Bipolar Disorder

Bipolar disorder

Key points about treatments for Bipolar Disorder

Bipolar Disorder is an illness which can require long-term treatment. Skilled medical management is needed.
Different medications are used to treat acute episodes of mania and of depression, and other medications ('mood stabilisers') are used to keep episodes at bay or to augment acute treatments.
Psychological therapies by themselves are unlikely to be effective but are valuable adjuncts to physical therapies.
Every person is different - he or she may need medication or combinations of medications that are quite different from somebody else with Bipolar Disorder.
Compliance with medications is important for long term stability.
Depending on the nature of the illness and how it is managed, hospitalisation can sometimes be required.
Treatments should take account the rare possibility of organic or medical causes for Bipolar Disorder (particularly if the person is 40 or older at the time of their first manic episode).
Some psychotropic medications (e.g. antidepressant drugs) can cause mania, as can some steroids or stimulant drugs.
Recurring mania is usually due to poor compliance with medication, or the particular medication not working properly.
The use of medications during pregnancy is an extremely important issue and needs consultation with an expert.

Different medications for mania and depression

Generally speaking, medications for Bipolar Disorder have two underlying strategies:

Medications that treat or prevent mania by stabilising the mood - such as lithium, valproate (in Australia termed 'epilim'), carbamazepine, or lamotrogine, and (increasingly) the atypical andipsychotic drugs:

Lithium and valproate are usually considered the first choice medications for most people experiencing their initial manic episode.
For those with Bipolar II Disorder, an SSRI antidepressant will sometimes modulate or prevent highs and lows (an approach yet to be formally established), and may avoid the need to proceed to a mood stabiliser such as lithium or valproate.
'Rapid cycling disorder' or 'mixed episodes' may need different medications.
Whether or not to treat mild mania and hypomania will depend upon the person's mood and the consequences (both positive and negative) of their 'highs'. Charting a person's moods can help this decision.

Medications that treat the depression - of which there are different classes (common ones used for Bipolar Disorder being the SSRIs and Dual Action Antidepressants as they are less likely to 'switch' the depressed individual to a high), or, as noted above, which may act as a stabiliser in an ongoing way.

Treatment often distinguishes between (i) management of the acute episode and (ii) maintenance. For example, an individual with mania might require an atypical antipsychotic and a mood stabiliser during an acute episode but, when settled, only require the mood stabiliser to prevent further episodes. Similarly, an individual with Bipolar Depression may only require an antidepressant at that time before relying only on the mood stabiliser when the depression has resolved.

Psychological therapies

Psychological therapies such as counselling and psychotherapy are important adjuncts to physical treatments for Bipolar Disorder, but, by themselves are ineffective and inappropriate.
Combining physical treatments and psychological therapies has been clearly demonstrated to be better than physical treatment alone, and not merely by improving compliance or adherence to medication (see Dominic H. Lam et al, 'A Randomized Controlled Study of Cognitive Therapy for Relapse Prevention of Bipolar Affective Disorder', Arch Gen Psychiatry, Vol 60, Feb 2003: 145-152).
Find out more about Psychological Treatments and Psychologists and Counsellors.

Every person is different

There are choices between medications as to the one (or combination of medications) that is the best for the individual. The 'pattern' of mood swings may take a while to establish itself, but, with the help of skilled medical management, the person with Bipolar Disorder is able to lead a stable and productive life.

Compliance

Poorly-controlled Bipolar Disorder indicates either the inherent severity of the condition or poor compliance with medication.
It is hard for most people to accept a diagnosis of Bipolar Disorder and, for younger people the prospect of taking preventative medication for long periods is very unappealing.
Other people fail to take medication either because they find the experience of mania seductive, or because of the unpleasant side-effects.
Side-effects are often easily remediable, although lowering the dose too far can lead to a loss of treatment efficacy.
It is important to recognise that without ongoing treatment Bipolar Disorder is unlikely to be controlled and relapse is likely to occur. Most people who have had one manic episode will go on to have further illness.
The benefits of ongoing treatment are a reduction in the severity and frequency of illness.
For most people the benefits of long term stability outweigh the drawbacks of being on medication. (Read Tony's story: 'On Living with Bipolar Disorder' [PDF, 128KB].)

Hospitalisation

If someone with Bipolar Disorder has become psychotic, highly excited, aggressive or involved in clearly destructive behaviour, the issue of hospitalisation often arises.
While some people may be manageable outside the hospital setting (perhaps with the assistance of community mental health resources), admission can be necessary.
The use of other medications (such as antipsychotics or benzodiazepines) may be necessary while waiting for the antimanic effect of lithium.

Rare 'comorbid' causes

Before, or while treatment is being initiated, the uncommon possibility of an organic cause of a first manic episode should be considered, particularly if the patient is in his or her 40s, or older.
Recognised causes of mania include use of medications such as treatments for Parkinson's disease, steroids or stimulant drugs such as cocaine or amphetamines.
Rarely, medical disorders such as Cushing's Disease, human immunodeficiency/acquired immunodeficiency syndrome, cerebral tumours or cerebrovascular disease, may be identified.

Antidepressant drugs can cause mania

Some antidepressants themselves will cause mania ('manic switching') in those without Bipolar Disorder, or for those with Bipolar Disorder, increase the frequency of episodes.
We believe that such switching is less common with narrow-action antidepressants (such as SSRIs and dual action antidepressants) and more common with tricyclics and MAOIs.

Recurring mania

Non-compliance with mood stabilisers is a common cause of recurrence, so it should be the first consideration when a person on preventative medication develops a new episode. When patients suddenly cease lithium, 50% will relapse into a manic episode within 5 months, and many within a few weeks. A blood test can confirm whether levels of medication are in the effective range. If blood levels of the mood stabiliser are shown to be low, then the dose can be lifted to the 'therapeutic' range.
If mania reoccurs, the treating practitioner would normally ask two questions: why has the patient stopped taking the medication, or, why is the medication no longer working?
If the person has ceased medication because of unpleasant side-effects, the dosage of the medication could be reduced or the patient changed to another mood stabiliser.
If the patient has relapsed despite good compliance and acceptable tolerance of the medication, changing or combining medications might be the solution. For example, valproate (known as 'epilim' in Australia) or carbamazepine could be added to lithium in patients who relapse despite maintenance of adequate blood levels and compliance with lithium.

Drug treatments during pregnancy

Drug treatment for mania and depression during pregnancy is an extremely important issue in terms of the health of the baby.
The general principles are that, if a woman is on antidepressant and mood stabilising medication, consultation with an expert should be undertaken and drug-free conception attempted.
In the first three months of pregnancy, certain medications should be avoided, but this is not always achievable. In such circumstances, the mother, her partner and her doctor need to work together to address the cost-benefit issues.