Medication for Bipolar Disorder

How is Bipolar Disorder Treated?

Bipolar disorder affects people differently and requires individualized treatment. Mental health professionals will carefully assess each patient’s symptoms and history to prescribe the most effective treatment plan, which may often include medication. The main types of medications prescribed include mood stabilizers, antipsychotic medications, antidepressants, and monoamine oxidase inhibitors (MAOIs).

Mood Stabilizers

Mood stabilizers help manage the intense mood swings that come with bipolar disorder, including the manic highs and the depressive lows. Although on a spectrum, bipolar disorder is broadly categorized into two types:

• Bipolar I involves at least one manic episode and may include depressive episodes, although depressive episodes are not required for diagnosis.
• Bipolar II includes at least one hypomanic episode and one major depressive episode.

The choice of mood stabilizer depends on the type of bipolar disorder and the individual’s symptoms. These medications include:

• Lithium (Lithobid) has been used for decades to prevent both manic and depressive episodes and is effective for long-term maintenance.
• Divalproex (Depakote) works well for mixed episodes and rapid-cycling bipolar disorder. This can be helpful when symptoms don’t fit neatly into one category.
• Carbamazepine (Tegretol, Equetro) is used for mixed or manic episodes, especially if other treatments haven’t worked.
• Lamotrigine (Lamictal) is effective for treating depressive episodes and maintaining long-term stability.

Antipsychotic Medications

Antipsychotic medications may be added to a treatment plan if mood stabilizers alone aren’t enough. These medications help manage symptoms like mania, psychosis, and bipolar depression. Antipsychotics are grouped into three generations:

• First-generation antipsychotics (FGAs) include haloperidol (Haldol) and phenothiazines. These are used for acute mania or psychotic depression and are often used in combination with antidepressants.
• Second-generation antipsychotics (SGAs), or atypical antipsychotics, include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). These medications help treat manic episodes and are also effective for long-term maintenance.
• Third-generation antipsychotics (TGAs) include aripiprazole (Abilify), brexpiprazole (Rexulti), lurasidone (Latuda), cariprazine (Vraylar), and lumateperone (Caplyta). These are newer medications that partially stimulate dopamine receptors and are useful for managing a wider range of symptoms.

Studies show that quetiapine works well as a standalone treatment for bipolar I and II depression and can also help in treatment-resistant cases when combined with other therapies. Cariprazine, at a dose of 1.5 mg, has been effective for bipolar I depression, while aripiprazole in a 400 mg monthly injection has proven helpful for preventing manic episodes, with fewer metabolic side effects compared to other medications.

Antidepressants

Antidepressants are prescribed to treat the depressive symptoms (e.g., feelings of sadness, loss of interest in activities, and changes in sleep and appetite) of bipolar disorder. Antidepressant medications can help reduce the risk of relapse into depressive episodes, especially for those with bipolar II disorder.

For patients with bipolar disorder, antidepressants are combined with mood stabilizers or second-generation antipsychotics to reduce the risk of triggering manic or hypomanic episodes. Long-term studies have shown that this treatment approach can lower the likelihood of recurrent depressive episodes without increasing manic symptoms.

The most commonly recommended antidepressants for bipolar disorder are selective serotonin reuptake inhibitors (SSRIs) such as Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft). These are often a first-line choice for managing depressive symptoms due to their effectiveness and relatively mild side effects.

Other antidepressants may also be considered, like:

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron) are alternatives for those who don’t respond well to SSRIs.
• Tricyclic antidepressants like amitriptyline (Elavil), desipramine (Norpramin), imipramine (Tofranil), and nortriptyline (Pamelor) are less commonly used due to their higher likelihood of inducing manic symptoms in some patients.

Monoamine oxidase inhibitors (MAOIs)

Monoamine oxidase inhibitors (MAOIs) were the first class of antidepressants introduced; however, they are rarely the first choice for the treatment of mental health conditions today. This is due to dietary restrictions, potential side effects, and safety concerns. MAOIs can still be an option for patients who haven’t responded to other medications.

MAOIs work by blocking the breakdown of brain chemicals like serotonin, norepinephrine, and dopamine, which can help improve mood and reduce depressive symptoms. Most MAOIs are taken orally, but a skin patch form, such as selegiline (Emsam), can be a more convenient option with fewer side effects.

FDA-approved MAOIs include:

• Isocarboxazid (Marplan)
• Phenelzine (Nardil)
• Selegiline (Emsam)
• Tranylcypromine (Parnate)

Bipolar Drugs and Side Effects

Medications for bipolar disorder can be effective at managing symptoms, but like all treatments, they can come with side effects. Here’s what to watch for:

• Mood stabilizers may cause side effects like increased thirst, nausea, weight changes, drowsiness, or skin issues. Rare side effects can include tremors, memory problems, or changes in visions.
• Antidepressants can cause nausea, nervousness, sleep disturbances, changes in weight, and reduced sexual drive.
• Antipsychotics can lead to drowsiness, dry mouth, weight gain, and emotional blunting. Some people may also experience increased anxiety.
• MAOIs can cause dry mouth, dizziness, digestive issues, or skin reactions when used as a patch.

Side effects depend on the person, and their severity often depends on the medication and dosage. If any side effects worsen or persist, or you experience serious side effects, seek medical attention immediately.

Bipolar Medications and Pregnancy

Pregnancy in women with bipolar disorder is considered high-risk and requires careful monitoring. Untreated bipolar disorder during pregnancy increases the risk of relapse, which can harm both the mother and the unborn child.

Some medications, like divalproic acid, are contraindicated during pregnancy due to serious risks to the baby. Lamotrigine and certain atypical antipsychotics may be safer options when medication is needed. Lithium carries a small risk of birth defects but may be considered for women with severe or suicidal symptoms who respond well to it.

Women of childbearing age are encouraged to plan ahead when considering pregnancy and work closely with their healthcare provider to monitor mental and physical health through the pregnancy.