MEDICATIONS: FREQUENTLY ASKED QUESTIONS: BIPOLAR DISORDER

Q:

What medications are used to treat bipolar disorder?
 

A:

Mood-stabilizing medications are used to treat mania and to help prevent the recurrence of mania and depression in people who have bipolar disorder.

Lithium is the best known and most well studied mood stabilizer. It has been used for over forty years, and it is a well-established and effective medication for mania, especially when mania is not complicated by rapid cycling (alternating between depression and mania four or more times per year) or mixed states (when mania and depression occur at the same time).

Lithium has some common side effects, including a frequent need to urinate, tremors, nausea, forgetfulness and weight gain. These side effects often can be controlled by working with your psychiatrist to adjust the medication.

Valproate (or divalproex) and carbamazepine are anticonvulsant medications that also can be used to stabilize moods and treat bipolar disorder. These drugs can be used alone or in combination with lithium. Psychiatrists may consider prescribing these medications for people who have serious trouble with the side effects of lithium, who do not respond well to it, or who have rapid cycling or mixed states. Many psychiatrists prescribe valproate as the first line of treatment. Blood testing also is necessary for people taking either valproate (or divalproex) or carbamazepine.

Gabapentin and lamotrigine are two new anticonvulsants that also may be used as mood stabilizers. These drugs are being studied for the treatment of bipolar disorder, and they may help people who cannot take lithium, valproate (or divalproex) or carbamazepine. In addition, olanzapine can provide a mood stabilizing effect, as may clozapine. The U.S. Food and Drug Administration approved olanzapine recently for treating mania.

As with any treatment, some people will respond well to medications for bipolar disorder and some will not. People with bipolar disorder may have to work closely with their psychiatrist and try several different treatments to find the medication that works best for them.
 

Q:

What are Bipolar II Disorder and hypomania?
 

A:

A person who has Bipolar II Disorder is diagnosed on the basis of having had one or more episodes of hypomania, which is a less severe form of mania. People who have full-blown episodes of mania are considered to have Bipolar I Disorder.

Hypomania is characterized by a period of elevated, expansive or irritable mood that is clearly different from the person's usual mood and that lasts at least four days. A hypomanic episode does not cause the psychotic symptoms (psychotic means losing touch with reality) sometimes seen in bipolar disorder and does not produce the severe problems in functioning also seen with mania. However, although hypomania can feel good to someone during a hypomanic episode, relationships and work often suffer under its pressured, self-absorbed behaviors. After an episode is over, people with hypomania may feel very ashamed by their behavior.

Researchers think the genes that play a role in Bipolar II may be different from those involved in Bipolar I. Close relatives of people with Bipolar II Disorder who develop a bipolar disorder may be more likely to get Bipolar II – not Bipolar I – Disorder, and vice versa.
 

Q:

What is rapid cycling?
 

A:

The term rapid cycling means that someone with bipolar disorder (either Bipolar I or II) has four or more episodes of mania (or hypomania), and/or depression in a year. People who experience rapid cycling also have at least two weeks of relatively normal mood between episodes or a rapid shift from high to low (or low to high).

Rapid cycling is most common in women and in people with Bipolar II Disorder. People who have thyroid problems, specifically hypothyroidism (underfunctioning of the thyroid gland), appear to be at increased risk for rapid cycling. Drug and alcohol abuse also increases the risk.

Some controversy exists about whether antidepressants cause or worsen rapid cycling. Because of this possible risk, antidepressants, if prescribed, should be administered with careful monitoring, possibly in combination with a mood-stabilizing medication.

Lithium may be less effective for people who have rapid cycling bipolar disorder. For these people, a combination of lithium and another mood-stabilizing medication may be needed to control their illness.
 

Q:

How do you prevent future bipolar episodes?
 

A:

Unfortunately, bipolar disorder often has a high rate of recurrence. Recurrence means another episode of mania or depression may occur after a person has recovered from a previous episode. (Recurrence is different from relapse, which means becoming ill again while in the recovery phase of an episode of illness.)

Mood-stabilizing medications can greatly reduce the likelihood of future episodes of illness, so it is important to continue taking these medications after an episode of mania or bipolar depression has ended. Studies have shown that lithium, in particular, is effective in preventing recurrence. Regular blood tests to check the level of lithium in the bloodstream are important because maintaining the proper level is necessary for the medication to work.

People with bipolar disorder who are treated with lithium are much less likely to commit suicide than those who do not receive treatment. If lithium treatment is stopped, the dosage should be reduced gradually because abruptly stopping the medication increases the risk of either a recurrence or a relapse.

Valproate (or divalproex), carbamazepine, gabapentin and lamontrigine have not been studied as well as lithium to understand their effectiveness in preventing future episodes of illness. Olanzapine and risperidone currently are being studied to see if they prevent recurrences of illness. All of these medications are potential alternatives to lithium or can be prescribed in combination with lithium. Some people will need a combination of mood-stabilizing medications to effectively control their illness.
 

Q:

Do people ever consider suicide during a manic episode, or is that a problem only during episodes of depression?
 

A:

Although it is difficult to predict who will commit suicide, studies have shown that certain factors are associated with greater risk: Being age sixty or older, being a male, and losing a loved one or a close relationship all are risk factors; so are feeling hopeless, experiencing severe anxiety or panic, and having psychosis (losing touch with reality). The risk of suicide increases when someone has had another family member commit suicide, has attempted suicide previously, or is abusing alcohol or drugs. Finally, the risk is increased if the person has a specific plan for suicide, has the means to do so (like a gun or pills), has rehearsed the plan, and feels he or she has no reason to live.

People with bipolar disorder may consider suicide during manic as well as depressive episodes. People who have mixed-state bipolar episodes (when mania and depression occur at the same time) and people whose mania is characterized by intense anger and grandiosity are not only at risk for suicide, they also are more likely to harm someone else.

If your loved one or friend seems at risk, don't be afraid or reluctant to ask whether he or she is thinking about suicide. Talking about suicide does not increase its risk, but isolation, hopelessness and feeling alone do.