8.3 Treatments for Bipolar Disorders

The bipolar disorders are lifelong illnesses, and episodes of mania or hypomania and depression typically recur. Between episodes, many people with bipolar disorder are free of mood disruption, but some people have lingering symptoms such as anxiety. Long-term, continuous treatment is recommended as it can help people manage symptoms and prevent manic or depressive episodes. An effective treatment plan for a bipolar disorder typically includes a combination of medications and psychotherapy.^[1]

Medications

Medications used to treat bipolar disorder include mood stabilizers, anti-seizure medications, and second-generation (“atypical”) antipsychotics. Treatment plans may also include medications that target sleep disruption or anxiety. Antidepressant medication may be used to treat depressive episodes in bipolar disorder in combination with a mood stabilizer and/or antipsychotic to prevent precipitating a manic episode.^[2] See Table 8.1 for a list of common medications used to treat bipolar disorders.^[3] Review information about neurotransmitters in the “Review of the Central Nervous System” section of Chapter 6.

Table 8.1 Common Medications Used to Treat Bipolar Disorders

Lithium

Lithium is considered the gold standard for treatment of bipolar disorders. When administered to a patient experiencing a manic episode, lithium may reduce symptoms within one to three weeks. It also possesses unique antisuicidal properties that sets it apart from antidepressants.^[4],[5]

Adverse/Side Effects

Lithium must be closely monitored with routine blood work because it has a narrow therapeutic range of 0.8 to 1.2 mEq/L. Levels above this range cause lithium toxicity. Lithium levels > 2.5 mEq/L constitute a medical emergency, even if the client is asymptomatic. Because of the narrow therapeutic range lithium has a Black Box Warning. Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy.^[6] Signs of early lithium toxicity include diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. At higher levels giddiness, ataxia, blurred vision, tinnitus, and a large output of dilute urine may be seen. Treatment of lithium toxicity includes withholding the lithium and pushing fluids; IV fluids may be required. In severe cases, gastric lavage, mannitol, urea, aminophylline, or dialysis may be used to hasten the excretion of the drug. Lithium is contraindicated in clients with renal or cardiovascular disease, severe dehydration or sodium depletion, and those receiving diuretics because these conditions increase the risk of lithium toxicity.^[7],[8] Lithium can cause fetal harm in pregnant women. Safety has not been established for children under 12 and is not recommended.^[9]

Fine hand tremor, polyuria, and mild thirst may persist throughout treatment. Lithium can cause abnormal electrocardiographic (ECG) findings and risk of sudden death. Patients should be advised to seek immediate emergency assistance if they experience fainting, light-headedness, abnormal heartbeats, or shortness of breath.^[10] Renal function is adversely affected by lithium and requires routine laboratory testing including urinalysis, blood urea nitrogen, and creatinine. Thyroid and parathyroid functioning can also be adversely affected by lithium, requiring routine laboratory testing including thyroid function studies and calcium levels.^[11]

Patient Education for Lithium

Lithium must be taken as prescribed or serious side effects can occur. Blood tests to measure lithium levels will be ordered regularly by the provider. The provider should be immediately notified of symptoms of elevated levels of lithium, including diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination, ringing in the ears (tinnitus), or large amounts of dilute urine. Driving or operating heavy machinery should be avoided when first starting lithium because it can impair mental alertness. Lithium should not be taken during pregnancy or while breastfeeding unless it is determined that the benefits to the mother outweigh the potential risks to the baby.^[12] Patients should be instructed to avoid non-steroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, as they alter lithium levels. If patients require relief for pain or fever, they should contact their healthcare providers.

Psychotherapy

Psychotherapy is a term for a variety of treatment techniques that help an individual identify and change troubling emotions, thoughts, and behaviors. Treatment may include therapies such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and psychoeducation. Read more information about CBT and DBT in the “Treatments for Depression” section of Chapter 7.

Treatment may also include newer therapies designed specifically for the treatment of bipolar disorder, including Interpersonal and Social Rhythm Therapy (IPSRT) and family-focused therapy. IPSRT emphasizes the importance of establishing stable daily routines such as sleeping, waking up, working, and eating meals. Family-focused therapy focuses on psychoeducation, communication enhancement training, and problem-solving skills. It includes attention to family dynamics and relationships as contributing factors to the patient’s mood.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is used to treat bipolar disorders. ECT is a brain stimulation procedure delivered under general anesthesia. It can be effective in treating severe depressive and manic episodes when medication and psychotherapy are not effective. ECT can also be effective when a rapid response is needed, as in the case of suicide risk or catatonia (a state of unresponsiveness). Read more about electroconvulsive therapy (ECT) in the “Treatments for Depression” section of Chapter 7.

Self-Care

Regular aerobic exercise, such as jogging, brisk walking, swimming, or bicycling, helps with depression and anxiety, promotes better sleep, and is healthy for the heart and brain. There is also some evidence that anaerobic exercise such as weightlifting, yoga, and Pilates can be helpful.^[13] Stress management is a crucial part of maintaining a stable mood. Coping skills taught in group or individual therapy and reinforced at home are essential for navigating work, interpersonal, and community functioning. Patients should adhere to regular sleep/wake routines, avoid alcohol and caffeine products.

Even with proper treatment, mood changes can occur. Treatment is more effective when a patient and health care provider work together and talk openly about concerns and choices. Keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events can help patients and health care providers track and treat bipolar disorder over time. Patients can easily share data collected via smartphone apps – including self-reports, self-ratings, and activity data – with their health care providers and therapists.^[14]