by: Michael G. Rayel, MD
How do we treat bipolar disorder? Specifically, how do we treat mania or depression associated with bipolar disorder? The treatment of these two clinical states is not the same.
The treatment of mania is dependent upon its severity and acuity. For mild to moderate mania, mood stabilizers such as lithium and valproic acid (Valproate) are still the standard of treatment and may be sufficient to contain the symptoms. Lithium starts to work after 10 to 14 days while valproic acid, about 7 to 10 days.
Also, recent studies have shown the effectiveness of atypical antipsychotics such as risperidone, olanzapine, and quetiapine even when used alone to treat the acute phase of bipolar disorder.
These drugs are relatively safe but they don’t come without side effects. Nausea, vomiting, tremors, and dizziness during the initial phase of treatment are commonly experienced. The more serious side effects such as renal and thyroid problem from lithium, liver dysfunction and pancreatitis from valproic acid, and increased risk of diabetes and high cholesterol from atypical antipsychotics are uncommon. However, regular blood tests are required to monitor any abnormalities.
For moderate to severe cases, atypical antipsychotics such as risperidone and quetiapine should be added to the mood stabilizers during the acute phase. Once the illness has stabilized and the symptoms have subsided, then the atypical neuroleptics can be gradually tapered off. But the mood stabilizers should continue. Regardless of severity, patients usually do well on a combination of mood stabilizer and atypical antipsychotic during the acute phase.
What is the treatment for bipolar depression? In general, the mood stabilizers’ dosage should be optimized or if the patient is not on any medication yet, a mood stabilizer such as lithium should be started. Physicians should make sure that the medication maintains a “therapeutic level.” If not, the dosage should be adjusted. Moreover, possible precipitants such as stresses at home should be addressed.
If these measures don’t help and the depression is so severe, an antidepressant with the least risk to induce mania such as bupropion should be added to the mood stabilizer. When the depression is resolved, then the antidepressant can be gradually tapered off because its prolonged use even in the presence of mood stabilizer can still induce mania.
When should the medication be discontinued? Bipolar patients have to continue taking the medication for several months even after they become normal. High relapse rate is common if medications are prematurely stopped. Also, for patients with multiple or difficult-to-treat episodes, they may need to take the medication for years or even for life to prevent recurrence.
Patients and their physicians should thoroughly discuss the risk and benefits of any treatment intervention. Knowledge about the drug’s indication, side effects, and prognosis with or without treatment is a must.
Furthermore, it is crucial that bipolar patients should also receive individual psychotherapy to help them deal with the many personal and psychosocial issues they face on a daily basis. As you know, medication alone won’t suffice to address financial problems, marital conflict, work issues, and prior abuse.
In summary, the combination of medication and psychotherapy is the best treatment for bipolar disorder.