: psychoanalysis, behavior therapy, cognitive therapy, humanistic therapy and integrative or holistic therapy.
  • Electro-convulsive therapy – a procedure in which small electric currents are passed through the brain to trigger a seizure. It is administered under anesthetic and is only used when the patient has not responded to other treatments, typically within a hospital.
  • Transcranial magnetic stimulation – a noninvasive treatment that uses electromagnetic pulses to stimulate nerve cells, possibly relieving symptoms of mental health disorders.
  • Light therapy a treatment in which the patient is exposed to an artificial source of light. As well as being primarily used to treat seasonal affective disorder (SAD), there is growing evidence of its efficacy in treating non-seasonal related depression.

Resources:

  1. Shah N, Grover S, Rao GP. Clinical Practice Guidelines for Management of Bipolar Disorder. Indian J Psychiatry. 2017 Jan;59(Suppl 1):S51-S66. doi: 10.4103/0019-5545.196974. PMID: 28216785; PMCID: PMC5310104.
  2. Nath M, Gupta V. Mood Stabilizers. [Updated 2022 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556141/
  3. Yatham LN. Atypical antipsychotics for bipolar disorder. Psychiatr Clin North Am. 2005 Jun;28(2):325-47. doi: 10.1016/j.psc.2005.01.001. PMID: 15826735.
  4. Stroup TS, Gray N. Management of common adverse effects of antipsychotic medications. World Psychiatry. 2018 Oct;17(3):341-356. doi: 10.1002/wps.20567. PMID: 30192094; PMCID: PMC6127750.
  5. Gitlin, M.J. Antidepressants in bipolar depression: an enduring controversy. Int J Bipolar Disord6, 25 (2018). https://doi.org/10.1186/s40345-018-0133-9
  6. Leo RJ, Narendran R. Anticonvulsant Use in the Treatment of Bipolar Disorder: A Primer for Primary Care Physicians. Prim Care Companion J Clin Psychiatry. 1999 Jun;1(3):74-84. doi: 10.4088/pcc.v01n0304. PMID: 15014689; PMCID: PMC181066.