Bipolar Disorder and Bipolar Depression Treatment

This article discusses the treatment of bipolar disorder, mania, hypomania and bipolar depression. The treatment of major depression is a topic for a separate discussion. Lithium is still the mainstay of treatment when bipolar disease is first diagnosed. Lithium was the first in the class of mood stabilizers.

The newer mood stabilizers are the new age anti-convulsants. These in order of efficacy in my opinion are Lamictal (lamitrogine), Depakote (valproic acid),Topamax (topiramate) and Neurontin (gabapentin) but the latter two are controversial as the drug trials for their use for bipolar disease are scant and inconclusive and their use is “off label.”
The use of lithium or lamictal alone for both the highs and lows of bipolar disease is a new approach. I, personally, do not believe in this approach.

The history of the use of Lithium is quite interesting starting in the 19th century when certain springs in Texas, called “crazy waters” were found to help “crazy people”, schizophrenia and mania. Also in the mid-nineteenth century lithium was used to dilute the urine for kidney stones composed of uric acid. Likewise, its use for stones in people with various mental diseases seemed to help both. Its use for bipolar disease became widely accepted in the late sixties when blood levels could be measured.

The side-effects include tremor, dehydration, hyperthyroidism, confusion, coma, bradycardia and long term use can cause kidney failure. Frequent drug levels need to be measured at initiation and anytime the dose is changed because the therapeutic to toxic levels are very small.

The newer or so-called atypical antipsychotics originally used for schizophrenia are used as add-on therapy for bipolar disease. The new age ones include Abilify (aripiprazole), Seroquel (quetiapine), Risperadol (risperidone) and others and are now widely used as mood stabilizers. The side-effect profile includes hypotension and akathesia (a most unpleasant feeling of restlessness including what I call feeling as though ants are under the skin). Muscle related symptoms such as slow jerky movements mimicking Parkinson’s disease can occur. Tardive dyskinesia which are involuntary movements usually starting in the mouth or tongue can become permanent if not recognized early.Fortunately the abnormal muscle movements are much less common than seen in the old anti-psychotics.

The drugs used in combination with mood stabilizers for bipolar depression include the SSRIs (selective serotonin reuptake inhibitors) and the SNRIs (serotonin, norepinephrine reuptake inhibitors) such as Prozac (fluoxetine) and Cymbalta (duloxetine) respectively. Some of these drugs also affect another neurotransmitter dopamine. These have become first line drugs for major depression. However, the use of SNRIs for bipolar depression should be avoided as they are so potent that they may flip bipolar depression to mania. A black box warning for all of these agents is that in adolescents or children their use can be associated with suicidal ideation.

The older drugs used for depression, tricyclics such as Elavil (amitriptyline) have been largely replaced by the above. Obviously there is much overlap of the use of drugs for bipolar depression and unipolar major depression but treatment of major depression will discussed at another time.

Lastly, the benzodiazepines, such as Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam), etc. are used short-term for sleep and anxiety until definitive therapies above kick in which can take six to eight weeks.

I believe that an ideal combination for the treatment of bipolar disease involves the combination of Lithium or Lamictal as mood stabilizer, an SSRI for depression and klonopin for anxiety and sleep.

ECT should be discussed separately with a discussion of unipolar depression. Some believe that ECT is the safest therapy or bipolar disease in pregnancy as most of the drugs have not been proven safe for the fetus.Newer experimental treatments are ketamine, deep brain stimulation and ablative neurosurgery.

We cannot forget the importance of psychotherapy to learn what is called “mindfulness” need to be added to drug therapy. Examples of mindfulness include all forms of relaxation therapy. In an ideal world patients with bipolar disease should be seeing both a psychiatrist and a psychologist.