Medication for Bipolar Disorder: A Foundational Treatment

Living with bipolar disorder is both a process and a journey. It's not simply a state of being that can be arrived at, but a journey filled with intense euphoria and extreme lows, overcome with energetic creativity, and sometimes, steeped in shadows.  For millions of Americans dealing with the disorder, the goal of any treatment plan goes beyond mitigating symptoms; it includes safety and stability, and rebuilding connections, and a sense of self. And at the center of that treatment plan, more often than not, and one of the steps to management, is medication.

It is important to emphasize right off the bat, that medication for bipolar disorder is not a medical "cure" in the way an antibiotic treats an infection. In that regard, when we think of "cure" it is more akin to wearing glasses. Wearing glasses is not a "cure" for your vision; rather, they correct the lens. With glasses on, the world you are seeing is now sharp, and much more manageable, and what was once blurred in vision, is now "clear!" And just like with glasses, a medication regimen ensures your neurochemical pathways are corrected, and that your life, emotions, and thoughts, are much clearer when treated. Remember, you have a indivisible life-long state of illness, and medication is the single best way to make the weeks, months, and years spent in mental wellness not just a wish, but rather a possibility!

The issue of medication is very complicated and each patient is personal. The medication that works like a charm for me, may not work for you. It's not that simple or easy, and that's why we have doctors! Medication is so personalized, like so many things in the world we live in! This is about the collaborative collaboration between you and your psychiatrist. It is continual; adjusting, and fine-tuning.The aim is invariably the same: to find the optimal balance of medications in the smallest viable doses, in order to effectively stabilize mood swings, prevent further episodes, and minimize side effects—all while allowing the person to live a full and productive life.

The Pillars of Treatment: A Brief Look at the Classes of Medications

In the U.S. , the mental health medications used to treat bipolar disorder are numerous, but most medications fall under a few main classes. Each medication plays an important role in soothing the rough waters of the disorder.

Mood Stabilizers: A Base

For bipolar treatment, these are the workhorses of the illness, especially for controlling and preventing manic and hypomanic episodes. To call them "mood stabilizers" is an understatement. The truth is, they are a significant force of regulation for severe mood disturbance.

Lithium: This has been in the psychopharmacon toolbox longer than any others and, in many respects, is the gold standard of the mood stabilizers and proven effective. Discovered in the mid-20th century, lithium is as simple as an element can be, yet it exerted a beneficial effect in the management of bipolar disorder. Lithium is well known to dramatically reduce the frequency and severity of mania as well, it helps to prevent the occurrence of recurrent depression in bipolar disorder. For many individuals witb bipolar disorder, lithium can be a life changing medication. However, lithium treatment requires respect and diligence. Once again, the magnitude of an effective dose of lithium is often close enough to a toxic dose that beneficiaries of lithium treatment must obtain blood tests periodically to ensure their level is therapeutic and safe. For lithium use subject to auditory threshold warning signs, for example, periodic blood monitoring must become non-negotiable and mandatory, as part of responsible treatment protocols.In addition to monitoring the blood levels, it is equally if not more important, for doctors to monitor kidney function and thyroid function over time, too. Many patients say this is more than worth it for the remarkable consistency lithium offers. Lithium use is a distinctly different experience; some may describe what they say is the subtle "dulling" of the highest peaks of joy, that most describe at least initially as a welcome tradeoff for being saved from the horrible despair and erratically high mania that had come to represent their life before the medication. It is not about feeling nothing; it may actually be much broader experience of feeling everything, but in a more sustainable, non-harmful way. 

Anticonvulsant Medications: Anticonvulsants originally developed for seizure disorders (epilepsy) have been found to be effective as mood stablizers. These medications include Valproate (Depakote), Carbamazepine (Tegretol) and Lamotrigine (Lamictal). Anticonvulsants are often used in circumstances when lithium does not work or is not tolerated. Valproate is a great med, and is often the first choice if someone presents in the hospital with an acute manic episode. Lamotrigine is gaining a great deal of attention and reputation for being effective in preventing the potential debilitating depressive episodes associated with bipolar disorder. All medications have varying side effects and require monitoring. Good psychiatrist will always explain the side effects and the required monitoring. Lamotrigine, in particular, requires a slow ramp up for dosage for two reasons, to avoid a serious rash or worse results from taking Lamotrigine. Being patient for ramping up a medication takes patience from everyone. It can be a frustrating waiting game, but everyone who has taken Lamotrigine then describes it as a quiet miracle. It mitigates or extracts the heavy fog of depression without the jittery activation one might experience when taking an antidepressant. In contrast, Valproate and Carbamazepine necessitate the monitoring of blood cells and liver enzymes, along with significant concerns in pregnancy, making the discussion of family planning an integral part of the conversation surrounding treatment.

Atypical Antipsychotic: a Utility Class of Medications

This class of medications has changed the treatment of bipolar disorder in the last several decades. Though the term "antipsychotic" can provoke trepidation,  they are quite useful. They manage acute manic and mixed episodes with incredible effectiveness and can also be used as maintenance therapies. Many have been approved for the treatment of bipolar depression, which increases their utility.

Medications such as Quetiapine (Seroquel), Olanzapine (Zyprexa), Risperidone (Risperdal), Aripiprazole (Abilify), and Lurasidone (Latuda) are commonly used. They target dopamine and serotonin pathways in the brain. Choosing among them often comes down to the psychosocial symptom profile of the individual and level of tolerance of side effects that can include, but are not limited to, weight gain, sedation, and metabolic effects. The decision to use one of these medications is always a careful decision weighing significant benefits against manageable risks. For example, if someone has insomnia and racing thoughts, the sedimentary effect of Quetiapine may have two effects. If another person is concerned about weight gain, Aripiprazole or Lurasidone may rank ahead, especially up front.  This is where the art of psychiatry lies, finding the right medication personality for the person’s life or priorities.  

Antidepressants: A Cautious Evaluation

This is where the treatment of Bipolar Disorder requires particular nuances.For individuals with unipolar depression, the first-line therapy will be antidepressants. But when depression complicates bipolar illness, antidepressants must be used very carefully, and never alone. The main danger is "switching," meaning that an antidepressant can kickstart a manic or hypomanic episode (or quicken the mood cycle), a complaint more formally know as rapid cycling. 

If a psychiatrist feels an antidepressant can be justified in an ongoing depressive episode, it is almost always given alongside a mood stabilizer or atypical antipsychotic agent. The mood stabilizer acts as a counterweight, so the antidepressant does not jettison the patient into mania. This is a key caveat that only an experienced psychiatrist can solidly walk beside you. Additionally, the class of antidepressant matters. An SSRI (e.g., fluoxetine (Prozac) or sertraline (Zoloft)) might be the prescribed agent while other clinician's, some might use bupropion (Wellbutrin) or an SNRI (e.g., venlafaxine (Effexor)), based on either side-effect profile or individual history of medications. This is a fraught routine, as the patient must be hyper-vigilate in telling the prescriber at the first sign of a change in energy, mood, or sleep at the very beginning of treatment.

The Treatment Milieu: Specificizing the Practice

Which medication to use, and when, is largely a function of the current state of the illness. Treatment is not one-size fits all. It's an undergoing, changing process based on the needs of the patient. Addressing an Acute Episode: When someone is in the throes of a significant an episode of mania/depression, the main goal is to get them back to a safe stable baseline as quickly as safely possible. This typically necessitates a short course of medications such as antipsychotics and/or benzodiazepines (for agitation or anxiety) to gain control of the situation. (Inpatient hospitalization is frequently required at this point to ensure safety and begin a treatment plan that can be monitored closely.) The goal is often different, and it is simply more aggressive; the goal is to put out the fire. Dosages are often larger than during the long-term course, typically focused on behavioral control and crisis stabilization rather than overall disposition. So, once the acute storm passes, and the person is safe and stable, the focus transitions to the much messier long-term maintenance work.

Long-Term Maintenance Work: This is the marathon, not the sprint. The goal, here, is to prevent relapse. The work (using a combination of mood stabilizers and/or atypical antipsychotics) is to develop a "prophylactic" shield from future episodes. This will take time, the process is often slow and takes patience. The doctor will use a trial and error to determine the optimal dosage used to minimize dosage and side effects. It is a matter of a little more of this, a little less of that. It is not unusual in establishing maintenance therapy to take upwards of one year or more fine-tuning this dose of medication. A measure of success is not merely the absence of major episodes, but it is overall quality of life. Is the person able to work? Maintain relationships? Have other activities for pleasure? Can they experience a range of emotions without being overwhelmed? These are the true markers of effective maintenance therapy.

The Art of the Combination: It is not uncommon for people with a diagnosis of bipolar disorder to be using more than one medication. The typical regimen is a primary mood stabilizer such as Lithium, or Lamotrigine, possibly also an atypical antipsychotic. This will allow the physician to address different aspects of the illness using different medications, but still use lower dosages of the medications for both effectiveness and side effect relief. For example, a low dose of Lithium may serve as foundational stability while a low dose of Quetiapine works for sleep and anxiety. Another person may be on Lamotrigine to be depressed, but Aripiprazole to prevent any hypomania. The combinations of medications is as varied as the people to whom it is prescribed.

The Human Element: Living the Experience

It is one thing to discuss medications in clinical terms, but it is another to actually live them. This is where the experience gets real, and everything is about empathy, and communication.

The side effect discussion: Let's be honest: every medication has side effects; it is part of existence. The most important component is the genuine, ongoing conversation with your doctor about your experience. Some side effects are temporary, such as initial nausea or sedation with some drugs. Others, such as weight gain or tremors, will continue, and need to be addressed. The question is never “Does this med work?” The real question is “Does it work well enough to balance the burden of the side effects?” Sometimes a change of dose or switching medication from the same class resolves the issues of the side effects.

This is where the reality of side effect turns many treatment plans useless. It is one thing to gain weight or experience sedation, who among us hasn’t had their self-esteem stripped away from weight gain on a medication or diabetes because of a medication (or both!)? The metabolic sedation accompanying some medications can feel like walking through mud and make it impossible to get through a work day much less be available to your family. Sexual side effects can disrupt the most intimate of relationships. Akathisia—a terrifying impatient sense of inner movement that makes it impossible to sit still—can sometimes be more distressing than the original symptoms. These are not trifles.They are important quality of life issues that should be addressed with as much attention and seriousness as the mood symptoms themselves. A good doctor will not dismiss these issues, but will work cooperatively to modify the medications if appropriate, add medications to treat the side effect (e.g., metformin for weight gain), or focus on lifestyle changes.

The Challenge of Adherence: This might be the most significant concern in long-term management. When people start to get better, it’s easy to believe that you don't need the medication any longer. They may want to have the energy and creativity of hypomania; they may feel that the medication is “dulling” them. They may prefer to have no side effect, or just want to feel “normal” without taking a medication. This is a dangerous moment. In addition to a rapid and strong risk of relapse from stopping their medication suddenly that can happen sooner rather than later, there is a definite risk that if they stop for any prolonged period of time, it will actually lessen the effectiveness of the medication if they return on it, even at a later time. Accepting the notion of medications as a long-term commitment (like use of insulin for chronically ill diabetes) is critical to achieving stability.

The reasons for non-adherence are simply human. One reason to stop simply ties-in with insight during a well period: anosognosia or lack of insight–literally the brain cannot detect there is ill. Or, it may be viewed as an act of rebellion against the diagnosis itself, and the notion of being given a life-long label. The best mechanism for supporting adherence will simply be the therapeutic alliance and relationship.A psychiatrist who listens, affirms distress about side effects, and actively engages the patient in treatment decisions increases the likelihood that the patient will adhere to the treatment plan. Psychoeducation—learning the "why" behind the pill—provides a strong foundation for treatment adherence. When patients know that failing to take their mood stabilizer increases the likelihood of a relapse by five times in one year , taking their medication becomes an active, empowered decision toward health, rather than a passive surrender to illness.

Beyond the pill: medication is just one part of a whole life plan

Any experienced psychiatrist or therapist will tell you that medication is necessary, but not enough. Medication is the bedrock of a comprehensive wellness plan; it is the frame of the house. Therapy, lifestyle, and support are the walls, the roof, and the plumbing that make the house a liveable home.

Therapy—especially Cognitive Behavioral Therapy (CBT) and Interpersonal and Social Rhythm Therapy (IPSRT)—offer tools for working with thoughts, behaviors, and lifestyle factors that make episodes more likely to occur. In IPSRT, patients learn to stabilize their daily routines (sleep, meals, activity), which is a major stabilizer for the bipolar brain. CBT provides individuals with a way to notice and change the distorted thinking patterns that ignite depressive and manic cycles. If you don't understand the grandiosity of mania and self-loathing of depression, CBT provides an articulated toolkit for developing that understanding. Family-Focused Therapy (FFT) can be helpful when some of the distress originates with family members, as it educates loved ones about the illness and engages them in communication strategies to help reduce household demands that are associated with episode triggers. Lifestyle choices are more than just adjuncts: they are therapeutic agents. A regular sleep cycle is essential. Disruption to one's sleep is among the most powerful precipitating factors to manic episodes. Going to bed and waking up the same time every day, even on the weekends, is among the most powerful non-pharmacological treatments available. A balanced diet, regular exercise (which has an established anti-depressant/anti-anxiety effect), avoiding alcohol and recreational drugs (which may not always interact well with medications, as well as affect mood), and learning to manage stress through alternatives such as mindfulness and meditation, all serve to bolster the neurological system in synergy with the psychotropic medication. This is not to recommend attaining perfection—instead, we are discussing establishing a platform or structure that can exist on days when the winds of change and modification are blowing in neurological chaos.

Navigating the U.S. Healthcare System

Access to and affordability of the medications in the U.S. presents an additional barrier to treatment. Brand new and often atypical unique medications can often be cost prohibitive. If a therapeutic approach includes navigating insurance formularies and pre-authorization or, co-pay assistance programs, this may seem like a part-time job. It is a reality that many Americans are navigating. The frustration of discovering that a medication is not covered by insurance or, the co-pay is $300 plus, may impede treatment at the very moment a person is attempting to obtain treatment.

That said, there are effective and older medications, like lithium, that are extremely affordable, and many of the prescribing pharmaceutical companies offer patient assistance for qualifying patients. The proactive doctor's office or a social worker in a hospital can usually assist with appropriate referrals or consider other avenues for medications. It never hurts to ask.Additionally, the availability of generic formulations for many of the older atypical antipsychotic medications has considerably lowered their cost. Being an informed consumer and a tenacious advocate for yourself is an unofficial part of the treatment regimen in the healthcare system in the U.S. This may involve simply asking your doctor to prescribe the generic when available, appealing an insurance plan denial, or using a prescription discount card, such as GoodRx.

Looking Forward: The Future of Bipolar Medications

The realm of psychopharmacology is not stagnant. Research is ongoing into innovative mechanisms of action that may be more effective and have fewer side effects. The pursuit of targeted treatments overall is the holy grail. There are a few avenues of research underway:

Glutamate Modulators: Ketamine and some of its derivatives are currently being investigated extensively for treatment-resistant bipolar depression with the potential for rapid acting, but probably transient, relief from severe depressive symptoms. The challenge is translating from rapid acting infusions to long-term maintenance.

Anti-inflammatory Agents: There is mounting evidence that inflammation in the brain is a factor in mood disorder. Clinical trials are underway to see if medications that address inflammation have a stabilizing effect on mood.

Precision Psychiatry: The future may be utilizing genetic testing to predict which medications an individual will have the best response to.Although pharmacogenetic testing is still developing (and is hardly definitive), it sometimes provides a clue towards avoiding prolonged trials of medications with unsatisfactory effects.

The hope is a future with less guessing, and more treatment which is an exact science like a specific fingerprint of one's own biological constitution.

A Note of Optimism

To start medications for bipolar disorder can feel intimidating: it is accepting you have a serious problem and having to experience something new. A 'trial-and-error' attitude may create avoidance/fear/frustration and cater to adaptation. Yet it's also a step toward empowerment. It is absolutely fine and appropriate to grieve the fact you have to take a medication for this illness, to feel anger or sadness about the hand you were dealt in life. All feelings are valid. The work is to process these feelings forward to acceptance, not accepting this illness but accepting medication efficaciously fighting for oneself with all resources possible.

The 'right medications' can mean the difference between a life overpopulated with overreactions to experiences, or a life with purpose, plan, direction, and stability. It can mean holding down a job, maintaining relationships that are meaningful, and pursuing passions without the crippling fear of the next emotional episode. It can provide the ground from which stones can be removed in order to reconstruct, discover who you are outside of your episodes, and build a life that is filled with meaning, care and connection, but not just the desire to survive or through to the next workday. 

Each journey is unique. Each requires a trusted mental health partner, a support network, and a lot of personal courage. Every single person with a bipolar diagnosis unwillingly feels medication is too often shackling; it is a buoy enabling an individual to live a life. A life not identified by an illness, but enriched by overcoming difficulties and finding strength in consistency. It is the science that makes recovery possible; taking it each day poses quietly, powerfully and steadfastly to the mind that one is attempting to heal.