Treatment

Specific Drugs and Other Treatments Used in Bipolar Disorder

The following are the treatment options for most patients with bipolar disorder, depending on the bipolar disorder phase or episode. Patients should understand that, even with aggressive therapy, either mania or depression recurs in almost three-quarters of patients.

Drugs Used in Bipolar Disorder. Mood stabilizing drugs are the mainstay for patients with bipolar disorder. They are defined as drugs that are effective for acute episodes of mania and depression and that can be used for maintenance. The standard first-line mood stabilizers are lithium and valproate. Both drugs stimulate the release of the neurotransmitter glutamate, although they appear to work through different mechanisms. Other drugs may also be used.

• Lithium. Lithium has been used for years for bipolar disorder. It remains the best drug for people with pure mania characterized by euphoria and pure depression. Although imperfect, it is also an effective long-term drug for many patients with other bipolar subtypes.
• Antiseizure Drugs. Valproate (valproic acid) is an anti-seizure drug that works well for many patients with mania, rapid-cycling, and mixed states, as well as for patients who are substance abusers. Carbamazepine (Tegretol, Carbatrol, Equetro) or oxcarbazepine (Trileptal) is usually the second anti-seizure medication of choice. Lamotrigine (Lamictal), a newer antiseizure drug, is proving to be an effective mood-stabilizer and may work better for depressive episodes than lithium. It appears to be particularly helpful for patients with rapid cycling and bipolar II disorder, in whom depression remains problematic after taking other mood stabilizers. Other anti-seizure drugs used or investigated for bipolar include gabapentin (Neurontin), zonisamide (Zonegran) and topiramate (Topamax). To date, it is not clear if any of these newer drugs are useful for the treatment of acute mania.
• Atypical Antipsychotics. Drugs known as atypical antipsychotics are used to treat schizophrenia and also have mood stabilizing properties that are applicable to bipolar disorder. They may be used either alone or in combination with lithium or valproate. Clozapine (Clozaril) was the first of these drugs, but it has not yet been approved for treatment of bipolar disorder. The newer atypical antipsychotics include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and ariprazole (Abilify). These five drugs have all been approved for treatment of bipolar mania and, with the exception of quetiapine, mixed episodes. Quetiapine is approved for treatment of both manic and depressive states. Olanzapine is the only atypical approved for bipolar maintenance treatment. A combination olanzapine and fluoxetine drug (Symbyax) is also approved for treatment of bipolar depression.