Medications for Bipolar Disorder

Lithium emerged more than 70 years ago as the first mood stabilizer. Healthcare professionals still consider it the first line of treatment for bipolar disorder.

Research has shown that lithium may help prevent both mania and, to a lesser extent, depression.

Lithium can help treat or prevent the following states:

• mania
• hypomania (a less severe form of mania)
• bipolar depression
• aggressive or self-harming behavior

Lithium can also reduce the likelihood of suicide, but the Food and Drug Administration (FDA) hasn’t officially approved it for this purpose.

People with rapid cycling bipolar disorder and those with mixed features tend to show less improvement in their symptoms with lithium.

Rapid cycling bipolar disorder is when you experience four or more episodes of mania or depression, or a combination of both, in a year.

Having bipolar disorder with mixed features means that you may experience symptoms of depression and mania at the same time.

How it works

Lithium is an element found naturally in the environment and in our bodies.

Researchers are still unsure how exactly lithium helps symptoms of bipolar disorder, but we do know some things:

• Lithium may help balance magnesium. Magnesium is important because it helps electrical signals move from one brain cell to another. People with bipolar disorder tend to have irregular levels of magnesium.
• Lithium competes with sodium. Typically, sodium binds with cell surface receptors called G-protein-coupled receptors. Some of these receptors regulate levels of serotonin and noradrenaline. When lithium reaches the receptors instead of sodium, it deactivates them. This can be a good thing, as these receptors are often overactive in bipolar disorder, according to research.

When you start taking lithium, a healthcare professional needs to monitor you frequently. You’ll likely need to do blood tests regularly because lithium can lead to kidney or thyroid problems.

According to the National Alliance on Mental Illness (NAMI), it takes several weeks to see a full reduction in symptoms after starting lithium. Some people’s symptoms only partially lessen, while many people don’t respond to lithium at all.

Healthcare professionals may prescribe lithium with another mood stabilizer, an atypical antipsychotic, or an antidepressant to treat more severe mood episodes or rapid cycling.

Side effects

Potential side effects of lithium include:

• dry mouth or mild thirst (more common in the beginning of treatment but may be longer term)
• digestive problems
• restlessness
• frequent urination
• hand tremor
• nausea or vomiting
• drowsiness
• loss of appetite
• weakness
• drying or thinning of hair
• weight gain
• alopecia, in which hair falls out in patches

Long-term use of lithium may lead to high blood calcium levels, kidney disease, hypothyroidism, hyperparathyroidism, and other thyroid problems.

Anticonvulsant medications act as mood stabilizers in people with bipolar disorder. Healthcare professionals often prescribe them for people with rapid cycling bipolar disorder. They treat mania, either alone or alongside another medication.

Anticonvulsants first caught the eye of clinicians when people being treated for epilepsy reported improvements in their mood and well-being.

Further investigation led the FDA to approve the medication valproate for the treatment of acute mania in 1995.

How they work

Researchers don’t know exactly how anticonvulsants work for bipolar disorder.

However, they may slow down hyperactive electrical signals in the brain. These signals are responsible for seizures and brain chemical imbalances, which are linked to mania.

Side effects

Side effects of anticonvulsants may include:

• drowsiness
• dizziness
• dry mouth
• headaches
• weight gain
• fatigue
• nausea
• tremor

Common medications

Anticonvulsants used to treat bipolar disorder include:

• Carbamazepine (Tegretol)/Oxcarbezopine (Trileptal): primarily for acute mania.
• Divalproex sodium (Depakote)/Valproic acid (Depakene): primarily for acute mania and recommended as first-line treatment for mixed episodes.
• Lamotrigine (Lamictal): primarily for depression and to prevent future episodes.
• Gabapentin (Neurontin): may help those who only partially respond to other mood stabilizers.

Several studies have demonstrated that antipsychotics can be effective in the management of acute mania, depression, or both. They’re also good for quickly reducing mania, and they may be used as either short- or long-term treatment.

There’s also evidence of that these medications work better and faster when they’re combined with lithium or valproate.

Antipsychotics may also be used “off-label” for:

• insomnia
• anxiety
• agitation

How they work

Antipsychotics appear to work by adjusting certain mood-altering brain chemicals, such as dopamine, serotonin, noradrenaline, and acetylcholine.

Side effects

Side effects of antipsychotics may include:

• dry mouth
• blurred vision
• tremors
• drowsiness
• sexual dysfunction
• weight gain

Common medications

The following antipsychotics may be effective for bipolar disorder:

• aripiprazole (Abilify): used for acute mania or mixed episodes
• asenapine (Saphris): used for acute mania or mixed episodes
• cariprazine (Vraylar): for acute mania, mixed mania, and depression
• lurasidone (Latuda): for acute episodes of bipolar depression
• olanzapine (Zyprexa): for acute mania, preventing relapse of both mania and depression (alone or with valproate), and bipolar depression (alone or with fluoxetine, brand name Symbyax)
• quetiapine (Seroquel): used for acute mania or mixed episodes; prevention of relapse of both mania and depression (alone or with valproate)
• risperidone (Risperdal): for acute mania and prevention of mania (alone or with lithium or valproate)
• ziprasidone (Geodon): used for acute mania or prevention of mania (alone or with valproate)

Other medications that might be used include clozapine (Clozaril) or paliperidone (Invega). However, these medications haven’t been approved by the FDA for bipolar disorder. Clozapine is rarely used for bipolar disorder.

Healthcare professionals sometimes prescribe antidepressants with mood stabilizers to help treat bipolar depression.

Controversy

Using antidepressants for bipolar disorder has been quite controversial. Medical experts caution against using antidepressants on their own for bipolar.

Certain antidepressants may trigger mania, worsen rapid cycling, or simply show no benefit at all. Some experts recommend against using them if you experience rapid cycling bipolar disorder and mixed episodes.

However, research suggests that this may happen primarily with the older antidepressants, such as tricyclics, but that it doesn’t tend to happen with the newer antidepressants, such as selective serotonin reuptake inhibitors (SSRIs).

Research suggests that, of all antidepressants, bupropion and SSRIs are associated with the lowest risk of antidepressant-induced mania.

In contrast, SNRIs (serotonin and norepinephrine reuptake inhibitors), such as venlafaxine, may pose a higher risk of triggering mania.

Other evidence suggests that adding antidepressants to mood stabilizers is more effective for depression than taking mood stabilizers alone, and that using antidepressants isn’t associated with an increased risk of triggering mania.

How they work

In general, antidepressants work by increasing the levels of mood-boosting neurotransmitters, such as serotonin, norepinephrine, or dopamine.

Side effects

Common side effects of antidepressants include:

• dry mouth
• dizziness
• fatigue
• headache
• insomnia
• sexual problems
• weight gain

Common medications

Antidepressants for bipolar depression may include:

• norepinephrine and dopamine reuptake inhibitor, such as bupropion (Wellbutrin)
• SSRIs, such as fluoxetine (Prozac) and citalopram (Celexa)
• serotonin and norepinephrine reuptake inhibitors (SNRIs), such as desvenlafaxine (Pristiq) and duloxetine (Cymbalta)

Healthcare professionals may prescribe other medications to people with bipolar disorder. These aren’t considered first-choice medications, but may help treat any additional symptoms.

Medications your doctor might add to your bipolar treatment regimen include:

• Calcium channel blockers. These may help with bipolar symptoms, but this hasn’t been sufficiently studied. Verapamil is one example.
• Acamprosate. This medication may help alcohol-dependent individuals with bipolar disorder.
• Omega-3 fatty acids. Research suggests that many people with bipolar disorder have low levels of omega-3 fatty acids. Taking these supplements may help improve depression and other bipolar symptoms.
• Allopurinol. This gout medication may be helpful in bipolar mania.
• Benzodiazepines. These may be beneficial in certain cases for short-term use during acute mania or to help manage agitation and catatonia, according to experts. However, they have the potential for addiction and can trigger or worsen symptoms in bipolar disorder. Lorazepam is one example.

Some medications may harm the developing fetus if you take them while you’re pregnant.

It’s a good idea to discuss your bipolar disorder medications with a healthcare professional as soon as you know you’re pregnant or if you’re planning to get pregnant.

Medications for bipolar disorder that may be harmful during pregnancy include:

• lithium
• divalproex sodium (Depakote)
• carbamazepine
• some antidepressants
• some antipsychotics

Researchers have noted that more studies are needed to investigate the effects of mood stabilizers during pregnancy, so some effects may still be unknown.

It’s also important to be cautious of medications you take while breastfeeding. Research suggests that certain medications for bipolar may be safe to take during lactation. Consider discussing your options with a healthcare professional.

Finding the right medication or combination of medications to help reduce your bipolar symptoms can take some time. Medications that work for one person may not work for another, and what works for you may change over time.

With the help of a healthcare professional, you can experiment with different medications, doses, and combinations of medications to see what works best.

Questions to ask your doctor

• When and how frequently will I need to take this medication?
• What are the side effects, and how can I manage them?
• How long should I take the medication before we know whether it’s working for me?
• Will any foods, other medications, or medical conditions interact with this medication?
• Will this medication cause withdrawal if I decide to stop taking it? If so, how could I manage that?
• Can you recommend self-treatment options that can provide additional support (e.g., therapy, diet)?

Medical advancements have improved our understanding of bipolar disorder significantly over the last several decades. Researchers continue to come out with new, more effective medications to manage bipolar symptoms.

If you’re living with bipolar disorder, it may take a little time to determine with your doctor which medications are right for you.

Also consider other treatments for bipolar disorder, including therapy and self-help strategies.

With proper treatment, it’s absolutely possible to have a high quality of life with bipolar disorder.