Treatment
Bipolar FAQ - Treatment
Your definitive cheat sheet.
Part II of this bipolar disorder FAQ deals with medical and therapeutic treatments for bipolar disorder, including antidepressants, mood stabilizers, antipsychotics, benzodiazepines, talking therapy, and ECT. All links but one are to articles on this site.
What is bipolar disorder treatment?
Ideally, a combination of different medications, talking therapies, natural treatments and lifestyle choices. No one treatment, therapy, or lifestyle choice on its own is likely to get the job done. A number of them working as complements to each other ensures your best chance of success.
Tell me about medications treatment.
Medications treatment involves three classes of drugs: antidepressants for depression and mood stabilizers and antipsychotics for mania. In addition, some patients may take a benzodiazepine to help calm them down. Patients are typically prescribed a combination of drugs referred to as a cocktail. The American Psychiatric Association in its bipolar disorder treatment guideline lists remission as the goal of medications treatment, meaning virtually no symptoms and a return to full functioning. This translates into our right to demand a best effort from our psychiatrist. Equally as important, side effects that interfere with our ability to think and function should not be regarded as an acceptable trade-off for reducing our symptoms.
Tell me about antidepressants.
A full discussion of antidepressants can be found in Part Two of the Depression FAQ. What you need to know about antidepressants from a bipolar perspective is there is divided opinion in psychiatry concerning the safety of bipolar patients on antidepressants. This is because an antidepressant without a concomitant antimania med is almost certain to switch a patient into mania. Some authorities contend that even with an antimania drug, the danger is there. Accordingly, the American Psychiatric Association in its bipolar disorder guidelines issued in 2002 does not recommend an antidepressant-antimania combination as a first option, and another guideline recommends tapering and discontinuing soon after remission is achieved.
On the other hand, there is a smaller body of opinion that feels the risk is overstated. One study found that those who stayed on their antidepressants fared better over 12 months than those who quit on them before six months. But the same study also found that antidepressants did not work for the large majority of those in the study.
Tell me about mood stabilizers.
Mood stabilizers mainly keep mania in check, though we are not sure precisely how they function in the brain. Lithium, which is a common salt, was discovered as a treatment for bipolar disorder by accident, is the only mood stabilizer with proven efficacy for treating all phases of bipolar depression and mania.
The other mood stabilizers - Depakote (valproic acid), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Neurontin (gabapentin), Topamax (topiramate) and Lamictal (lamotrigine) - first came on the market as antiseizure medications. Depakote, Tegretol, and Trileptal are used to treat mania. Neurontin is useful for co-occurring anxiety, and Topamax is effective for weight loss. Lamictal is the flavor of the month for treating bipolar depression. Because we don't know exactly how they work and what we should be targeting, it comes as no surprise that their clinical benefit leaves much to be desired, with burdensome side effects ranging from dry mouth to weight gain to tremors to sedation to skin rash. A lot of these effects go away as the body adjusts to the medication. Because of the side effects, noncompliance is common. What one needs to keep in mind is as imperfect as these meds are, they offer one a fighting chance at recovery, as well as a welcome alternative to what would have been a lifetime of institutionalization a generation ago.
Lithium and Lamictal have antidepressant properties. Although Lamictal has flavor of the month status for treating bipolar depression, its FDA indication is for relapse prevention.
Tell me about antipsychotics.
Antipsychotics are yet another medication that first came on the market to treat another illness, in this case schizophrenia. The drugs work by binding to dopamine receptors in the brain, preventing overstimulation from the neurotransmitter dopamine. The older antipsychotics bind tightly to these receptors, resulting in considerable side effects, including sexual dysfunction, increased lactation (which can result in loss of menses in women and lower testosterone in men), dulled cognition, sedation, and involuntary facial and muscular spasms. One of these, Haldol, is still in common use.
The newer "atypical" antipsychotics bind more loosely to the dopamine receptors, resulting in less risk of these side effects, though they still remain fairly common. Nevertheless, the APA and other guidelines recommend the atypicals as a first option for treating mania in the initial phase, often in combination with a mood stabilizer. The same guidelines and product labeling on these meds also recommend gradual tapering following remission, owing to the risk of tardive dyskinesia (involuntary spasms), unless needed. The atypicals include Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Geodon (ziprasidone), and Abilify (aripiprazole). Abilify, the newest, is thought to have the best side effects profile.
Zyprexa and Seroquel also have significant antidepressant effects. Further studies are likely to find antidepressant effects in other atypicals. Combination Zyprexa-Prozac (Symbyax) is FDA-approved to treat bipolar depression.
What do I do about sexual dysfunction?
Viagra may help, for women as well as men.
What about the other side effects?
There are meds to treat tremors and spasms, and wakefulness agents to handle sedation. Sometimes simply lowering the dose may solve the problem, or changing to a different med. Please let your psychiatrist know of any side effects, so the two of you can work on a solution. Also keep in mind that good lifestyle choices can reduce side effects.
Tell me about benzodiazepines.
These include Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam). Their main purpose is to relieve anxiety and promote sleep, but they can be very effective in quickly bringing down a person from a manic state or as an additional med in the cocktail. Their main drawback is they can be habit forming, with severe withdrawal symptoms, as well as having a depressive effect, so they are typically prescribed short-term or on an as-needed basis.
What about pregnancy and breastfeeding?
Please check with your doctor or psychiatrist. In general, antidepressants are considered safe through all phases of pregnancy and breastfeeding. As for the mood stabilizers, lithium runs an outside risk of heart defect in the first trimester, while the risk of spina bifida is too great to be taking Depakote or Tegretol (and possibly the other mood stabilizers) during the first trimester. Of the antipsychotics, Haldol, the most studied, can be used safely during pregnancy. Frederick Goodwin MD, author of the definitive book on bipolar disorder, at a 2001 conference stated that because of the risk of postpartum mania, it is critical for expectant mothers to get back on meds well before giving birth. Alternatives to meds include omega-3 and light therapy, and, as a last option, ECT. Drugs to avoid while breastfeeding: Lithium, Lamictal, antipsychotics.
Can I drink alcohol?
Not if you are expecting your meds to work. Those who find it hard to quit should bring this up with their psychiatrist. Caffeine and nicotine are other drugs you should seriously consider eliminating or cutting back on.
How do I know which meds I should be on?
The short answer is you don't. Every individual is unique and no two cases of bipolar disorder are the same, so what works for one person in your support group may not work for you and vice versa. The American Psychiatric Association and other organizations implicitly recognize this in their treatment guidelines, which set out a number of first options for meds treatment, graduating to a stepped series of different options should those first options fail.
As a general rule, finding the right combination of meds takes time. Patience and persistence are required. You may have to perservere through a number of failures or partial successes before you and your psychiatrist (it's a team effort) hit upon a satisfactory solution.
This sounds very discouraging.
Only if you believe you should sit back and let your meds do all the work. Smart lifestyle choices and various coping techniques can make a world of difference. Meds treatment can also be combined with talking therapy to great effect.
What is cognitive therapy?
Cognitive therapy - also called cognitive behavioral therapy - works to change erroneous thoughts (such as "It's the end of the world.") into more positive ones (such as, "Let's find a solution.") Once one is thinking and behaving in a positive way - such as working toward a solution rather than bewailing the end of the world - one actually begins feeling better. The therapy applies equally well to depression and mania. The therapy typically lasts 10 to 20 sessions, and involves active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone.
What are behavioral therapy and interpersonal therapy?
These are also short-term, manual-based therapies that focus on coping skills. By changing destructive behaviors and dealing better with people, one can successfully negotiate the stressful situations that can trigger a mood episode.
What about other types of talking therapy?
Before you engage in therapy that involves working on painful issues or suppressed memories, it is very important that your mood be stabilized, as otherwise these therapies can cause your condition to deteriorate. Some talking therapists take a dim view of medications, and their opinions on the subject are the last thing you need to be exposed to while you are still recovering and vulnerable. Having said that, if your boss is making you unhappy and your family is causing you stress, simply taking meds only invites another episode. These situations represent very dangerous triggers that need to be addressed. Long-term talking therapy that can help you resolve these issues may literally save your life.
What about ECT?
Electroconvulsive therapy, also known as shock treatment, has been used successfully to treat both depression and mania, but because of risk of short-term memory loss - and in rare cases long-term memory loss - is regarded as a treatment of last resort, except if the patient's condition puts him or her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on.
The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than candid over the memory loss element, and neglects to mention that relapses are common, which necessitates additional periodic "booster" treatments.
Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their bipolar in remission should do their research now and make their decision accordingly, while they have their wits about them. You can state your wishes in the form of a psychiatric advance directive.
Are there alternative or complementary treatments for depression?
Yes. These include St John's wort, Sam-e, omega-3 fatty acids, vitamin and mineral supplements, and acupuncture.
Tell me about Sam-e and St John's wort.
These are advertised as natural antidepressants, and have demonstrated efficacy for partial improvement. Consult your doctor before using, and buy only from a reputable supplier.
Tell me about omega-3 fatty acids.
Omega-3 is found in deepwater fish such as salmon and in flax. Two studies found that countries with low fish consumption coincided with high depression and bipolar rates. A pilot study using omega-3 found it effective in treating the depressed phase of bipolar, and another using an omega-3 extract found the substance to be effective in treating depression. Until we know more, it is advised that omega-3 be considered as a complement to, rather than as a replacement for, one's normal meds. Buy only preparations that have more EPA than DHA.
Tell me about vitamins and mineral supplements.
Unfortunately, much of the food we eat comes from soil depleted of nutrients. The raw materials for producing neurotransmitters are nutrients. A deficiency of vitamin B6, for instance, may affect how serotonin is synthesized. Various small studies are finding single nutrients or nutrient combos can have affects ranging from subtle to pronounced. One pilot study found a certain supplement combination dramatically improved symptoms in bipolar patients. And it isn't just about mood. Antioxidants, for example, can improve memory and protect against free radicals that can damage neurons. Use under a doctor's supervision. Consulting a nutritionist is also recommended. It is advisable to use supplements as a complement to meds rather than as a replacement.
Updated Feb 10, 2008
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