Bipolar Disorder (Manic Depression)Treatment |
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Treatment
Treatment for bipolar disorder includes medication, psychotherapy, and, when necessary, electroconvulsive shock therapy (ECT). Treating the acute episode is similar to treating the underlying mood disorder (continual), though there are differences between the two approaches.
Acute Treatment of Manic Episode
The following drugs may be used to treat manic episodes:
- Lithium (Eskalith®)
- Valproate (Depakote®)
- Carbamazepine (Tegretol®)
- Olanzapine (Zyprexa®)
- Ziprasidone (Geodon®)
- Risperidone (Risperdal®)
- Aripiprazole (Abilify®)
These medications control mood swings and acute symptoms, manage recurrences, reduce the risk of suicide, and restore a sense of well-being.
Lithium revolutionized psychiatry when first introduced as a drug of treatment in the 1950s. The use of a simple salt to effectively treat mental illness supported the theory that chemical imbalances caused the disorders and dispelled beliefs that bad parenting or neglect were the only causes. Lithium is the mainstay of bipolar treatment, and the condition can often be controlled with lithium alone. It effectively treats both manic and depressive episodes and prevents devastating relapses. It typically takes 1 to 2 weeks for lithium to be effective.
There is a high rate of suicide among people with untreated bipolar disorder, and studies show that lithium treatment significantly reduces this risk. Conversely, patients who discontinue lithium treatment are 20 times as likely to commit suicide during the first 6 months following discontinuation.
Common side effects of lithium treatment include the following:
- Blurred vision
- Dry mouth
- Fine hand tremor
- Frequent urination
- Mild nausea, occasional vomiting
Long-term effects include weight gain, possible hypothyroidism, and kidney dysfunction. Patients who have kidney disease should not take lithium. Levels of lithium in the blood are monitored regularly to ensure that the proper concentration is maintained.
Lithium may cause birth defects and pregnant women should discuss the risks of taking the drug during pregnancy with their health care providers.
Valproate, which was initially used to treat seizures, is also approved to treat bipolar disorder. This drug is more effective than lithium in treating rapid-cycling bipolar disorder. Blood levels of valproate must be monitored regularly because high levels can be toxic. Common side effects of valproate include the following:
- Dizziness
- Drowsiness
- Nausea
- Tremor
Long-term effects include weight gain and possible liver dysfunction. Patients with liver disease should not take this medication.
Carbamazapine is also an antiseizure drug. Although not approved by the FDA for the treatment of bipolar disorder, it can be used to control mania and depression in patients with the disorder. Common side effects include the following:
- Dizziness
- Drowsiness
- Nausea and occasional vomiting
- Rash
Long-term effects include reduced white blood cell count (leukopenia) and liver dysfunction. Patients who have liver disease should not take this drug. Blood levels of carbamazapine are monitored regularly.
Carbamazepine may cause birth defects and pregnant women should discuss the risks of taking the drug during pregnancy with their health care providers. Carbamazepine may cause oral contraceptive (i.e., birth control pill) failure. To avoid becoming pregnant, another form of birth control should be used while taking the drug.
Antipsychotic medications (e.g., olanzapine [Zyprexa®]) can be used to treat psychosis when it occurs in a manic episode. Symbyax® combines olanzapine with fluoxetine hydrochloride (the active ingredient in Prozac®) to treat bipolar disorder. Antipsychotic medications may cause serious long-term side effects (e.g., tardive dyskinesia) and should be used at the lowest effective dose and discontinued as soon as symptoms resolve.
Patients taking antipsychotic medications should be evaluated periodically to assess the need for maintenance therapy (see treatment of schizophrenia). Side effects include the following:
- Blurred vision
- Drowsiness
- Dry mouth
- Weight gain
Ziprasidone (Geodon®) is an antipsychotic medication that recently has been approved by the FDA to treat manic episodes. This medication, which also is used to treat schizophrenia, is prescribed at higher doses to treat bipolar disorder. Side effects include the following:
- Constipation
- Cough
- Diarrea
- Difficulty swallowing
- Extreme tiredness
- Increased or decreased body temperature
- Low blood pressure (dizziness, increased heart rate, fainting)
- Muscle spasms
- Nausea
- Seizures
Studies indicate that ziprasidone may cause fewer side effects (e.g., weight gain, movement disorders) than other medications.
Benzodiazepines are used to treat anxiety or agitation during a manic episode.
Risperidone (Risperdal®) has been approved by the Food and Drug Administration (FDA) as short-term treatment for acute mania associated with bipolar I disorder. This drug, which also is used to treat schizophrenia, may be used alone (called monotherapy) or in combination with lithium or valproate.
Side effects include the following:
- Agitation
- Anxiety
- Dizziness
- Excessive sleepiness (somnolence)
- Headache
Aripiprazole (Abilify®) is a dopamine partial agonist that was approved by the FDA in 2002 to treat acute mania or mixed episodes in adults who have bipolar I disorder. In February 2008, this drug was also approved for use in pediatric patients between the ages of 10 and 17.
Patients who are taking aripiprazole should be monitored closely for unusual changes in behavior, worsening of symptoms, and suicidal tendencies. Side effects include nausea and vomiting, constipation, headache, dizziness, and insomnia. In children, common side effects include excessive sleepiness (somnolence) and headache. Elderly patients with dementia disorders are at higher risk for severe side effects and death.
Acute Treatment of Depressive Episode
Treating the depressive episode in bipolar disorder is controversial for two main reasons. First, antidepressant medication may send a person into a manic or hypomanic episode. Second, antidepressants may cause rapid cycling. A person may recover more quickly from depression, but may experience the next episode sooner.
To reduce these risks, most psychiatrists prescribe mood stabilizers (e.g., lithium, valproate) in combination with antidepressants. Once the symptoms of the depressive episode resolve, the dosage of the antidepressant medication is tapered down over several weeks and finally discontinued.
If psychotic symptoms are present during an acute depressive episode, antipsychotic medication is prescribed. This medication is not used for maintenance therapy because of serious side effects that develop over the long term.
Otherwise, treating an episode of depression in bipolar disorder is the same as major depressive disorder (see treatment of depression).
Chronic Treatment (Prophylaxis) of Bipolar Disorder
Once bipolar disorder is diagnosed, it is necessary to continue treatment indefinitely. Various mood stabilizers are typically used for continual treatment, alone or combined. In some cases, an antidepressant or antipsychotic drug is used in the combination.
Patients require lifelong lithium therapy to prevent relapses. When lithium treatment stops, relapses occur within 6 months in 90% of patients, and subsequent lithium treatment and other treatments are less likely to be effective.
Chronic treatment with more than one type of medication requires close monitoring to ensure that the proper concentrations of the drugs are maintained and to make any necessary adjustments (e.g., change medications or dosages) to alleviate side effects.
Ongoing psychotherapy is necessary for the following reasons:
- Ensures compliance with the schedule of medication
- Helps patients deal with effects of the disorder on their social and work relationships
- Helps patients maintain a positive self-image
Support groups are beneficial for patients, their families, and close friends. Patients receive encouragement, learn coping skills from others, share their concerns, and feel less isolated. Family members and friends acquire a better understanding of the illness, share their concerns, and learn how to support their loved ones.
Hospitalization
Hospitalization is required for severe episodes of mania and depression to protect patients from injuring themselves or others.
Electroconvulsive therapy (ECT) is used primarily as an acute treatment for hospitalized patients who are suicidal, psychotic, or dangerous to others. It is effective in nearly 75% of patients who undergo this treatment. Receiving ECT during pregnancy is considered safe.
Bipolar Disorder (Manic Depression) (continued...)
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