What are the main treatments for bipolar disorder?

Bipolar Disorder: An Information Guide

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Biological Treatments
Newer Treatments for Bipolar Disorder, Including “Alternative” Medicines
Psychosocial Treatments
Special Treatment Situations

Treatment of bipolar disorder includes biological treatments (medications) and psychosocial treatments (psychotherapy, rehabilitation). Often both types of treatment are needed, but usually biological treatment is needed first to bring symptoms under control.

Biological Treatments

Because bipolar disorder is a biological illness, the main forms of treatment are biological. These consist mainly of medications, but also include other treatments, such as electroconvulsive therapy (ECT) and light therapy.

Medications

Medications fall into two broad categories - mood stabilizers and adjunct medications.

Mood stabilizers

Mood stabilizers are medicines that help reduce swings in abnormal moods. They also help prevent fresh mood episodes. The first, and most studied, of these is lithium, a naturally occurring salt that has been used for 50 years. Lithium still has a major role in bipolar disorder. Carbamazepine, a medicine first used for epilepsy as an anticonvulsant, is used occasionally. It was found to be a mood stabilizer in the 1970s. Valproic acid (also including its various forms of sodium valproate and divalproex sodium) is another anticonvulsant that has become widely used in the 1990s to stabilize moods. It is used so often because many doctors feel it helps more types of mood swings and symptoms than lithium, and has fewer side-effects than lithium.

However, all of the newer treatments are not necessarily “better” simply because they are newer. For some patients, lithium may be the most effective treatment.

Adjunct medications

Adjunct medications are simply other medications that can be used to treat specific symptoms, for example, depression, poor sleep, anxiety and psychotic symptoms. Adjunct medications include antidepressants, anti-anxiety medications, and antipsychotics, or “neuroleptics.” These medications are often only used for the short term. In contrast, mood stabilizers are used for the long term.

Antidepressant medication

Antidepressants are medications that were originally found to be useful in treating depression, and more recently have often been found helpful to treat anxiety disorders. The first antidepressant was discovered by accident: patients with tuberculosis in the 1950s were often treated with iproniazid, which was found to elevate mood. Later research resulted in the development of tricyclic antidepressants such as imipramine (Tofranil®) and amitriptyiline (Elavil®). These were followed by fluoxetine (Prozac®), the first of the “new” antidepressants, in the 1980s. Currently, there are over 40 antidepressants available, spanning many different classes of medications.

Antidepressants are thought to work primarily by affecting the concentration of neurotransmitters in the brain. Key neurotransmitters that are affected include serotonin, norepinephrine, and dopamine. While antidepressants can be used in bipolar disorder during depression episodes, they must be used with caution since they can also cause a switch into mania and may precipitate a cycle of frequent mood episodes (rapid cycling).

Anti-anxiety medications

Anxiety is common in bipolar disorder. Sleep disturbance is also very frequent during an acute episode. Benzodiazepines, a family of medications (the most well known is Valium®) with mild sedating ability, are often prescribed - particularly lorazepam (Ativan®) and clonazepam (Rivotril®). These may be used for short periods without the patient becoming addicted. Clonazepam is particularly useful for treating the excessive energy and reduced sleep of hypomania. For more severe anxiety problems, such as panic attacks, a special type of psychotherapy, known as cognitive behaviour therapy, may be very helpful. It may, in fact, be needed, because the antidepressants that are also sometimes used to treat anxiety disorders may provoke manic episodes.

Antipsychotic medication

Antipsychotic medications are commonly used in bipolar disorder. These medications have powerful sedating effects, which help control mania, and can treat psychotic symptoms. Such symptoms may include delusions of grandeur or persecution, and hallucinations. Traditional antipsychotics, such as haloperidol and loxapine, can also prevent new episodes of mania, but their long-term use may bring serious side-effects, such as tardive dyskinesia, a movement disorder.

Newer antipsychotics are also proving useful in bipolar disorder. These include olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and clozapine (Clozaril®). The new drugs may work to some extent like mood stabilizers. Research continues to see if these medications can treat not only mania but also depression, and prevent new episodes. These newer medications have fewer side-effects than the old antipsychotics.

Newer Treatments for Bipolar Disorder, Including “Alternative” Medicines

Many of the newest medications in bipolar disorder were first developed as anticonvulsants - medications used to treat epilepsy. Most of these are now systematically being tested in clinical trials with bipolar patients. Carbamazepine and valproic acid, both regular mood stabilizers, were developed in this way.

Most recently, the novel anticonvulsant lamotrigine (Lamictal®) has proved effective in bipolar depression and useful in rapid-cycling bipolar disorder, and may become a very common treatment. Gabapentin (Neuroatim®) and topiramate (Topamax®) are newer anticonvulsants with some usefulness in treating bipolar disorder. However, to date, no major studies on these medications have been published.

It is helpful to ask your doctor about new and emerging treatments in bipolar disorder. In some university medical centres, it is also possible to participate in clinical trials of new treatments.

“Natural” remedies may have a role. These include fish oil and inosital, a type of sugar. Yet when these products are sold through health food stores, they are often unreliable. Because they have not been precisely formulated, they cannot be recommended. Furthermore, little research has been done on these products. St. John’s wort has been well studied in unipolar depression (depression without mania). However, it has not been studied in bipolar disorder.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is perhaps the most controversial and misunderstood of psychiatric treatments, due in part to sensationalized and misleading depictions of the treatment in the popular media. In fact, ECT is a highly effective and safe treatment for both the depressive and manic phases of bipolar disorder, and is sometimes used as a long-term “maintenance” treatment to prevent recurrence of illness after recovery.

Procedure

ECT involves administering a brief electrical stimulus through the scalp to the surface of the brain. This stimulus produces an epileptic-type convulsion, lasting typically from 15 seconds to two minutes.

During the treatment, a team of psychiatrist, anaesthetist and one or more nurses are present. The patient is given an anaesthetic intravenously to put him or her to sleep briefly during the treatment. A muscle relaxant is also given to prevent physical injury, by lessening the intensity of muscle spasms that accompany a seizure. Oxygen is administered and heart rate and blood pressure are monitored. Although the anaesthetic lasts only a few minutes, patients feel groggy after an ECT treatment and may rest or sleep for about one hour.

Usually the treatments are administered three times a week over three to four weeks, for a total of eight to 12 treatments. For longer-term maintenance treatment, the treatments may be spread out, for example, once a month, and continued for as long as the patient and doctor feel is appropriate. ECT is usually given to hospitalized inpatients, but outpatients can receive ECT as well.

Side-effects

Patients may have a headache or jaw pain on awakening after ECT, usually requiring only a mild pain killer such as acetaminophen (Tylenol®). Some loss of recent memory or problems with concentration usually occur during treatment (for example patients may not recall what they had for supper the night before the treatment), but these symptoms improve quickly after the course of ECT is finished, over a few weeks. Some patients report mild memory problems persisting much longer after ECT, but this is likely due to their depression, not to the treatment.

ECT can be given bilaterally (the electric current is applied to both sides of the brain) or unilaterally (only on the right side of the brain). Although bilateral ECT causes more memory disruption than unilateral ECT, it is also somewhat more effective and is usually the preferred choice.

Uses of ECT in bipolar disorder

ECT is the most effective, and possibly the fastest-acting treatment for severe depression, and is particularly helpful for highly agitated or suicidal patients or those with psychotic or catatonic symptoms. Some patients receive ECT early in their episode of illness because of the urgency of their situation or their particular symptoms, while others may prefer to use ECT only after various medications have failed. ECT works well for severe mania as well.

While ECT is highly effective at ending an episode of depression or mania, the benefits may not last more than a few weeks or months following treatment. Therefore, patients usually start or continue treatment with mood stabilizers and/or other medication following a course of ECT. Maintenance ECT can be used in cases where medications have not prevented recurrence of illness, or are intolerable due to side-effects.

Transcranial magnetic stimulation

Finally, there is transcranial magnetic stimulation (TMS). TMS is a treatment involving magnetic pulses to the brain. TMS is being tested, but its effectiveness has not yet been proven.

Psychosocial Treatments

Psychosocial treatments include psychoeducation, psychotherapy, support groups and rehabilitation.

Psychoeducation

Psychoeducation is a specific term for health education for psychiatric illnesses. All new patients should be routinely treated with psychoeducation. It can also be helpful to give patients psychoeducation periodically throughout their illness. Psychoeducation teaches what causes the illness, how to treat it, how to self-manage the illness to some extent, and how to prevent future episodes.

Psychotherapy

Psychotherapy is a general term used to describe a form of treatment that is based on “talking work” done with a therapist. The aim is to relieve distress by discussing and expressing feelings, to help change attitudes, behaviour and habits that may be unhelpful, and to promote more constructive and adaptive ways of coping.

Successful psychotherapy depends on a supportive, comfortable relationship with a trusted therapist. Doctors, social workers, psychologists and other mental health professionals are trained in various models of psychotherapy and work in hospitals, clinics and private practice.

There are many different models of psychotherapy. They fall into two general categories. Short-term structured psychotherapy and long-term psychotherapy. Short-term therapy has a specific focus and the therapist is active and directs the process. On average, the treatment lasts for between 10 and 20 sessions. In long-term therapy the therapist is generally less active and the process is less structured. This treatment usually lasts for a year or more. The aim is to facilitate the patient coming up with his or her own answers.

Psychotherapy is a very helpful treatment. For bipolar disorder, though, it only works as an add-on to medications, not as a substitute. Every patient should get some supportive therapy that involves not only managing medication, but also dealing with the various problems that a person with bipolar disorder may experience. Practical suggestions and emotional support are the main features of supportive therapy.

Cognitive behaviour therapy

Cognitive behaviour therapy is an example of a short-term structured psychotherapy that has worked well for many other disorders. It is based on the idea that deeply held beliefs or thoughts influence how we look at ourselves and the world, and have a strong influence on our mood and behaviour. For instance, if we are depressed and think no treatment will help, then we might not bother to seek treatment. This almost guarantees that we will feel worse. Cognitive therapy attempts to identify and change such thoughts and to improve mood and functioning. It is now being tested in bipolar disorder. The early results are promising, both in preventing future episodes and in treating depression.

Insight-oriented or psychodynamic psychotherapy

Insight-oriented or psychodynamic psychotherapy is an example of a long-term, unstructured psychotherapy. This therapy reduces distress by helping an individual to gain insight into the underlying motives of his or her overall behaviour. While this is not a specific treatment for bipolar disorder, it can be very helpful as increased self- knowledge and awareness leads to more effective management of the illness.

Group therapy

Historically, group therapy has been used successfully to provide elements of support and psychoeducation. Cognitive therapy may also be provided in a group. However, group cognitive therapy has not yet been tested with bipolar patients.

Family and couple therapy

Finally, family and couple therapy can be very helpful in addressing problems that may have existed before the illness and have become highlighted, or to deal with issues that have arisen as a result of the illness. The timing, however, is of utmost importance. During an acute episode, the family or spouse should be given only support and education. Formal family or marital therapy should wait until the patient is more stable.

Self-Help Support Groups

Self-help support groups can be very important to treatment. A group of people who all have bipolar disorder can accept and understand one another, and can share their struggles in a safe, supportive environment. A strong bond usually develops among group members for the reasons just stated. People who have recently been diagnosed with bipolar disorder can benefit from others who have learned successful coping strategies for managing the illness. These groups are usually organized under the auspices of the local chapters of the Mood Disorders Association (see "Resources" for additional information).

Special Treatment Situations

Hospitalization

During severe episodes of depression or mania, patients with bipolar disorder may need to be hospitalized.

Hospitalization is needed if the illness is out of control and putting patients at risk of serious consequences, for example, due to aggressive behaviour, risk-taking, failing to look after their own basic needs, or suicidal tendencies.

Voluntary versus involuntary admissions

Patients are usually admitted to hospital voluntarily. This means that they are free to leave hospital at any time if they so choose. However, in Ontario, as in most other jurisdictions, the law also allows any doctor (not just a psychiatrist) to admit a patient to hospital involuntarily (sometimes called “certifying” the patient). This can happen if the doctor believes there is a serious risk of the patient or someone else being physically harmed because of the patient’s disorder. If no doctor has seen the patient, families also have the option of asking a justice of the peace to order a psychiatric assessment, and must provide convincing evidence that the patient's illness represents a danger to the patient or others.

Legal safeguards are in place to protect the involuntary patient’s rights. For instance, a “rights advisor” will visit and ensure that the patient has the chance to appeal the involuntary status before an independent board of lawyers, doctors and lay-persons, if the patient wishes.

Inpatient treatment

A typical hospital stay may be anywhere from a few days up to several weeks, and rarely, several months. Usually patients are expected (or required, if they are involuntary) to remain on the psychiatric unit for the first few days of their stay. As they recover they may be granted increasing privileges to visit other parts of the hospital or to walk outside. Later they will be given passes to go home overnight or for the weekend.

Patients participate in a variety of group educational and therapeutic programs during the day or evening and also have individual sessions with medical, nursing and other professional staff. Medications may be changed or doses adjusted, and families may be interviewed by medical or social work or other staff.

Discharge planning begins immediately following admission to hospital. Patients should expect to leave hospital as soon as reasonable follow-up arrangements are in place and their symptoms have improved enough to ensure they are able to function safely and care for themselves at home. Staying in hospital after symptoms have improved may not benefit the patient. It may in fact cause difficulties, by reducing the patient’s connection to family and social supports and possibly undermining his or her independent living skills.