Let's Talk About Bipolar Disorder Medication
Learning that you have bipolar might feel frightening, but a diagnosis means you can now find some symptom relief—and be on your way to living better.
Many people with mental health conditions fear that they’ll never feel better, but we’re here to tell you can (and will!) as long as you get to a pro and start treatment. For patients with bipolar, doctors typically turn to medication first to stabilize the severe ups and downs associated with the disorder. Once those are under control, continuing with meds can help prevent—or at least lessen—future manic and depressive episodes.
Our Pro Panel
We went to some of the nation's top experts in bipolar disorder to bring you the most up-to-date information possible:
Po Wang, M.D.
Psychiatrist and Clinic Chief
Bipolar Disorders Clinic at Stanford University Department of Psychiatry
Linda Hubbard, L.M.F.T.
Department of Behavioral Health, Psychiatry & Psychology at the Mayo Clinic
Adam Rosenblatt, M.D.
Clinical Director of the Behavioral Health Unit and Geriatric Psychiatry
University of Maryland Upper Chesapeake Health System
Studies have shown that, for reasons experts can’t fully explain, antidepressants are not very effective in treating bipolar depression. In fact, they can make things worse. Antidepressants taken alone (without a mood stabilizer) can sometimes trigger a manic episode. Experts also think that using antidepressants can increase the frequency of manic and depressive episodes over the long term.
Not really. Lithium, Depakote, and Tegretol, three of the most common mood stabilizers prescribed for bipolar, must be discontinued during the first trimester to avoid the risk of birth defects, though they may be able to be used again later in the pregnancy. Electroconvulsive therapy (ECT) is usually the best treatment during pregnancy. Women thinking about getting pregnant should work closely with a psychiatrist and obstetrician to go over the various alternatives.
There’s no hard and fast rule. It bears repeating: Every single person with bipolar will react differently to the drugs prescribed, the combination of those drugs, and at what dosages they’re taken. Working closely with your doctor to experiment with a medication scheme that works for you is crucial. Another thing you and your doctor will want to take into consideration: Your insurance company may cover the cost of some drugs more fully than for others—copays can have as much to do with the prices set by pharmaceutical companies as they do with the effectiveness of the drugs themselves. Your doctor will bring into play her previous experience with the drugs: Did it work well with other patients? Did it have side effects? She can work with you to find what’s best physiologically and financially.
Lithium can be difficult to use. It has what experts call a “narrow therapeutic window,” which means there’s a small difference between a dose that works and a dose that’s toxic, so it requires frequent blood tests. At toxic levels, it can damage your kidneys or your thyroid system, so people who already have conditions affecting those organs should not go on lithium. However, for most otherwise healthy people, it’s often worth trying lithium so long as you can maintain careful monitoring. If that’s not possible for you (because of schedule or cost or simple preference), your doctor will likely lead with other mood stabilizers.
First, Let's Recap What Exactly Bipolar Disorder Is
In bipolar, a person experiences episodes of low moods (depression) and high ones (mania) that are more pronounced than the everyday goods and bads most of us go through.
In fact, in bipolar, these mood swings can make it hard to get through life—you might find yourself struggling in your relationships or at your job or even have trouble handling regular tasks like making dinner, getting to bed on time, or keeping appointments.
In order to be diagnosed with bipolar, you must have had at least one episode of mania or hypomania, a milder form of mania.
Once you’ve got a diagnosis, treatment can make a huge difference, and with bipolar, doctors usually consider medication a main part of that treatment. The right meds can steady the intense shifts from high to low and back again and reduce the severity of your symptoms.
That’s why it’s critical to work with an expert in bipolar medications, particularly when you’re at the treatment starting line. Rather than a primary care doctor, the recommended choice is a psychiatrist or psychiatric nurse practitioner who has experience treating patients with bipolar disorder.
What Are the Typical Medications for Bipolar Disorder?
There are dozens of different drugs, and everybody responds in their own way—so finding the right drug at the right dose can be tricky. It can take a lot of trial and error with various medications, or even a mix of them, to see what gives the best results with the fewest side effects.
That said, there are two main meds classically used for bipolar:
Mood stabilizers. Usually, these are the initial go-to for docs. Researchers haven’t fully pinned down how they work, but a prevailing theory is that this class of drugs calms (in other words, stabilizes) overactive areas of the brain associated with bipolar. Since mood stabilizers can take up to two weeks to kick in—and some docs say that's when the meds just start to work, with full effects at four to six weeks—you may also be given an antipsychotic, which do their thing within a few hours. Which brings us to…
Antipsychotics. These meds are a bit mysterious in terms of how exactly they work, but what we know is they act on your brain’s neurotransmitters (those chemicals, like dopamine and serotonin, that you often hear referred to in discussions about “standard” depression). They might reduce the level of neurotransmitters or blunt their effect—each drug works differently physiologically and on each individual.
What Are the Common Mood Stabilizers?
Sold under the brand names Eskalith, Lithonate, and Lithobid, lithium has age on its side. As the longest-used mood stabilizer, it has historically been the most prescribed for two main reasons:
It’s the most effective mood stabilizer for reducing the severity and frequency of mania and hypomania.
It may help lessen the depression and decrease the risk of suicide.
The downsides to lithium (a.k.a. the potential side effects):
Kidney and thyroid function can be affected. It has what docs call a “narrow therapeutic window,” which means that the drug can go from helpful to harmful very quickly. Hence, you’ll need to be monitored with blood tests every few months to make sure your lithium levels don’t climb too high.
Watching your hydration: It can affect the amount of lithium in your blood, so your doctor will talk to you about how much water and salt you should have every day.
Anticonvulsants were originally used to treat epilepsy—to stop seizures (convulsions). When those patients also reported that their moods seemed more stable, the drugs began to be described for bipolar (and other mood disorders).
Researchers believe they work by allaying the electrical activity in the brain. For patients who don’t do well on lithium—the side effects are too great, or lithium just doesn’t seem to alleviate symptoms—anticonvulsants are likely the next mood stabilizer your doctor will try. Depakote (valproate) is a major drug in this category. While it’s usually less effective than lithium, it’s not as toxic and, hence, no blood tests are needed. If your bipolar is not super severe, doctors may start with Depakote and only move to lithium if Depakote fails to help. Common side effects include nausea, headache, dizziness, and sleepiness.
If neither lithium nor Depakote work—or if the side effects of either prove too difficult for a patient to endure—doctors can try other anticonvulsants. Tegretol (carbamazepine) and Lamictal (lamotrigine) are two common ones. But again: Each drug works slightly differently on the brain, and every brain is unique, so it may take a while to hit that sweet spot of “works best” and “causes the fewest ill effects.”
Mood Stabilizers and Pregnancy
If you’re planning to get pregnant, know this, because it’s critical: Lithium, Depakote, and Tegretol, should not be used during the first trimester, as they have been linked to birth defects; they may be able to be used again later in the pregnancy.
While there is some evidence that Lamictal could be safer, but there’s conflicting research and medical opinions, so do not take anything without consulting your own physician first. Electroconvulsive Therapy (ECT), a non-med treatment option for bipolar, is considered the safest for the pregnant.
How Do Antipsychotics Work?
Because mood stabilizers can be slowpokes, doctors might also prescribe quick-acting antipsychotics to balance the mania or depression (they can work on both) for relief within hours.
Antipsychotics do their thing by blocking the brain receptors for dopamine, a brain chemical that helps regulate thinking, mood, and perception.
Once your bipolar symptoms are under control, the antipsychotic may be able to be cut out, though some people continue to need both meds to stay healthy.
Some patients also respond well to antipsychotics without mood stabilizers—that’s why it’s important to stay in close touch with your doctor to ensure you’ve got the right combination of drugs and the right dosages of the ones you do end up with.
Potential common side effects include drowsiness, constipation, muscles stiffness, blurred vision, dry mouth, and dizziness. But you may or may not have any of these—it all depends on your body chemistry.
Just because someone you know felt constantly tired when taking a certain drug for bipolar doesn’t mean that’ll happen to you. And changing the dosage of a medicine can also lessen (or increase) side effects.
One thing to know: While most antipsychotics can be taken with or without food (try eating something if you tend to get an upset stomach), Geodon and Latuda should always be taken with food; on an empty stomach, they are less bioavailable, meaning less of their active ingredient is absorbed by the body.
How Long Do You Have to Be on Bipolar Medicine?
Real talk here: Treatment with bipolar drugs isn’t temporary. Even if you feel better, you still need to take your medication every day, forever. People who skip their meds are at high risk of relapse. Even a minor mood swing can progress into an all-out manic or depressive episode.
Sometimes, after a while, a medication that worked well for years begins to work not so well anymore. You must carefully monitor your symptoms and side effects and stay in constant contact with your doctor.
Questions to Ask Your Doctor About Your Medication
It’s important to know what you’re putting into your body—especially because this is a long-term thing. Here are a few Qs to bring up at your appointment:
What are the side effects?
Should I report the side effects to you? At what point?
Is there a particular time of day I should take this?
Should I take this with food or on an empty stomach?
Are there any foods or drinks that I should not take while on this?
Does this interact with anything else I’m taking?
What happens if I miss a dose?
If I do miss a dose, what are the side effects and should I call you about them?
How Do I Remember to Take My Bipolar Medication?
As we’ve said, bipolar meds must be taken on a regular basis. But sometimes, no matter how dedicated you are to feeling better, you forget every once in awhile (um, hi, you’re human). The effects of this—and how fast they kick in—are personal and variable, just like your brain.
To stay on track, try these tips:
Use tech. So many people have a smart phone these days, making it easy to set a daily alarm to take your pills. Step it up a notch by downloading a medication app on your phone—search “medication reminder” in the app store. Many will allow you to set reminders at certain times of the day, keep a history on whether or not you’ve taken your pills, and even give you access to information about the drug you take, such as possible side effects and drug interactions.
Keep pills in sight. Don’t tuck those bottles away in the medicine cabinet (which is the worst place they can be anyway—both warmth and moisture are the enemies of most drugs; they might go bad before the expiration date or even become less potent). Stash bottles in easy-to-spot places like next to your coffee maker if you take your meds with breakfast, or on your nightstand if you take them at night. If you have children or pets, keep all bottles sealed tightly in child-proof containers and out of their reach.
Ask a buddy for help. A trusted friend or family member can send you a daily text or call you every night to make sure you remembered your medicine.
- Lithium Treatment: American Journal of Medicine. (2005). “Lithium: Clinical Considerations in Internal Medicine.” amjmed.com/article/S0002-9343(05)01058-2/fulltext
- Lithium Side Effects: Mayo Clinic. (2020). “Lithium (Oral Route).” mayoclinic.org/drugs-supplements/lithium-oral-route/side-effects/drg-20064603?p=1
- Anticonvulsants for Bipolar: Journal of Clinical Psychiatry. (1999). “Anticonvulsant Use in the Treatment of Bipolar Disorder: A Primer for Primary Care Physicians.” ncbi.nlm.nih.gov/pmc/articles/PMC181066/
- Side Effects of Antipsychotics: National Institute of Mental Health. (2016). “Mental Health Medications, Antipsychotics.” nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149866
- Antidepressants and Bipolar: Acta Psychiatrica Scandinavica. (2008). “Long-term antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks.” ncbi.nlm.nih.gov/pubmed/18727689