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BIPOLAR DISORDER: TREATMENT




Last time we discussed the symptoms and diagnosis of bipolar disorder. Today, I want to talk a little about the treatment of bipolar disorder.


The treatment of bipolar disorder is mostly pharmacological. Unfortunately, bipolar disorder strongly tends to be a lifelong condition, and so patients must always remain on medicine preventatively.


Therapy may help folks with bipolar disorder manage their lives, but it doesn’t prevent or stop episodes. In the days before medications, the best therapists in the world theorized what psychological damage had caused it and attempted to treat it with intensive psychotherapy. They got exactly nowhere. Then along came lithium.


Lithium, a naturally occurring element, had been used to treat gout and kidney stones since the mid-1800s. Some physicians started using it for bipolar disorder by the latter half of the nineteenth century, but this got little notice. One formulation of Coca-Cola, Lithia Coke, contained lithium. 7Up was originally named "Bib-Label Lithiated Lemon-Lime Soda” and was marketed in 1929 as a cure for hangover. Lithium was banned by the FDA in 1948, but after careful research starting in the 1950s and 1960s showed good efficacy, other countries started using it, and the FDA finally approved its use in 1970. Its main usefulness remains in the prevention of episodes.


But lithium is a twitchy drug. Ideally, the dose of a medication that gets you sick should be many times the dose that gets you well. But with lithium, it’s about 1½ times, so it must be monitored very closely with blood tests. Also, among its possible side effects is kidney damage, which may not get better when the drug is stopped. It turns out to be a really good thing they removed it from Coke and 7Up!


So, medicine has gone and looked for alternatives, and interestingly, many of the drugs used for epilepsy have turned out to be very useful in treating bipolar disorder. The reason for this connection is still being debated. But they often work well, especially again for prevention of episodes. These medications include Depakote (valproate), Tegretol (carbamazepine), Trileptal (oxcarbazepine), and Topamax (topiramate).


For manic episodes that break through the preventatives, most of the “antipsychotics”—medications most commonly thought of as treatments for schizophrenia—turn out to be very effective, even if no psychotic symptoms are present. Some even help with depressive episodes.


Break-through depression can be treated with antidepressants, but often they don’t work as well as they do for unipolar depression. And as we have discussed above, they can switch people into mania.


ECT (shock treatment) has a long history of strong effectiveness for both depression and mania. But ECT has a lot of logistical problems and can cause memory loss. So as better medications have appeared, its use has been limited mostly to the acute treatment of severe cases.


TMS is a newer form of non-pharmacological treatment which uses focused magnetic pulses to treat depression. It is safer than ECT and does not damage memory. The research for using TMS in bipolar depression is ongoing and so far, mostly positive. The FDA has granted TMS “Breakthrough Therapy” status. This, however, is short of full FDA approval. The standard TMS treatment for unipolar depression (left sided, high frequency) can be a bit stimulating and, like antidepressants, possibly switch people from depression into mania. But there is a right-sided, low-frequency option that is not stimulatory and therefore presents an interesting alternative. This, however, has not been studied scientifically. Because it is not known if TMS is preventative, its best application may be for those with difficult-to-treat, long depressive episodes. 


A big pitfall is when patients go off their medicine. They may do it because of side effects, lack of full effectiveness or even because of effectiveness. They may be doing so well they start to think they don’t need medicine. But as I said earlier, bipolar disorder rarely goes away.


A common scenario is one in which people start to get a little manic, feel really good (too good), and then decide “Hey, what do I need medicine for? I’ve never felt better in my life!” And so they stop their meds and it’s off to the races. This is why I often ask my patients if they will allow a partner or close relative to contact me if they suspect the patient is getting manic. I also stress that when they really get manic, they may no longer be able to recognize it, so they should call me as soon as they even think a manic episode may be starting.


Sadly, the success rate for treating bipolar disorder with a single medicine is not great; only about 7% of patients are managed with a single medication. But the good news is that when the medications do work well, the patient may then live a completely symptom-free life.



Article written by:


Gary Warstadt, MD.


31+ years in practice.


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