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Bipolar disorder: Treatment

Treatment for bipolar disorder aims to reduce the severity and number of episodes of depression and mania.

Treatment options for bipolar disorder

If you don't get treatment, episodes can last for between three and six months. Episodes of depression tend to last longer, for between 6 and 12 months.

With effective treatment, episodes usually improve within about 3 months.

Treatment can be with one or more of the following.

Medication

Medication can prevent episodes of mania, hypomania (less severe mania) and depression. These are called mood stabilisers.

Short-term medication can reduce distressing symptoms during an episode. Longer term preventative (prophylactic) medication will reduce the chances of relapse.

Medication will also treat the main symptoms of depression and mania when they occur.

Psychological treatment

Talking therapies can help you deal with depression. They can also give you advice on how to improve relationships and address any unresolved trauma or emotional distress.

Lifestyle advice

Lifestyle advice can include information about:

  • regular exercise
  • planning activities you enjoy that give you a sense of achievement
  • improving your diet
  • getting more sleep

Most people get the most of their treatment without having to stay in hospital.

You may need hospital treatment if your symptoms are severe. You might also need it if you are in hospital involuntarily.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilise mood swings. These are mood stabilisers and include:

  • lithium carbonate
  • anticonvulsant medicines
  • antipsychotic medicines

If you're already taking medication for bipolar disorder and you develop depression, your GP will check the dose. If you aren't taking the right dose, the GP will change it.

Episodes of depression are treated slightly differently in bipolar disorder. This is because the use of antidepressants alone may lead to a hypomanic relapse.

Depression in bipolar disorder can be treated with a mood stabiliser and psychological supports and therapy.

Your GP or psychiatrist may recommend you stop taking medication for bipolar disorder. If so, the dose will be reduced over at least 4 weeks. It can be up to 3 months if you are taking an antipsychotic or lithium.

You may wish to try to gradually stop taking medication. It is always best to do this with professional advice and support. An advanced directive is very useful in this circumstance.

If you have to stop taking lithium for any reason, see your GP about taking an antipsychotic or valproate.

Lithium carbonate

Lithium carbonate is the medication most commonly used to treat bipolar disorder.

It is a long-term method of treatment for episodes of mania, hypomania and depression. It's usually prescribed for at least 6 months.

Stick to the prescribed dose and don't stop taking it suddenly (unless told to by your doctor).

For lithium to be effective, the dosage must be correct. If it's incorrect, you may get side effects such as diarrhoea and vomiting. But tell your doctor immediately if you have side effects while taking lithium.

You'll need regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels aren't too high or too low.

Avoid using non-steroidal anti-inflammatory drugs (NSAIDs) with lithium, unless prescribed by your GP.

Your community pharmacist will advise about all over the counter (OTC) preparations which may interact with lithium. It is always a good idea to attend the same community pharmacy each time you need one.

Lithium and aripiprazole are the only medications given to adolescents over 13 years of age with bipolar disorder.

Unlicensed medicines may be prescribed for children. This is only if there are no suitable alternatives and it can be justified by expert agreement.

Anticonvulsant medicines

Anticonvulsant medicines include:

  • valproate
  • carbamazepine
  • lamotrigine

These medicines are sometimes used to treat episodes of mania. They're also long-term mood stabilisers.

Anticonvulsant medicines are often used to treat epilepsy. But they're also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used. They may also be used with lithium when the condition doesn't respond to lithium on its own.

Valproate

Valproate isn't usually prescribed for women of childbearing age.

This is because there's a risk of physical defects to babies, such as:

  • spina bifida
  • heart abnormalities
  • cleft lip

There may also be an increased risk of developmental problems, such as:

  • lower intellectual abilities
  • poor speaking and understanding
  • memory problems
  • autistic spectrum disorders
  • delayed walking and talking

Your GP may use valproate if there's no alternative. Or if it's unlikely you'll respond to other treatments. They'll tell you about the risks and check you're using reliable contraception.

You'll need to visit your GP to have a blood count when you begin the medication, and then again 6 months later.

Carbamazepine

Carbamazepine is usually only prescribed an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you're taking other medication. This includes the contraceptive pill.

Your liver and kidney function will be checked when you start and after 6 months.

You'll also need to have a blood count at the start and after 6 months. You may also have your weight and height monitored.

Lamotrigine

You'll usually start on a low dose and gradually increase.

See your GP immediately if you're taking lamotrigine and develop a rash. You'll need to have an annual health check, but other tests aren't usually needed.

If you are on the pill, talk to their GP about different methods of contraception

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include:

  • aripiprazole
  • olanzapine
  • quetiapine
  • risperidone

They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be useful if symptoms are severe or behaviour is disturbed. The initial dose may be low, as they can cause side effects. For example:

  • blurred vision
  • dry mouth
  • constipation
  • weight gain

You'll need to have health checks at least every 3 months. These might be more often, particularly if you have diabetes. If your symptoms don't improve, you may be offered lithium and valproate as well.

It is also recommended for moderate to severe manic episodes in adolescents with bipolar disorder.

Rapid cycling

You may need lithium and valproate if you experience rapid cycling. This where you quickly change from highs to lows without a "normal" period in between.

If this doesn't help, you may be offered lithium on its own. Or a combination of lithium, valproate and lamotrigine.

Learning to recognise triggers

You can learn to recognise the warning signs of an episode of mania or depression.

A mental health professional, peer support worker or a close supporter may be able to help you identify your early signs of relapse from your history. Wellness Recovery Action Plans (WRAP) are very useful and your local community mental health team can advise you on how to develop this plan.

This won't prevent the episode from occurring, but it will allow you to get help in time.

This may mean making some changes to your treatment. Your GP or specialist can talk to you about this.

Psychological treatment

Some people find psychological treatment helpful.

This may include:

  • psychoeducation – to find out more about bipolar disorder
  • cognitive behavioural therapy (CBT)
  • family therapy
  • Supportive psychotherapy (counselling)
  • Trauma informed psychotherapy

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of 6 to 9 months.

Pregnancy

Managing bipolar disorder in women who are pregnant or trying to conceive is complex.

The risks of taking medication during pregnancy aren't always that well understood.

The risks of treating or not treating women with bipolar disorder during pregnancy will be discussed. The specialist mental health services will need to work closely with maternity services.

The services will develop a written plan for managing the treatment.

The plan should be drawn up with:

  • patient
  • partner
  • obstetrician
  • midwife
  • GP
  • public health nurse

The following medication isn't routinely prescribed for pregnant women with bipolar disorder:

  • valproate – there's a risk to the foetus and the subsequent development of the child
  • carbamazepine – it has limited effectiveness and there's risk of harm to the foetus
  • lithium – there's a risk of harm to the foetus, such as cardiac problems
  • lamotrigine – there's a risk of harm to the foetus
  • paroxetine – there's a risk of harm to the foetus, such as cardiovascular malformations
  • benzodiazepines – risks during the pregnancy and immediately after the birth

You may become pregnant while taking medication prescribed to treat bipolar disorder. It's important that you don't stop taking it until you've discussed it with your doctor.

If you are prescribed medication after the birth, it may affect your decision to breastfeed. Talk to your pharmacist, midwife or mental health team.

Page last reviewed: 04/10/2018
Next review due: 04/10/2021

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