Antipsychotic Treatment for Bipolar Disorders

In the treatment of bipolar disorder, healthcare professionals often prescribe a combination of mood stabilizers and antipsychotic medications. However, there is no one-size-fits-all solution. The most appropriate antipsychotic depends on the individual’s specific symptoms, treatment history, and response to drugs. Understanding how antipsychotics work and how they affect different phases of the disorder is essential for tailoring effective treatment plans and improving long-term outcomes.

What are Antipsychotics?

Antipsychotics are medications primarily used to treat psychosis, a state where a person loses touch with reality. This can involve hallucinations, delusions, or severe mood disturbances. One of the causes of psychosis is an overproduction of dopamine, a neurotransmitter responsible for mood, motivation, and pleasure. Antipsychotics work by blocking dopamine receptors in the brain, helping to regulate the flow and restore balance. They also influence serotonin, another neurotransmitter that plays a crucial role in mood regulation ^[1].

Antipsychotic medications have multiple uses in the treatment of bipolar disorder. They help manage the psychotic symptoms of the condition, including hallucinations and delusions, while also treating mania and depression ^[2].

Beyond bipolar, antipsychotics treat a wide variety of mental health conditions, including schizophrenia and severe depression. Some are also used to treat conditions like dementia, severe anxiety or agitation, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) ^[1].

Some doctors also prescribe antipsychotics ‘off-label’ as sedatives to help with insomnia and agitation. Antipsychotics are often prescribed in combination with a mood-stabilizing drug and can decrease symptoms of mania until the mood stabilizers take effect ^[3].

Typical vs. Atypical Antipsychotics

Antipsychotic medications are generally classified into two categories: typical (first-generation) and atypical (second-generation) antipsychotics ^[4].

• Typical antipsychotics, introduced in the 1950s, are effective in managing symptoms such as mania and psychosis. However, they are associated with a higher risk of extrapyramidal side effects, particularly movement disorders like tardive dyskinesia, which involves involuntary facial movements and tics.
• Atypical antipsychotics, developed in the late 1980s, tend to cause fewer movement-related side effects and are generally better tolerated. However, they can lead to metabolic complications, including weight gain, elevated cholesterol, and blood sugar dysregulation, which may increase the risk of diabetes and cardiovascular issues.

Due to their improved safety profile, particularly regarding movement disorders, second-generation antipsychotics are more commonly prescribed in the treatment of bipolar disorder, especially for long-term management.

How Antipsychotics Help Manage Bipolar Disorder

A healthcare professional will prescribe different antipsychotics based on a patient’s needs. Some antipsychotic treatments are most effective at managing manic phases, while others will help the most during depressive phases. Others treat mixed episodes, which involve experiencing manic and depressive symptoms simultaneously.

Others are helpful during the maintenance phase, which is the time between bipolar episodes. According to a 2013 study, some people with bipolar disorder may benefit from using atypical antipsychotics during the maintenance phase of the condition. Adherence to medication during this phase is essential to prevent relapse, reduce cycling frequency and suicide risk, and improve overall functioning ^[5].

Common Antipsychotics Used for Bipolar Disorder

There is a wide variety of antipsychotic drugs for bipolar disorder available, each one treating different symptoms. The FDA-approved antipsychotics for bipolar disorder treatment are ^[4]:

• Aripiprazole (Abilify): Effective for treating manic episodes and mixed episodes. Also used in the maintenance phase.
• Asenapine (Saphris): Effective for treating manic and mixed episodes.
• Cariprazine (Vraylar): Effective for treating manic episodes, mixed episodes, and depressive episodes.
• Lurasidone (Latuda): Effective for treating depressive episodes.
• Olanzapine (Zyprexa): Used to treat manic and mixed episodes and the maintenance phase.
• Olanzapine/fluoxetine combination (Symbyax): Used to treat depressive episodes.
• Quetiapine (Seroquel): Used to treat manic and depressive episodes.
• Risperidone (Risperdal): Used to treat manic and mixed episodes.
• Ziprasidone (Geodon): Used to treat manic and mixed episodes.

What Is the Best Antipsychotic for Bipolar Disorder?

The most effective antipsychotic medication for bipolar disorder varies from person to person. Healthcare providers tailor prescriptions based on several individual factors, including whether the person is experiencing a manic or depressive episode, any co-occurring mental health conditions, current medication regimens, past responses to treatment, and personal preferences ^[6].

There is no one-size-fits-all solution. Each individual may require a different medication or combination of drugs to address their specific symptoms and treatment goals. In many cases, finding the right antipsychotic involves a period of trial and adjustment, during which different medications and dosages may be tested.

If a prescribed medication is not effective or causes intolerable side effects, it is important to communicate with a healthcare provider. They can modify the treatment plan and explore alternative options to identify the most suitable and well-tolerated approach for managing bipolar disorder.

Combining Antipsychotics with Other Medications

Depending on the case, a healthcare professional may prescribe a mood stabilizer or an antidepressant along with an atypical antipsychotic. If, for example, a patient is experiencing a manic episode, a healthcare professional could prescribe an atypical antipsychotic, a mood stabilizer like Lithium or valproic acid, and a benzodiazepine like quetiapine or risperidone, which can assist with sleep.

On the other hand, if a patient is experiencing a depressive episode, they may be prescribed an antipsychotic like quetiapine (Seroquel), cariprazine (Vraylar), or lurasidone (Latuda) in combination with a mood stabilizer like lithium or valproic acid. If mood stabilizers alone don’t help, they may also be prescribed selective serotonin reuptake inhibitors or bupropion (Wellbutrin).

If a patient is experiencing a mixed episode, anticonvulsants like valproate (Depakote) may be prescribed alongside atypical antipsychotics and mood stabilizers. Anticonvulsants control abnormal electrical activity in the brain, helping manage manic symptoms ^[7].

Antipsychotic Side Effects

While atypical antipsychotics generally have a lower risk of movement-related side effects compared to typical antipsychotics, they are not without risks. One of the most common concerns is the potential for metabolic side effects, including weight gain, elevated cholesterol levels, and an increased risk of developing type 2 diabetes. These effects can impact long-term health and may require ongoing monitoring and lifestyle adjustments during treatment.

Some of the side effects of antipsychotics for bipolar disorder include ^[8]:

• Changes in blood pressure
• Constipation
• Difficulty concentrating and speaking
• Dizziness
• Drowsiness
• Dry mouth and drooling
• Mask-like face
• Metabolic changes
• Sexual dysfunction
• Shuffling gait while walking
• Weight gain
• Vision problems, including blurred or double vision

Due to the side effects of antipsychotics, people taking these medications must maintain regular contact with their healthcare provider. People are encouraged to keep a list of their side effects to share with their doctor and take note of any changes in symptoms.

Special Considerations for Antipsychotic Use in Bipolar Treatment

When using antipsychotics for bipolar disorder, there are some considerations to keep in mind based on different age ranges and life experiences. 

Children & Adolescents

To help alleviate the symptoms of bipolar disorder, the FDA has approved a few specific drugs for children, including aripiprazole, asenapine, quetiapine, and risperidone. These medications are all approved for use in children ages 10 and up.

Because atypical antipsychotics can lead to weight gain and an increased risk of type 2 diabetes, it’s essential to monitor children taking this medication carefully. Healthcare professionals recommend assessing personal and family histories for obesity, diabetes, high cholesterol, and cardiovascular disease before starting treatment in children. Doctors should also monitor fasting lipids, glucose levels, and blood pressure at the first appointment, three months into taking the medication, and then annually ^[9].

Pregnancy

There are some considerations pregnant people should keep in mind. In general, it is recommended that pregnant people continue taking the antipsychotic that is most effective for symptom remission. However, there is some concern that atypical antipsychotics may be associated with gestational diabetes. Also, metabolic changes during pregnancy may lead to necessary dose adjustments.

Researchers have reported mixed findings about risperidone specifically and its effect on congenital malformations in utero. Because of that, it is not considered a first-line treatment for those with bipolar disorder who are pregnant ^[10]. 

Elderly Patients

Studies reveal that elderly individuals on antipsychotics have a higher risk of strokes and pneumonia. As a result, the FDA has issued a black box warning (the most serious type of warning placed on prescription drug packaging by the US Food and Drug Administration) about prescribing antipsychotics to elderly patients ^[11].

Stopping Antipsychotics

It’s also essential to speak to a doctor before stopping taking any antipsychotic medication. Coming off an antipsychotic too quickly can be dangerous, and it can lead to a relapse of psychotic symptoms and increase a person’s risk of tardive psychosis, psychotic symptoms that emerge or worsen after prolonged use of antipsychotic medications. For individuals considering coming off antipsychotics, they must speak to their doctor and create a plan to safely come off the medication and transition to a new medication if needed ^[12].

Final Thoughts

Antipsychotics are a key component in the treatment of bipolar disorder, helping to manage both manic and depressive symptoms. However, finding the proper medication and dosage often requires time, patience, and ongoing collaboration with a healthcare provider. Everyone responds to treatment differently, and finding the best combination for each individual may require adjustments.

It’s important to remember that you don’t have to navigate this journey alone. If you experience side effects or feel your medication isn’t helping, reach out to your provider. Open communication is essential in fine-tuning your treatment plan and ensuring your care aligns with your needs and goals.

Managing bipolar disorder is not without its challenges, but recovery and stability are entirely possible. With the proper support, medication, and self-care strategies, many individuals lead full, balanced, and meaningful lives. Treatment is not just about control; it’s about reclaiming wellness and hope.