There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications (sometimes up to five). Some people with bipolar disorder add to or replace their Western medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms. Cognitive therapy may to lessen the severity of mood swings by recognizing and managing triggering symptoms or events.
Medications called mood stabilizers are be used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants, although this carries a risk of inducing mania (especially when no mood stabilizer is also prescribed). In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), antipsychotic drugs may also be used.
Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is usually episodic, and patients may experience remissions and periods of normal functioning (which may last years) whether or not they receive treatment. Evaluation of patients is usually carried out using a "life chart" which graphs moods over a long period of time, ranging from weeks to years. It is also generally necessary to "titrate" the dosage of a drug, seeking to achieve the most effective treatment possible while minimizing side effects. Most mood stabilizers have common side effects which may range from inconvenient to having a major impact on quality of life; many also have potentially dangerous side effects which make medical monitoring of patients undergoing drug treatment vitally important. For details of particular drugs, see the section below. Often, a customized combination of medications are needed to stabilize moods.
Compliance with medications can be a major problem, because some people becoming manic lose insight, or the awareness, of having an illness, and they therefore discontinue medications. Then they often suffer a manic episode and may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, are often disastrous because of the impulsiveness and irrationality that comes with them.
Depression does not respond instantaneously to resumed medication, typically taking 2Ð6 weeks to respond. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a strong threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment laws exist for bipolar disorder and other mental illnesses.
While bipolar disorder can be one of the most severe and devastating medical conditions, fortunately many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals in contrast to persons with bipolar disorder who often appear completely healthy when they are between mood swings.
The use of lithium salts as a treatment of bipolar disorder was first discovered by Dr. John Cade.
Lithium salts have long been used as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from "alkali springs" as a treatment. They did not know it, but they were really prescribing lithium, which was present in high concentration in the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li+. The two lithium salts used for bipolar therapy are lithium carbonate (mostly) and lithium citrate (sometimes). Approved for the treatment of acute mania in 1970 by the FDA, lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide. Although lithium is among the most effective mood stabilizers, most persons taking it experience side effects similar to the effects of ingesting too much table salt, such as high blood pressure, water retention, and constipation. Regular blood testing is required when taking lithium to determine the correct lithium levels since the therapeutic dose is close to the toxic dose.
The mechanism of lithium salt treatment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.
Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of bipolar disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous.
Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives or adjuncts to lithium in many cases. Valproate (Depakote and Depakene) was FDA approved for the treatment of acute mania in 1995, and is now considered by many to be the first line of therapy for bipolar disorder. It is preferable to lithium because its side effect profile seems to be less severe, compliance with the medication is better, and fewer breakthrough manic episodes occur. However, valproate is not as effective as lithium in preventing or managing depressive episodes, so patients taking valproate may also need an SSRI or other antidepressant as an adjunct medicinal therapy. Some research suggests that different combinations of lithium and anticonvulsants may be helpful. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, have been studied to determine their efficacy as mood stabilizers in bipolar disorder. Lamotrigine is particularly promising, as there is evidence it acts as a mood stabilizer and particularly helps bipolar persons with severe depression. Topiramate has not done well in clinical trials, which may be because it seems to help a few patients very much but most not at all. Unfortunately, there are several controlled studies that show that gabapentin is very effective for certain types of epilepsy and has a mild side effect profile but is ineffective for bipolar disorder. Nevertheless, many psychiatrists continue to prescribe topiramate and gabapentin for bipolar disorder, although this is becoming increasingly controversial.
According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician. It should be noted, however, that the therapeutic dose for a patient taking valproate for epilepsy is very different than the therapeutic dose of valproate for an individual with bipolar disorder.
The newer atypical antipsychotic drugs such as risperidone, quetiapine, and olanzapine are often used in acutely manic patients, because these medications have a rapid onset of psychomotor inhibition, which may be lifesaving in the case of a violent or psychotic patient. Parenteral and orally disintegrating (in particular, Zyprexa Zydis) forms are favoured in emergency room settings. These drugs can also be used as adjunctives to lithium or anticonvulsants in refractory bipolar disorder and in prevention of mania recurrence. In light of recent evidence, olanzapine (Zyprexa) has been FDA approved as an effective monotherapy for the maintenance of bipolar disorder. A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be just as effective and safe as Lithium in prophylaxis.
Although the use of marijuana for the treatment of bipolar disorder is seldom mentioned by proponents of medical marijuana, there is anecdotal evidence that its use can alleviate the mood swings associated with the disease. The euphoriant effect of marijuana may be useful for mood elevation during the depressive phase, while the manic phase may be moderated by the tranquilizing effects of the drug.
Omega-3 fatty acids are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are polyunsaturated fatty acids which can be found in wild salmon, flaxseed and walnuts. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a fish oil supplement. It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this compound to be beneficial.
Certain types of psychotherapy or psychosocial interventions, in combination with medication or instead of medication, often can provide tremendous additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family systems therapy, and psychoeducation.
Electroconvulsive therapy is very occasionally used to treat severe bipolar depression.
Nearly all bipolar treatment studies have involved treating patients in the acute (initial) mania stage, where overmedication is often justified in removing a patient from danger. Much less is known, however, about long-term treatment, where relapse prevention and full remission are the main treatment goals.
Virtually nothing is known about treating hypomania. Conceivably patients in hypomania, if otherwise stable, could be treated with reduced medication doses, various forms of talking therapy, or relaxation exercises, but there are no studies to guide patients and psychiatrists. On one hand, mild hypomania may be a legitimate baseline for some patients. For others, hypomania may signal the beginning of a cycle into more severe mania, necessitating immediate intervention.
Until recently, depression was largely overlooked in bipolar disorder. The anticonvulsant medication, lamotrigine (Lamictal¨) was briefly popular for treating bipolar depression. New clinical trials are finding that certain new-generation antipsychotics such as olanzapine (Zyprexa ¨) and quetiapine (Seroquel¨) show some beneficial effect in treating bipolar depression. Lithium also has an antidepressant effect.
Because there is a danger of antidepressant medications such as SSRIs switching bipolar patients into mania, these medications are used with caution, nearly always with an antimania agent