Bipolar Today

Medications are an integral part of treatment for people with bipolar disorder. Even though therapy can be helpful, bipolar episodes and especially manic episodes recur without medication in most cases. Bipolar medications assist in a number of different ways, from preventing depression to stabilizing mood to preventing psychosis. On this page, I will discuss the different types of bipolar medications.

On this page, I will only discuss the FDA-approved, on-label medications for bipolar treatment. Many physicians use medications off-label, meaning that they use medications for purposes for which they have not been approved. Physicians are allowed to do this, but I believe that knowing which medications have been approved by the FDA for treatment of bipolar disorder is especially important.

Please note: I am neither a physician or a pharmacist. The below information is intended only to provide a brief and incomplete introduction to these medications. I have not included lists of all side effects, for example. For further information, please consult a physician or pharmacist.

The Different Types of Bipolar Medications

Bipolar medications approved by the FDA for use in bipolar disorder basically fall into two different categories: mood stabilizers and antipsychotics. Each of these has a different effect, and because of this, they are often used together.

Mood Stabilizers

Mood stabilizers do exactly what it sounds like what they would do: they stabilize mood. They can do this in one or both of two ways, when they are effective for a given patient. First, they can extend the length of time between episodes, hopefully making the euthymic or “well” phase longer and the bipolar states shorter. Second, they can lessen the severity of the episodes that the patient has, without necessarily changing the pattern.

One can think of bipolar moods like a wave. A wave has its wavelength, which is the width of the waves, and it has its amplitude, which is the height of the waves. Mood stabilizers can affect either or both. They can widen the time between the waves and they can make the various waves less severe.

Some of the most common mood stabilizers are the following:

Lithium

Lithium’s affect on manic-depressive patients was discovered in the 1960s, and it was the only readily available treatment until the 1980s. It also has remained the “gold standard” for treatment, assuming that one can tolerate it. The problem for lithium is that it is an especially harsh medication and it can cause long-term kidney damage if not monitored properly. Still, if a patient can handle the side-effects, it is often the best choice. It is also now generic, which means it is relatively inexpensive. It is also one of only three medications (along with risperadone and aripiprazole) to be approved for use in children 10-17.

Valproate (Depakote)

Valproate is another mood stabilizer that fares very well, but has never been shown to be quite as effective as lithium in stabilizing mood. It was originally (and still is) used as an anticonvulsant, but physicians discovered that the bipolar symptoms of bipolar epileptics were also improving. It has the advantage of often having less severe side effects than lithium. However, some people have an extremely bad reaction to it, especially at first, and it can cause serious impairment to the liver or pancreas in a small percentage of cases, so this needs to be watched for. It is also now generic, and therefore relatively affordable.

Lamotrigine (Lamictal)

Lamotrigine is another mood stabilizer that is also an anticonvulsant. It is not quite as effective as lithium, but is better tolerated by many patients. Like volproate, it sometimes has a dangerous reaction in the case of some patients, especially in the early stages. Several severe skin reactions are possible that can even prove fatal in a very small percentage of cases, so patients and physicians should watch out for these symptoms. Like lithium and valproate, it is now generic. Note that lamotrigine was recently shown in a recent meta-analysis to not be significantly more effective than placebo in preventing acute mania, so its use in Bipolar I is limited.

Carbamazepine (Equestro)

Carbamazepine is yet another anticonvulsant that has been shown to be effective for bipolar disorder. Like the other anticonvulsants, it is not as effective overall as lithium, but it is generally better tolerated. It, too, has a serious side-effect that must be monitored, as it can significantly reduce white blood cell count in patients who are taking it. It is as old as lithium and is therefore generic. It was used in Japan before being used in other jurisdictions.

Atypical Antipsychotics

The use of “atypical” here is, well, atypical, if you’ll pardon the pun. Basically, it means they are new. However, this new generation of antipsychotics is less likely to cause tremors than previous generations of antipsychotics. They have been shown to be especially effective at preventing the manias associated with bipolar I. In fact, most of them, with the exception of Seroquel XR, have not been approved for treating bipolar depression or use in bipolar II. All atypical antipsychotics have a small chance of causing tardive dyskinesia, a difficult to treat movement disorder.

Ziprasidone (Geodon)

Ziprasidone has been approved by the FDA for the treatment of acute manic and mixed states in patients with bipolar disorder. It is worth noting that, because only people with bipolar I disorder have manic and mixed states, this medication has not been approved for bipolar II disorder. The medication can has been shown to be dangerous for elderly patients with dementia-related psychosis and can cause a heart condition known as torsades de pointes.

Pfizer was fined $2.3 billion for promoting Geodon and three other drugs for off-label use in 2009, which remains the largest such fine in history. They had been promoting Geodon for depression, OCD and autism, according to this article.

Risperidone (Risperdal)

Risperidone is another atypical antipsychotic, and has been approved for short-term use in manic and mixed episodes of bipolar disorder (which again only occur in bipolar-I patients). It should not be taken by elderly patients with dementia. It is also one of only a few medications (along with lithium and aripiprazole) to be approved for children 10-17. The largest complain about risperidone is perhaps its tendency to create weight gain, which can in turn cause problems with diabetes.

Aripiprazole (Abilify)

Aripiprazole is an atypical antipsychotic that has been approved for use in treating both acute manic and mixed states in people with bipolar disorder I. It is also used as an antidepressant for people with major depressive disorder, but it has not been approved for the treatment of depression in people with bipolar disorder (bipolar depression seems to have a different cause than major depressive depression, which means that different medications work for each). It should not be taken by elderly patients with dementia. It is one of the few drugs (along with lithium and risperidone) to be approved for use with children 10-17.

Quetiapine (Seroquel)

Quetiapine is one of the most popular atypical antipsychotics on the market right now. It has been approved for use in preventing acute mania in bipolar-I patients. One of the primary complaints among patients on quetiapine is that it makes people very tired, and another issue is weight gain. Quetiapine is scheduled to become generic in 2011, which means that it will be one of the least expensive atypical antipsychotics available.

A new form of Seroquel, called Seroquel XR was approved in 2008 for use not only in bipolar mania, but also in bipolar depression. The patent on Seroquel XR does not run out until 2017, however.

Olanzapine (Zyprexa) and Olanzapine/Fluoexatine (Symbyax)

Olanzapine is an atypical antipsychotic that is sometimes mixed with fluoexatine, an antidepressant. It has been approved for treatment of mania in bipolar disorder, and, when combined with fluoexatine, has been approved for bipolar depression. It can be dangerous when given to elderly patients with dementia. Olanzapine can also cause significant weight gain. The patent for olanzapine runs out this year (2011).

In 2009, Eli Lilly, the company that produces Zyprexa, was fined $1.4 billion for marketing Zyprexa for off-label use, according to this press release from the Department of Justice.

Typical Antipsychotic

One typical antipsychotic has been approved for use in bipolar disorder.

Chlorpromazine (Thorazine)

Chlorpromazine is an antipsychotic that dates back to 1950, and has been used to treat bipolar manias. However, as a typical antipsychotic, it has risks of tardive dyskinesia, like atypical antipsychotics. It has also been known to cause seizures. Atypical antipsychotics have generally been used more commonly than typical antipsychotics, because they are generally better tolerated, but chlorpromazine is still prescribed in some cases.

Where are the Antidepressants?

The antidepressants are not on this list, for a fairly straightforward reason: no antidepressant has been FDA approved for use in bipolar disorder. The only two exceptions are aripiprazone, which only happens to be an antidepressant as well as an atypical antipsychotic and isn’t approved for bipolar depression, and Symyax, a combined atypical antipsychotic/antidepressant medication.

Antidepressants can be dangerous for someone with bipolar disorder, as they are well known to cause mania and other symptoms. Some physicians may use them off-label if they believe that they can be applied without causing any mania or other adverse reactions. However, many other physicians avoid using antidepressants for bipolar patients at all for fear of possible adverse reactions. This is currently a large debate within the medical community, and one that I am not qualified to adjudicate. However, I have excluded antidepressants entirely due to their lack of approval for treatment of bipolar depression.

Conclusion

Lithium was the first medication for bipolar disorder, but in recent decades, numerous other mood stabilizing and antipsychotic options have become available for people with bipolar disorder. All of the medications have adverse effects, but the wide range of options gives us choices as to which medications we wish to use and which side-effects we are willing to tolerate. When speaking to a physician, be sure to ask the physician about side-effects and consider which ones may be tolerable for you.

Please note that the above list does not include a complete list of side effects, but is intended only to provide a brief introduction to the medications for the sake of future research and questions to a physician or pharmacist.