Table of Contents
- 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, generic) carbamazepine (Tegretol, Carbatrol, Equetro, generic), oxcarbazepine (Trileptal, generic), and lamotrigine (Lamictal, generic) are the antiseizure drugs used most often in treating bipolar illness. Other antiseizure drugs used or investigated for bipolar include gabapentin (Neurontin, generic), zonisamide (Zonegran, generic) and topiramate (Topamax, generic). 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, generic) was the first of these drugs, but it is not approved for treatment of bipolar disorder. The newer atypical antipsychotics approved for treating bipolar disorder include olanzapine (Zyprexa), risperidone (Risperdal, generic), quetiapine (Seroquel), ziprasidone (Geodon), ariprazole (Abilify), and asenapine (Saphis).
- Antidepressants. Antidepressants alone are not recommended, but may be used with care for depressive symptoms that do not respond to lithium and antiseizure drugs.. The first choices for antidepressants are bupropion (Wellbutrin, generic) or paroxetine (Paxil, generic). Alternatives include one of the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), a newer antidepressant such as venlafaxine (Effexor, generic), or a monoamine oxidase inhibitor (MAOI).
Such drugs may be used in combination with each other. Additional drugs, such as conventional antipsychotics or anti-anxiety drugs, are used as necessary.
Electroconvulsive Therapy. Electroconvulsive therapy is a treatment that may be helpful for select patients who require stabilization or who have severe mania or depression.
Non-Medical Treatments. In addition to medical treatments, psychotherapy and sleep management are also parts of bipolar disorder treatment. They can help reduce symptoms and prevent relapse.
Treatment Guidelines for Manic Episodes
Step 1. Determine the Need for Hospitalization and Eliminate Triggers. The first step in treating an acute manic episode is to rule out any life-threatening conditions and eliminate any triggers, such as antidepressants or other substances that can elevate moods. Patients often require hospitalization at the onset of acute mania.
Step 2. Control Symptoms of Mania with a Mood Stabilizer. Initiation of a mood-stabilizing drug is the critical first step. It may take several weeks for a mood stabilizer to take effect, and other drugs may be needed.
- Either valproate or lithium is the standard first drug for most manic episodes. Lithium is effective for most hypomanic and manic episodes.
- Carbamazepine may be used in place of valproate to treat patients with multiple manic episodes, mixed episodes, and rapid cycling. Combinations of these mood stabilizers may be used if the patient does not respond to a single drug.
Step 3. Addition of Other Treatments. Other treatments may be added to speed recovery, treat any psychosis, and achieve remission:
- If the patient does not respond fully within a week and symptoms are more severe, antipsychotics may be added to mood stabilizers. Atypical antipsychotics are more likely to be used first. They include olanzapine (Zyprexa), risperidone (Risperdal, generic), quetiapine (Seroquel), apriprazole (Abilify), ziprasidone (Geodon), and asenapine (Saphis). Clozapine (Clozaril) is not generally used because of its potential for severe side effects.
- Older antipsychotic drugs (also called typical antipsychotics), such as haloperidol (Haldol, generic), may be used for acute mania. They may be more likely to cause extrapyramidal effects, which disrupt motor control, and are not generally used on a long-term basis.
- Benzodiazepines, such as clonazepam (Klonopin, generic) or lorazepam (Ativan, generic), are anti-anxiety drugs that may be beneficial if the patient is experiencing severe mania.
- Electroconvulsive therapy. This non-drug treatment may help patients who do not respond to medication.
Step 4. Withdrawal of Some Drug Treatments. In cases of improvement and sustained recovery, the antipsychotic or benzodiazepine drugs are slowly withdrawn and only the mood-stabilizing drug is continued.
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Review Date: 01/28/2011
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine,
Harvard Medical School; Physician, Massachusetts General Hospital.
Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M.,
Inc.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org)
