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Bipolar disorder

Highlights

What is Bipolar Disorder?

Bipolar disorder is a type of mental illness. It usually develops in a person's mid-teens or early adult years but can affect people of all ages. With proper treatment, many patients are able to control their mood swings. Untreated bipolar disorder can lead to many serious problems, including substance abuse, financial crises, interpersonal difficulties, and increased risk of suicide.

Bipolar Disorder Symptoms

In bipolar disorder, manic symptoms alternate with depressive symptoms. Manic symptoms include:

Diagnosis

Bipolar disorder is diagnosed based on specific criteria defined by the American Psychiatric Association. There are several different types of bipolar disorder.

Treatment

Bipolar disorder is treated with mood stabilizing drugs. They include:

Many of these drugs are used in combination with one another. Side effects vary depending on the drug. Some of these drugs are not safe for pregnant women or should be used with caution.

Psychotherapy is an important component of treatment. Other types of therapies (like electroconvulsive therapy) may also be used.

Drug Approval

The depressive episodes of bipolar disorder can be very difficult to treat. In 2013, the FDA approved the atypical antipsychotic lurasidone (Latuda) for treatment of bipolar depression in adults.

New Diagnostic Criteria

In 2013, the American Psychiatric Association (APA) released the revised edition of its diagnostic manual for psychiatric conditions. Among the changes for bipolar disorder:

Introduction

Bipolar disorder, formerly called manic-depression, is a mental illness characterized by periods of extreme moods that swing between two opposite poles:

Types of Bipolar Disorder

The American Psychiatric Association classifies bipolar disorder according to the pattern and severity of the symptoms. The main types of bipolar disorder are:

Specifiers

A bipolar classification can also have a "specifier" to describe certain features specific to that patient's condition.

For example, a patient with bipolar I disorder may have a manic episode "with mixed features" to describe episodes of mania accompanied by severe depression. Similarly, a patient with bipolar II disorder who experiences depression accompanied by mania or hypomania is described as having a depressive episode "with mixed features."

The specifier "with anxious distress" is used to describe patients who experience symptoms of anxiety that are not part of the bipolar diagnostic criteria.

Causes

The exact causes of bipolar disorder are unknown. It is likely due to a combination of biochemical, genetic, and environmental factors.

Neurotransmitters (chemical messengers in the brain) that may be associated with bipolar disorder include dopamine, serotonin, and norepinephrine.

Multiple genes, involving several chromosomes, have been linked to the development of bipolar disorder. Research increasingly indicates that bipolar disorder may also share genetic factors with other disorders such as schizophrenia, epilepsy. It is not clear if some of these disorders are variations of a single disease or separate disorders.

For people who have a genetic or biochemical predisposition for bipolar disorder, environmental factors (such as stressful life events or emotional trauma) may play a role, in combination with other factors, in triggering bipolar episodes.

In certain instances, bipolar symptoms can be caused by substance abuse, medication reactions, or some medical conditions (such as systemic lupus erythematosus or stroke).

Risk Factors

Age

Bipolar disorder usually first occurs between the ages of 15 to 30 years, with an average age of onset at 25 years. However, bipolar disorder can affect people of all ages, including children. Bipolar disorder that occurs late in life often accompanies medical and neurological problems (particularly cerebrovascular disease, such as stroke). It is less likely to be associated with a family history of the disorder than earlier-onset bipolar disorder.

Gender

Bipolar disorder affects both sexes equally, but there is a higher incidence of rapid cycling, mixed states, and cyclothymia in women. Early-onset bipolar disorder tends to occur more frequently in men and it is associated with a more severe condition. Men with bipolar disorder also tend to have higher rates of substance abuse (drugs, alcohol) than women.

Family History

Bipolar disorder frequently occurs within families. Family members of patients with bipolar disorder are also more likely to have other psychiatric disorders. They include schizophrenia, schizoaffective disorder, anxiety disorders, ADHD, and major depression.

Complications

Other Psychiatric Illnesses

Many patients with bipolar disorder often have accompanying psychiatric disorders. They include:

Anxiety and eating disorders are often associated with depressive mood states, while substance abuse more frequently accompanies manic symptoms. Although drug and alcohol abuse may be a form of self-medication, substance abuse can trigger or worsen bipolar symptoms.

Medical Illnesses

People with bipolar disorder often suffer from migraine headaches. They are also more likely than people without this disorder to have metabolic syndrome, a cluster of symptoms that includes abdominal obesity, unhealthy cholesterol and triglyceride levels, high blood pressure, and insulin resistance. Metabolic syndrome can increase the risk for type 2 diabetes, heart disease, and stroke. Some research suggests there may be an underlying genetic link between metabolic syndrome and bipolar disorder.

Patients with bipolar disorder that is not well controlled may not have routine medical care and health screenings, and thus face an increased risk for dying from heart disease and cancer. Smoking, drinking, and other forms of substance abuse can also lead to medical problems (such as heart disease, cirrhosis, and malnutrition). In addition, certain medications used to treat bipolar disorder can cause weight gain, metabolic disorders, and heart problems.

Behavioral and Emotional Complications

A small percentage of bipolar disorder patients demonstrate heightened productivity or creativity during manic phases. More often, however, the distorted thinking and impaired judgment that are characteristic of manic episodes can lead to dangerous behavior including:

Such behaviors are often followed by low self-esteem and guilt, which are experienced during the depressed phases. During all stages of the illness, patients need to be reminded that the mood disturbance will pass and that its severity can be diminished by treatment. Manic episodes also affect a patient's family members and social circle and can create difficulties and tensions in interfamily and interpersonal relationships, as well as the workplace.

Both the depressive as well as manic phases of bipolar disorder can have a significant negative impact on a patient's ability to function.

Prognosis

Bipolar disorder can be severe and long-term, or it can be mild with infrequent episodes. Patients with the disease may experience symptoms in very different ways. A typical patient with bipolar disorder averages 8 to 10 manic or depressive episodes over a lifetime. However, some people experience more and others fewer episodes.

Patients with bipolar disorder generally have higher death rates from suicide, heart problems, and death from all causes than those in the general population. Patients who get treatment, however, experience great improvement in survival rates.

Typical Bipolar Cycles

In most cases of bipolar disorder, the depressive phases outnumber manic phases, and the cycles of mania and depression are neither regular nor predictable. Patients can also experience states in which both mania and depression coexist. With treatment, many people are able to have long periods living free of symptoms, although they may still experience intermittent episodes. Treatment can also help reduce the severity of symptoms when they do occur.

Rapid Cycling

About 15% of patients with the disorder have a temporary complicated phase known as rapid cycling. With this phase the manic and depressive episodes alternate at least four times a year and, in severe cases, can even progress to several cycles a day. Rapid cycling tends to occur more often in women and in those with bipolar II. Typically, rapid cycling starts in the depressive phase, and frequent and severe episodes of depression may be the hallmark of this event. This phase is difficult to treat, particularly since antidepressants can trigger the switch to mania and set up a cyclical pattern.

Differences Between Children and Adults

Research suggests that symptoms of bipolar disorder in children and adolescents differ from those of adults. While adults with bipolar disorder usually have distinct and persistent periods of mania and depression, children with bipolar disorder fluctuate rapidly in their mood and behavior. Mania in children is characterized by irritability and belligerence whereas adults tend to experience euphoria. Children with bipolar depression are frequently angry and restless, and may have additional mood and behavioral disorders such as anxiety, attention deficit hyperactivity disorder, conduct disorder, and substance abuse problems.

It is not yet clear how often childhood bipolar disorder persists into adulthood or if treating childhood bipolar disorder can help prevent future illness.

Symptoms

Symptoms of bipolar disorder tend to fluctuate dramatically between two extremes: mania and depression. Sometimes a patient may have an episode in which both symptoms of mania and depression are present at the same time. This is called a "mixed state."

Symptoms vary among patients. The types of symptoms experienced also depend on the type of bipolar disorder. Patients with bipolar I disorder typically have severe manic episodes that alternate with shorter bouts of depressive symptoms. Patients with bipolar II disorder, experience longer periods of depression that alternate with manic episodes that are shorter in duration and less severe (hypomania) than those associated with bipolar I disorder.

Symptoms of Mania

Symptoms associated with manic episodes include:

Symptoms of Depression

The symptoms of depression experienced in bipolar disorder are almost identical to those of major depression, the primary form of unipolar depressive disorder. They include:

Diagnosis

Doctors diagnose bipolar disorder based on criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). These criteria include the presence of mania and depression, how frequently these symptoms occur, and how often they last.

A major difficulty with a diagnosis of bipolar disorder is the tendency for a patient to be unable to recognize his or her own condition, particularly when in the manic state. Patients often deny their symptoms, which may be perceived as positive feelings. The doctor should take a careful and complete history of any and all episodes of depression, mania, or both.

Ruling out Similar Conditions

When making a diagnosis of bipolar disorder, it is important that the doctor rule out other conditions that may be causing symptoms similar to bipolar disorder.

Depression

Bipolar disorder needs to be distinguished from unipolar disorder, which is clinically referred to as major depressive disorder. The main difference between bipolar and unipolar depression is that a person with unipolar depression does not experience any episodes of mania. An accurate diagnosis is critical because patients with bipolar disorder who are inappropriately medicated solely with antidepressants (without also taking a mood stabilizer) have a serious risk of switching to manic or rapid cycling symptoms.

Anxiety Disorders

Certain symptoms of anxiety disorders, such as racing thoughts, can resemble those of bipolar disorder. It is also possible for patients to have both bipolar and anxiety disorders.

Attention-Deficit Hyperactivity Disorder (ADHD)

Children or adolescents with bipolar disorder may be inappropriately diagnosed with attention-deficit hyperactivity disorder. ADHD and bipolar disorder can both often cause inattention, distractibility, and racing speech.

Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a new condition included in the latest edition of the diagnostic manual of the American Psychiatric Association (APA). One of the APA's goals in creating this category was to prevent the misdiagnosis of bipolar disorder in children who may actually have DMDD.

Children with DMDD have severe and constant temper outbursts. In contrast, children with bipolar disorder have intermittent irritability that is associated with episodes of mania and depression. Children with DMDD do not go on to develop bipolar disorder, but they are at increased risk for later developing major depression or anxiety disorders.

Schizophrenia

Psychotic features (such as delusions and hallucinations) that are predominant in schizophrenia can also occur with bipolar II disorder. However, with schizophrenia, these symptoms are usually present without mood-related symptoms.

Substance Abuse and Medications

Drug and alcohol abuse, and certain medications, can trigger manic symptoms that resemble those of bipolar I disorder. In addition, people with bipolar disorder often abuse drugs and alcohol. A diagnosis of bipolar disorder can be established if symptoms remain even though the substances are no longer being used.

Laboratory Tests

Patients should be tested for drugs or alcohol if the doctor suspects that they have been using these substances. Blood tests for thyroid function should also be performed. Symptoms of overactive thyroid (hyperthyroidism) can mimic mania, while those of underactive thyroid (hypothyroidism) can be associated with depression.

Diagnosis in Children

The number of children diagnosed with bipolar disorder has increased dramatically during the past decade and there is concern that children are being overdiagnosed with the condition. Part of the controversy concerns the diagnostic criteria used for children and adolescents. Some bipolar symptoms, such as irritable mania, share characteristics with common childhood anger outbursts or behavioral disorders such as conduct disorder and attention deficit hyperactivity disorder. In addition, many children with bipolar disorder also have behavioral and developmental disorders. These overlapping conditions can complicate diagnosis.

The American Academy of Child and Adolescent Psychiatry (AACP) recommends that doctors use specific screening questions to diagnose bipolar disorder. These questions are designed to evaluate periods of mood changes associated with sleep disorders and restlessness. Doctors should also ask about family histories of mood disorders. The AACP cautions that the validity of diagnosing bipolar disorder in children younger than 6 years old has not been established.

Bipolar disorder is treated with powerful psychiatric drugs that can cause serious side effects. It is very important to make sure that a child's symptoms are due to bipolar disorder, rather than emotional or behavioral issues, before prescribing these medications.

Treatment

Bipolar disorder is a recurrent disease that can be unpredictable. It is treatable, however, and many patients have healthy and productive lives. The major goals of treatment are to:

Challenges of Bipolar Treatment

The treatments for bipolar disorder, while very effective, pose some specific challenges for the patient:

Specific Drugs and Other Treatments Used in Bipolar Disorder

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. Drugs to treat bipolar disorder should be prescribed and managed by a psychiatrist.

The following are some of the standard drugs used for treatment of bipolar disorder:

These drugs may be used singly or in various combinations. Other drugs, such as typical 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 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.

Step 3. Addition of Other Treatments

Other treatments may be added to speed recovery, treat any psychosis, and achieve remission:

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.

Step 5. Continuation of Mood Stabilizers

Mood stabilizers are typically continued for about 8 weeks, unless the patient shows signs of shifting to another mood state. If the patient remains stable at that time, the doctor may decide to continue maintenance treatment or to gradually withdraw medications.

Treatment for Depressive Episodes

Depressive episodes are a particular challenge because many antidepressant drugs pose a risk for triggering mania. It is not clear if standard antidepressants work for bipolar depression. Depressive episodes are very difficult to control and patients who do not respond to mood stabilizers may endure prolonged depressive episodes up to 2 to 3 months.

Lithium or lamotrigine are the standard first-line treatments for depressive episodes. Many studies indicate that lithium works better for controlling manic states, and that lamotrigine works better for bipolar depression.

If improvement does not occur within 2 to 4 weeks, an antidepressant may be added. Antidepressants alone are not recommended. The first choices for antidepressants are bupropion (Wellbutrin, generic) or a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac, generic).

Other drugs are also approved specifically for treatment of bipolar depression. Symbyax combines the atypical antipsychotic olanzapine with the SSRI antidepressant fluoxetine. Quetiapine (Seroquel, generic) is an atypical antipsychotic which is approved for both treatment of bipolar mania and bipolar depression. Lurasidone (Latuda) is an atypical antipsychotic approved in 2013 for treating adults with depression associated with bipolar I disorder. It can be used either alone or in combination with lithium or valproate.

Other Treatments

Cognitive-behavioral therapy or other psychotherapy programs may help patients cope with depressive episodes by developing ways to manage negative thoughts and behaviors. Electroconvulsive therapy is another treatment option for severe depression.

Treatment for Maintenance

Drugs Used During Maintenance

Relapse occurs in most patients after treatment of acute attacks, and patients who are at high risk for recurring episodes should consider life-long maintenance therapy. This usually involves mood-stabilizing drugs:

The general recommendations for maintenance therapy with lithium are as follows:

Treatment for Rapid Cycling

The first step in treating rapid cycling is to try to identify and resolve other factors, such as drug abuse or hypothyroidism (underactive thyroid), which may have caused this condition. Antidepressants, particularly SSRIs, may contribute to rapid cycling and are usually tapered off.

Rapid cycling can be challenging to control and there is no consensus on how which drugs are most effective in treating it. Patients may need to try different medications to see what works.

In general, lithium and valproate are the first-line treatments for rapid cycling associated with bipolar I disorder, and lamotrigine for bipolar II disorder. Atypical antipsychotics such as aripiprazole, olanzapine, and quetiapine may also be tried. Electroconvulsive therapy may be useful in some situations.

In addition, other measures should be taken:

Treatment for Pregnant Patients

Treatment of pregnant women with bipolar disorder poses specific challenges. All psychiatric medications can cross the placenta into amniotic fluid. These drugs can also enter breast milk. While certain types of medications present more risks to the fetus than others, not taking medications also carries substantial risks. Untreated women may be less likely to receive appropriate prenatal care, and more likely to engage in risky behaviors, including alcohol and tobacco use. Non-treatment may also cause difficulties with mother-infant bonding and disruptions in the family environment.

A woman with bipolar disorder who is considering pregnancy should consult with her gynecologist/obstetrician, psychiatrist, and primary care physician. Close follow-up with all of these providers should take place during the pregnancy.

The American College of Obstetricians and Gynecologists (ACOG) has guidelines for psychiatric drug treatment during pregnancy:

For antiseizure drugs, valproate should not be used during the first trimester of pregnancy, if possible. Valproate is specifically associated with neural tube, craniofacial, and heart birth defects as well as growth delay and cognitive impairment. Carbamazepine may also increase facial malformation but, like lamotrigine, is considered a safer drug than valproate for use during pregnancy.

For atypical antipsychotics, safety data is limited and there have been no long-term studies on the effects of children exposed to these drugs during pregnancy. Some studies indicate that these drugs can increase the risk of low birth weight. In general, doctors do not recommend the routine use of atypical antipsychotics during pregnancy.

For antidepressants, doctors decide on the appropriateness of these drugs on a case-by-case basis. The SSRI paroxetine should be avoided by women who plan on becoming pregnant as this drug significantly increases the risk of fetal heart defects. Other SSRIs are generally considered safe for use during pregnancy and breastfeeding.

Treatment for Children and Adolescents

Doctors are still trying to decide the best treatment approaches to bipolar disorder in children and adolescents. The drugs used for bipolar disorder have considerable side effects, which may be more severe in young people. Parents should consider the potential risks and benefits of treatment for their children.

Lithium is generally used as the first-line treatment, with valproate or atypical antipsychotics as alternatives. If treatment with a single drug does not work, a combination of drugs may be used. For atypical antipsychotic drugs, risperidone (Risperdal, generic), aripiprazole (Abilify), quetiapine (Seroquel, generic), and olanzapine (Zyprexa, generic) are approved for the treatment of mania in children and adolescents with bipolar disorder.

When prescribing atypical antipsychotics to children and adolescents, the benefits of treatment must be weighed against the potential harms of side effects. Atypical antipsychotics can increase the risk for weight gain and type 2 diabetes, heart problems, increased prolactin levels, sedation, and movement disorders (extrapyramidal side effects). Doctors need to carefully monitor pediatric patients for potential development of any of these side effects.

Psychotherapy is also an important addition to drug treatment. Therapy that includes the entire family is important. Electroconvulsive therapy (ECT) may benefit adolescents who have not been helped by medication.

Medications

Lithium

Lithium (Eskalith, Lithobid, generic) is the most widely used and studied mood stabilizing drug for bipolar disorder. Lithium is extremely helpful for most patients. It can help control symptoms of mania and prevent recurrent manic episodes. It can also help treat bipolar depression and reduce suicide risk.

Administration of Lithium

Lithium may take several weeks to become fully effective, so patients should not expect an immediate response during an acute episode.

Side Effects

Mild nausea and diarrhea are common initial side effects of lithium that usually go away after a few weeks. Long-term side effects may include:

Lithium blood levels should be monitored regularly to determine the best dosage and to prevent lithium toxicity. In addition, the doctor needs to monitor the patient's kidney and thyroid function. Lithium can cause low thyroid levels (hypothyroidism), which can affect mood and may lead to rapid cycling. Some patients need to take thyroid medication while on lithium.

If lithium levels in the blood are too high, lithium toxicity (overdose) can occur. Signs of toxicity include diarrhea, dizziness and nausea, vomiting, slurred speech, and tremors. At very high blood levels, severe lithium toxicity can cause kidney failure, psychosis, and coma.

Drug Interactions

Because lithium is eliminated from the body by the kidneys, any drugs or dietary factors that reduce kidney function may increase lithium blood levels and should be used with great caution. Such drugs include:

Some of these drugs can worsen lithium side effects.

Valproate and Other Antiseizure Drugs

Antiseizure drugs, also called anti-epileptics or anticonvulsants, affect the neurotransmitter gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. They are used for treating epilepsy, bipolar disorder, and other medical conditions. These drugs may be an alternative for patients who do not tolerate or respond to lithium. They also may be used in combination with lithium, atypical antipsychotics, or other drugs.

Standard Antiseizure Drugs.

Side Effects

These drugs have a number of side effects that vary depending on the specific drug, the dosage, and duration of use. Most side effects occur early in therapy and then subside. Some of the most common side effects are upset stomach and weight gain. Less common side effects include dizziness, hair thinning and loss, and difficulty concentrating.

Very serious side effects are possible. Antiseizure drugs can increase the risk for suicidal thoughts and behavior as soon as 1 week after starting drug therapy. This risk can continue for at least 6 months. All patients who take these drugs should be monitored for worsening depression or unusual changes in behavior.

Stevens-Johnson syndrome (SJS) is a rare but severe and potentially life-threatening, rash that can develop as a side effect of carbamazepine, lamotrigine, oxcarbazepine and other anticonvulsants. Because this is a very serious condition, these drugs are discontinued at the first sign of rash. The risk of serious skin reactions is 10 times higher for patients of Asian ancestry than Caucasians. The FDA recommends that people of Asian ancestry get a genetic test before starting carbamazepine to determine if they are at risk for this side effect.

Other serious side effects, also rare, may include liver damage, aseptic meningitis (with lamotrigine), convulsions, coma, and pancreatitis.

Antiseizure drugs can increase the risk for birth defects if taken during pregnancy. Valproate carries the highest risk for causing birth defects and should be avoided, if possible, during the first trimester.

Atypical Antipsychotics

Atypical antipsychotics are standard drugs for schizophrenia. They are also used to treat bipolar disorder alone or in combination with the mood stabilizers that treat mania.

Antipsychotic medications are generally categorized as either "typical antipsychotics" or "atypical antipsychotics." Typical antipsychotics are older medications, which were first developed in the 1950s. Atypical antipsychotics are newer medications that first became available in the 1990s; new ones are still being developed. Atypical antipsychotics are sometimes referred to as "second-generation" to distinguish them from the older "first-generation" typical antipsychotics.

Atypical antipsychotics approved for treatment of bipolar disorder include:

Side Effects

Side effects vary depending on the specific drug but can include:

The following are more severe side effects or complications that may occur with atypical antipsychotics:

Diabetes Risk and Atypical Antipsychotics

All atypical antipsychotics can increase the risk of high blood sugar (hyperglycemia) and type 2 diabetes. (Olanzapine is more likely to cause high blood sugar levels than other atypical antipsychotic medicines.) The FDA recommends that:

Antidepressants

Lithium or lamotrigine (Lamictal, generic) are usually the first choices for treating depressive episodes in bipolar disorder. Antidepressants are sometimes used, but their use is controversial. They may trigger mania in some patients, more so those with depression associated with bipolar I than bipolar II disorder. In addition, a number of studies report no additional benefits from antidepressants.

Specific antidepressants may be beneficial in certain circumstances, especially when prescribed in combination with a mood stabilizer medication. However, any patient on antidepressants who develops symptoms of hypomania should stop taking these drugs (under the care of a doctor), since hypomania is often a sign of impending mania.

Bupropion

The antidepressant bupropion (Wellbutrin, generic) appears to pose a lower risk for triggering mania than do other antidepressants. Side effects may include restlessness, agitation, sleeplessness, headache, rashes, stomach problems, and in rare cases, hallucinations and bizarre thinking. Bupropion has also been associated with changes in behavior, hostility, agitation, and suicidal thoughts and behaviors. Initial weight loss occurs in many patients. High doses may cause seizures. This side effect is uncommon and tends to occur in patients with eating disorders or those with risk factors for seizures.

Selective Serotonin Reuptake Inhibitors

Serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, generic), citalopram (Celexa, generic), sertraline (Zoloft, generic), and paroxetine (Paxil, generic), are sometimes used to treat bipolar depression, but their benefits have not yet been fully established. They may be useful in patients whose depression does not respond to lithium alone.

Side effects of SSRIs may include:

Other Treatments

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a non-drug treatment for bipolar disease and other mental disorders, such as severe depression. It is commonly called shock therapy. ECT has received bad press since it was introduced in the 1930s. But over the years it has been refined, and is now considered a very safe treatment.

Research suggests ECT may be particularly beneficial for:

The Procedure

ECT is performed on an outpatient basis and does not require hospitalization. In general, the ECT procedure is performed as follows:

Side Effects

Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness, and heart disturbances. Concerns about permanent memory loss appear to be unfounded.

The ECT procedure affects heart rate and blood pressure. Doctors should perform a medical evaluation of patients before they receive ECT. Patients, (especially those who are elderly), who have high blood pressure, atrial fibrillation, asthma, or other heart or lung problems may be at increased risk for heart-related side effects.

Psychotherapy and Lifestyle Changes

Psychotherapy is an important addition to medication. There are many approaches. Trained mental health professionals can:

In addition, psychotherapy can help patients:

Cognitive-Behavioral Therapy

Therapists trained in cognitive-behavioral therapy (CBT) may be particularly helpful for many patients. CBT is a structured, conscious method that aims to help a patient recognize negative thoughts and behavioral patterns and to change them. CBT is known to be helpful for other mood disorders, including depression and anxiety, and some studies suggest that it benefits patients with bipolar disorder as well.

Typical goals of CBT for patients with bipolar disorder patients include:

Interpersonal and Social Rhythm Therapy

Interpersonal problems (such as family disputes) and disruptions in daily routines or social rhythms (such as loss of sleep or changes in meal times) may make people with bipolar disorder more susceptible to new episodes of mania. A form of psychosocial treatment called interpersonal and social rhythm therapy (IPSRT) focuses on maintaining a regular schedule of daily activities to reduce these potential triggers and improve emotional stability. Patients also learn how to avoid problems with personal relationships.

Family Therapy

It is important that partners, family members, or both be involved in therapy. Therapy can help them learn how to accept and cope with the condition.

Support for the Patient

Recommendations for supporting the patient include:

Support for the Family

Bipolar disorder can take a serious toll on family members. Loved ones must also learn to care for themselves and reduce the stress that accompanies the illness. Support groups can be very helpful for sharing education about the illness, treatment information, and advocacy resources.

Lifestyle Factors

Exercise

Exercise can help manage weight gain, relieve stress, and increase feelings of well-being.

Sleep Management

Good sleep hygiene is particularly important for patients. Techniques used to enforce healthy sleep may help reduce mood cycling.

Diet

A healthy diet low in saturated foods and rich in whole grains, fresh fruits, and vegetables is important for anyone. People with bipolar disorder should be sure to maintain a regular healthy diet. They may need to restrict calories if they are on medications that increase weight.

Some research indicates that consumption of omega-3 polyunsaturated fatty acids found in oily fish (such as mackerel, sardines, salmon, and bluefish) may help reduce the symptoms of a variety of mental illnesses, including bipolar disorder. Researchers are investigating the mental health effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) omega-3 fatty acid supplements.

Resources

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Review Date: 4/21/2016
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