Treatments for bipolar disorder include medication. They can treat the acute phases of depression or mania, or provide protection form additional periods of depression or mania in the future. Different medicines apply to one or more of these phases of the condition.
That depends on several things. First, are you in a depressed phase or a manic phase or a mixed phase, or are you in a stable, normal mood state at this time? Manic and mixed phases are treated with the same algorithm or decision tree while the depressed phase is treated with a different decision tree. Secondly, how severe and urgent is your current state? The more potent, rapidly acting medicines tend to have a higher risk of side effects. And finally, what has you or your close blood relative’s experience been with previous medicine trials? You are likely to have the same reaction to a medicine that helped or caused side previously. You are more likely to respond to a medicine that helped a close blood relative.
Now I’ll talk more about which medicines are chosen for which phase. If you are in a hypomanic or manic phase with euphoric features, we usually start with an atypical antipsychotic, mood stabilizer(Geodon, Abilify, Risperdal, Seroquel),or another type of mood stabilizer as Depakote, or lithium. If one fails to work or has side effects, we switch to another one in this group. If you have a partial response to one, we may add another one to it to try to get a full response. If this approach fails, we may add or substitute with medicines that have less evidence of effectiveness or more frequent side effects. This group includes Zyprexa, Tegretol, Trileptal, older antipsychotics like Haldol, or Clozaril. For those who have not responded at this point, we may turned to combinations of three medicines or ECT. I will talk more about the specific medications later.
If you are in a mixed phase with hypomanic/manic symptoms and depressed symptoms, especially with more of an irritable versus a euphoric presentation, the algorithm is basically the same as that described above, except lithium and Seroquel are not used in the first stage because of lower effectiveness rates.
If you are in a depressed bipolar phase, the decision tree starts like this. Lamictal is usually the first choice. If you’re already on another anti-manic medicine, Lamictal is added to it. If the patient has an inadequate response or side effects, the next steps go in order. Next is a trial of Seroquel, or Zyprexa with Prozac. Next is a combination of Lamictal, lithium, Seroquel, or Zyprexa/Prozac. Finally comes trials of combinations of the above medicines with medicines that have less evidence of effectiveness in research. These include Depakote, Tegretol, ECT, traditional antidepressants, Mirapex, Trileptal, Inositol, stimulants, and thyroid.
Now I will talk about how I actually choose which medicine to prescribe. If someone comes to me or is brought to me in my outpatient office in a manic state, and if I feel they don’t have to be hospitalized, I will most likely prescribe Geodon. There are several reasons I choose it. It is faster than Abilify or Depakote for calming the mania. It has the lowest risk of weight gain of all the atypical antipsychotics (Abilify, Seroquel, Risperdal, Zyprexa), or the anticonvulsant mood stabilizers (Depakote, Tegretol), or lithium.
Of course, Geodon has its drawbacks. I tell my patients that starting Geodon is like going through an initiation into a sorority or a fraternity. About 25% of my patients have some treatable, temporary, muscle side effects. I described them in detail so the patient can recognize them as side effects if they do occur. I encourage my patients to keep the side effect medicines with them so that if they happen, the side effect pills can take them away in 30 to 60 minutes. Most patients can then continue on Geodon and get the benefits of the Geodon fraternity. If I have to change from Geodon, my order of preference for manic patients is roughly Abilify, Depakote, Risperdal, Seroquel, lithium, Tegretol, and Trileptal.
If a patient is in a mixed phase with mania or hypomania, I generally follow the same protocol I just described for mania. The major differences are two. I often add Lamictal early to help with the depression symptoms. And if the patient has a predominantly dysphoric, irritable, non-euphoric mania, lithium ranks low for effectiveness in this population.
Finally, here is the way I usually handle a bipolar depression. Usually I will start with Lamictal alone. If the patient is already on a mood stabilizer, I’ll usually continue it. If the person is on a typical antidepressant, I will be aiming to get them off it after they are starting to respond to Lamictal. There are several reasons we try to get bipolar patients off atypical antidepressants. These agents can precipitate manic or hypomanic episodes. They have been shown to increase mood instability over longer studies. Additionally, studies have shown that only about 20% of bipolar patients benefit from typical antidepressants without adverse mood consequences.
If Lamictal does not sufficiently relieved the depression or causes side effects, I will often go to Mirapex next. I skip over Seroquel, olanzapine with Prozac, lithium, Depakote, and typical antidepressants because of such frequent problems with weight gain, metabolic risks, sexual side effects, or weak scientific evidence. The evidence for Mirapex’s effectiveness in bipolar depression is growing and its low incidence of weight gain or sexual side effects merits its use. I have used it in over 200 patients in the past two to three years. See my blog for more information regarding Mirapex.
If Mirapex fails or has unacceptable side effects, I then go back and resume the medicines I skipped over. If none of those work out, then I recommend ECT and/or other atypical antipsychotics, stimulants, thyroid, Trileptal, and/or MAOIs.
Augmentation with 1:1 therapy that includes CBT has been proven to help bipolar disorder in numerous studies. Hence, I strongly recommend it in addition to my medication efforts. Many patients find it very helpful and informative to attend the bipolar self-help groups as well.
Bipolar depression patients spend much more time struggling with depression than with mania or hypomania. Bipolar depression responds less often and less completely to treatment than none polar depression. Psychiatrists have extensive training and experience with the most recent advances for more effective and safer medicines to treat bipolar depression episodes and to prevent recurrences.
Are you seeking answers about treatments for Bipolar Disorder?