Medicine to treat bipolar

Mood Stabilizers as a Treatment for Bipolar Mania

Written by WebMD Editorial Contributors

Which Bipolar Medicine Is Best?

Doctors use many types of drugs to treat bipolar disorder. Some fight the extreme highs of mania and others treat the lows of depression. You might take one drug at a time or a few at the same time.

The best bipolar medicine is the one that works best for you. Work with your doctor to decide on the medication plan that helps you the most.

You may keep taking these medications for years or decades, even if it’s been a long time since your last manic or depressive episode. This is called maintenance therapy and helps prevent recurrence of symptoms.

What Is Mood-Stabilizing Medication?

Mood stabilizers are medicines that treat and prevent highs (mania) and lows (depression). They also help to keep your moods from interfering with work, school, or your social life.

Examples include:

Carbamazepine (Carbatrol, Epitol, Equetro, Tegretol)
Divalproex sodium (Depakote)
Lamotrigine (Lamictal)
Lithium
Valproic acid (Depakene)

Some of these drugs are known as anticonvulsants, which are also used to treat seizure disorders, including carbamazepine, lamotrigine, and valproic acid.

Not all of these drugs have the same effects, though. Some (such as lithium) are better at treating mania. Others (such as lamotrigine) may be more useful for depression.

Keep in mind that the term "mood stabilizer" can be misleading. If you take one, your mood can still change during the day. These medicines treat full episodes of mania or depression that last for several days or weeks at a time.

Other Mood-Stabilizing Medicines

Drugs called antipsychotic medications are also common in bipolar treatment plans. You can take them alone or with mood stabilizers to help with symptoms of mania. These drugs include:

Haloperidol (Haldol)
Loxapine (Loxitane) or loxapine inhaled (Adasuve)

Today, doctors may prescribe newer antipsychotic drugs, including:

Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lumateperone (Caplyta)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Olanzapine/samidorphan (Lybalvi)
Quetiapine fumarate (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)

Medicines for Bipolar Depression

Most of the time, doctors will start bipolar disorder treatment by prescribing a mood-stabilizing drug like lithium. But the FDA has approved some medicines for bipolar depression, too:

Fluoxetine combined with olanzapine (Symbyax)
lumateperone (Caplyta)
Lurasidone (Latuda). You might take it alone or with lithium or valproic acid.
Quetiapine fumarate (Seroquel)

For some people, traditional antidepressants may trigger a manic episode. Because of this risk, your doctor should keep track of you closely if you take one.

Will the Medicine Work for Me?

Your doctor can’t predict how well a particular bipolar medication will work for you. You may need to try several different kinds and different doses to figure out the right approach. And that can take time.

It can be frustrating, but don't give up. Eventually, you and your doctor should be able to find a prescription that works for you.

Medication Tips

If you have bipolar disorder, taking your medication should be part of your routine. Take it at the same time every day. It's easier to remember if you do it along with another daily activity, like brushing your teeth, eating breakfast, or getting into bed. A weekly pillbox can help you see if you've missed a dose.

Be sure to talk to your pharmacist or doctor about the best time of day to take your bipolar medications. Some are best if you take them in the morning or at bedtime and others with meals or after meals.

Make sure you know what to do if you accidentally miss a dose. Ask your doctor. Don't assume that doubling up is a good idea.

Side Effects of Bipolar Drugs

Like any drug, bipolar medicines can cause some side effects. They vary depending on which medications you use. These side effects can include:

Nausea
Tremors
Hair loss
Sexual problems
Weight gain
Liver damage
Kidney damage
Diarrhea
Belly pain
Skin reaction

Some medications can affect how well your liver works or the amount of white blood cells or platelets you have. You may need regular tests to make sure that you're staying healthy. The antipsychotic drug ziprasidone (Geodon) is linked to a rare but serious skin reaction called DRESS syndrome (drug reaction with eosinophilia and systemic symptoms).

Many side effects will go away after a few weeks of treatment. If you still feel bad after that, see your doctor. Don't assume you have to just live with the side effects. Your doctor may be able to change your dose, give you another medicine to control the side effects, or try a different medication altogether.

Stick to Your Treatment

Medications for bipolar disorder are powerful drugs, and you must take them exactly as your doctor recommends. Don't stop taking a medicine without your doctor's approval. It can be dangerous.

When you're feeling good, you might decide that you want to stop taking your medication. But that's a bad idea unless your doctor agrees. Treatment only during mood episodes may not be enough to prevent symptoms from coming back. In most people, maintenance treatment between mood episodes makes mania and depression happen less often and makes them less severe. If you're feeling good now, that's likely because your medication is working. So stick with it.

Bipolar Disorder Guide

Overview
Symptoms & Types
Treatment & Prevention
Living & Support

What’s Next for Bipolar Treatment?

In this Article

By Paula Zimbrean, MD, as told to Hallie Levine

Over the last 2 decades, there have been huge advancements in the treatment of bipolar disorder. We’ve learned that there are several types: bipolar I, bipolar II, and cyclothymic. All present differently and require different treatments.

We’ve gotten better at teasing out if symptoms are truly due to bipolar disorder or something else. And we’ve developed groundbreaking new treatments that are easier on the body and make it possible for people with bipolar disorder to live full lives. Here’s what I’m most excited about.

We’ve moved away from lithium.

A study published in the American Journal of Psychiatry looked at data collected over 2 decades -- from 1997 to 2016 -- and found that patients today are much more likely to be prescribed an antipsychotic or an antidepressant medication than a mood stabilizer like lithium. There’s no doubt lithium is an important drug

when it comes to bipolar disorder, and it’s very effective. But it carries a risk of side effects, especially at high doses, including both kidney and thyroid disease. I’ve worked with patients who took lithium for many years who eventually required kidney transplants. The good news is today we know much more about lithium and how it works, so when we do need to use it, we prescribe much lower doses.

Over the last couple of decades, we’ve also realized that some of the anticonvulsant medications, such as carbamazepine, lamotrigine, and valproate are effective ways to treat the mania from bipolar disorder. At the same time, a group of drugs known as second-generation antipsychotics became available, too. These medications, which include aripiprazole, cariprazine, lumateperone,olanzapine, quetiapine, and risperidone, among others, carry lower risk of side effects than earlier antipsychotics. These side effects include weight gain, elevated cholesterol and blood sugar levels, and tardive dyskinesia -- stiff, jerky movements of the face and body.

There are even more of these being approved. Some seem to carry a much lower risk of side effects such as weight gain or elevated cholesterol or blood sugars. Some also appear less likely to interact with other medications, which is something I worry about daily as a prescriber.

There are more long-term medications.

Another important step forward has been the availability of long-acting atypical antipsychotics. These drugs play an important role in treating bipolar disorder, since there’s often a high rate of noncompliance. But medications such as aripiprazole monohydrate and risperidone are now available as long-acting injectables, given in your doctor’s office every 2 weeks or once a month. This is much more acceptable to people with bipolar disorder, especially those who are active and don’t want to think about taking a pill every single day. Research shows these long-term injectables improve recovery outcomes. People are more likely to stick to treatment and gain control of symptoms. Hopefully, we will see more and more of them in the future.

We’re shifting toward gene therapy.

We know there are specific genes associated with your risk of developing bipolar disorder. Just this past year, the largest genetic study of bipolar disorder thus far was able to identify 64 different spots on the genome that raise your odds of bipolar disorder. But we’re not quite there yet when it comes to making the leap that modifying certain genes will cure the disease. The hope is eventually we’ll be able to apply what’s known as precision medicine to bipolar disorder. Ideally, we’ll analyze a patient’s gene to figure out which targeted treatments and therapies they’ll most benefit from, just like we do for patients with other conditions, such as breast cancer.

There are drugs to treat unwanted side effects.

One of the reasons people don’t stick to their medication regime is because of side effects like weight gain or tardive dyskinesia. But we’re learning that there are other drugs we can give them to counter these side effects. For example, we now often use metformin to help reverse rises in blood sugar, or the anticonvulsant drug topiramate to offset weight gain. While you never want to give patients too many prescriptions, these drugs can ward off some of the adverse effects that make it hard for some people to take antipsychotic medication long term. Eventually, we hope pharmacies will be able to combine two to three different drugs to maximize a treatment’s effectiveness and reduce the risk of side effects.

Nondrug therapies are on the rise.

Electroconvulsant treatment can be effective for bipolar disorder that hasn’t responded to medications. It’s when an electric current is sent through the brain to cause a controlled seizure. But it requires general anesthesia and has side effects such as confusion, headache, and nausea. Now, researchers are studying whether transcranial magnetic stimulation (TMS), a noninvasive procedure that uses magnetic fields to stimulate brain nerve cells, is effective. Early research is promising, especially for the depressive stages of bipolar disorder.

SOURCES:

Paula Zimbrean, MD, associate professor of psychiatry, Yale School of Medicine, New Haven, CT.

American Journal of Psychiatry: “20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings.”

The Psychiatrist: “Long-Acting Injectable Antipsychotic Medication Plus Customized Adherence Enhancement in Poor Adherence Patients with Bipolar Disorder.”

Nature Genetics: “Genome-wide association study of more than 40,000 bipolar disorder cases provides new insights into the underlying biology.”

Brain and Behavior: “Clinical applications of transcranial magnetic stimulation in bipolar disorder.”

what they are and what effects they have

Psychiatrists usually recommend medication as the initial treatment to control symptoms as quickly as possible.

Once your symptoms are under control, you will receive supportive care to reduce your risk of relapse.

Supportive care also reduces the chance that minor mood changes turn into mania or depression.

Several types of drugs are used to treat bipolar disorder. nine0010
These include mood stabilizers, antidepressants and anti-anxiety drugs. Your doctor may prescribe one or a combination of medications for maximum effect.

Finding the right remedy or combination of remedies will require trial and error.

You may need to change your medications because of side effects.

Each drug may take up to eight weeks to see the full effect.

Usually only one drug is changed at a time. nine0003
This helps your doctor better monitor and determine which one is not working.

The following types of drugs are used to treat bipolar disorder

Lithium
Lithium (such as Lithobid) is a mood-stabilizing drug that has been used since the 1970s.

It helps control the symptoms of acute mania.

It is also effective in preventing the recurrence of periods of mania and depression. nine0003
Common side effects include weight gain and digestive problems.

The drug may also affect the thyroid and kidneys. Periodic blood tests are needed to monitor the condition of the thyroid gland and kidneys.

Lithium is a category D drug that should be avoided during pregnancy if possible.

However, in some cases the benefits may outweigh the potential risks.

Anticonvulsants
Anticonvulsants are mood stabilizers used to treat bipolar disorder.

They have been in use since the mid-1990s. A

Anticonvulsants include:

divalproex sodium (Depakot)

lamotrigine (lamiktal)

valproic acid (Depaken)

Common side effects of anticonvulsants include weight gain, drowsiness and inability to sit still. nine0003
Anticonvulsants are also associated with an increased risk of suicidal thoughts and behavior.

Valproic acid is known to cause birth defects.

Lamictal is known to cause a dangerous rash.

Tell your doctor about any new rash that develops while taking Lamictal.

Antipsychotics
Antipsychotics are another treatment option. Some commonly prescribed antipsychotics include:

olanzapine (Zyprexa)

risperidone (Risperdal)

Quetiapine (Seroquel)

lurasidone (Latuda)

aripiprazole (Abilify)

Azenapine (Saphris)

Common side effects include weight gain, drowsiness, dry mouth, decreased libido and blurred vision.

Antipsychotics may also affect memory and attention.

They are also known to cause involuntary movements of the face or body. nine0003

Antidepressants
These include serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and tricyclics.

Antidepressants may be added to help manage depression in bipolar disorder, but they can sometimes cause manic episodes.

To reduce the risk of a mixed or manic episode, they are often given with mood stabilizers or antipsychotics. nine0003
As with any medication, talk to your doctor about the risks and benefits of taking antidepressants for bipolar disorder.

Some of the most commonly prescribed antidepressants are:

SNRIs

desvenlafaxine (Pristiq)

duloxetine (Cymbalta, Yentreve)

venlafaxine (Effexor)

SSRIs

citalopram (Celexa)

escitalopram (Lexapro)

fluoxetine (Prozac, weekly Prozac)

paroxetine (Paxil, Paxil CR, Pekseva)

sertraline (Zoloft)

Tricyclics

amitriptyline

desipramine (Norpramine)

imipramine (Tofranil, Tofranil-PM)

nortriptyline (pamelor)

IMAO

phenelzine (nardil)

tranylcypromine (parnate)

In general, MAOIs are rarely prescribed unless the patient has a poor response to SNRIs or SSRIs.

Common side effects include decreased sex drive, disturbed sleep, increased appetite, dry mouth, gastrointestinal disturbances, and menstrual problems. nine0003
While taking an MAOI, it is important to avoid other drugs and foods, such as wine and cheese, which can cause a rare but dangerous condition known as serotonin syndrome.

Benzodiazepines and Bipolar Disorder
This is a group of drugs with anti-anxiety properties. Benzodiazepines include:

alprazolam (Xanax)

chlordiazepoxide (librium)

clonazepam (Klonopin)

diazepam (Valium)

lorazepam (ativan)

Side effects may include drowsiness, decreased muscle coordination, and problems with balance and memory.

These drugs should be used with caution due to the risk of dependence.

Symbiax
This medication is a combination of fluoxetine and the antipsychotic olanzapine. Symbyax has both antidepressant and mood stabilizer properties.

Side effects may include increased appetite, sexual problems, drowsiness, fatigue, and dry mouth. nine0003
If your doctor prescribes this medicine, ask if separate prescriptions for the two ingredients are cheaper.

There is nothing special about the combination tablet. It's just a new formulation of two existing drugs.

References:

Bipolar disorder. (2016).
nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

FDA pregnancy categories (2017).
chemm.nlm.nih.gov/pregnancycategories.htm

Mayo Clinic staff. (2017). serotonin syndrome.
mayoclinic.org/diseases-conditions/serotonin syndrome/symptoms-causes/syc-20354758

Mayo Clinic staff. (2018). Bipolar disorder.
mayoclinic.org/diseases-conditions/bipolar disorder/symptoms-causes/syc-20355955

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Everything you need to know about bipolar disorder

source:
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