Bipolar disorderTreatment

Treatment for bipolar disorder aims to reduce the severity and number of episodes of depression and mania to allow as normal a life as possible.

If a person is not treated, episodes of bipolar-related mania can last for between 3 and 6 months.

Episodes of depression tend to last longer, often 6 to 12 months.

But with effective treatment, episodes usually improve within about 3 months.

Most people with bipolar disorder can be treated using a combination of different treatments.

These can include 1 or more of the following:

• medicine to prevent episodes of mania and depression – these are known as mood stabilisers, and you take them every day on a long-term basis
• medicine to treat the main symptoms of depression and mania when they happen
• learning to recognise the triggers and signs of an episode of depression or mania
• psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
• lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

But hospital treatment may be needed if your symptoms are severe or you're being treated under the Mental Health Act, as there's a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medicines for bipolar disorder

Several medicines are available to help stabilise mood swings.

These are commonly called mood stabilisers and include:

• lithium
• anticonvulsant medicines
• antipsychotic medicines

If you're already taking medicine for bipolar disorder and you develop depression, your GP will check you're taking the correct dose. If you're not, they'll change it.

Episodes of depression are treated slightly differently in bipolar disorder, as taking antidepressants alone may lead to a relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabiliser.

But antidepressants are commonly used alongside a mood stabiliser or antipsychotic.

Find out more about antidepressants

If your GP or psychiatrist recommends you stop taking bipolar disorder medicine, the dose should be gradually reduced over at least 4 weeks, and up to 3 months if you're taking an antipsychotic or lithium.

If you have to stop taking lithium for any reason, talk to your GP about taking an antipsychotic or valproate instead.

Lithium

In the UK, lithium is the main medicine used to treat bipolar disorder.

Lithium is a long-term treatment for episodes of mania and depression. It's usually prescribed for at least 6 months.

If you're prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly unless told to by your doctor.

For lithium to be effective, the dosage must be correct. If it's incorrect, you may get side effects such as diarrhoea and getting sick.

Tell your doctor immediately if you have side effects while taking lithium.

You'll need regular blood tests at least every 3 months while taking lithium. This is to make sure your lithium levels are not too high or too low.

Your kidney and thyroid function will also need to be checked every 2 to 3 months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you're taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they're prescribed by your GP. 

In the UK, lithium and the antipsychotic medicine aripiprazole are currently the only medicines that are officially approved for use in teenagers with bipolar disorder.

But the Royal College of Paediatrics and Child Health says that other bipolar medicines may be prescribed for children if recommended by their doctor.

Anticonvulsant medicines

Anticonvulsant medicines include:

• valproate 
• carbamazepine
• lamotrigine

These medicines are sometimes used to treat episodes of mania. They're also long-term mood stabilisers.

Anticonvulsant medicines are often used to treat epilepsy, but they're also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used, or they may be used in combination with lithium when bipolar disorder does not respond to lithium on its own.

Valproate

Valproate is not usually prescribed for women of childbearing age because there's a risk of physical defects in babies, such as spina bifida, heart abnormalities and cleft lip.

There may also be an increased risk of developmental problems, such as lower intellectual abilities, poor speaking and understanding, memory problems, autistic spectrum disorders, and delayed walking and talking.

Learn more about the risks of valproate medicines during pregnancy

In women, your GP may decide to use valproate if there's no alternative or you have been assessed and it's unlikely you'll respond to other treatments.

They'll need to check you're using a reliable contraception and will advise you on the risks of taking the medicine during pregnancy.

Find out more about pregnancy and taking medicine for a mental health condition

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you're taking other medication, including the contraceptive pill.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine and again after 6 months.

You'll also need to have a blood count at the start and after 6 months, and you may also have your weight and height monitored.  

Lamotrigine

If you're prescribed lamotrigine, you'll usually be started on a low dose, which will be increased gradually.

See your GP straight away if you're taking lamotrigine and develop a rash. You'll need to have an annual health check, but other tests are not usually needed.

Women who are taking the contraceptive pill should talk to their GP about switching to a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania.

They include:

• aripiprazole
• olanzapine
• quetiapine
• risperidone

They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed.

As antipsychotics can cause side effects, such as blurred vision, a dry mouth, constipation and weight gain, the initial dose will usually be low.

If you're prescribed an antipsychotic medicine, you'll need to have regular health checks at least every 3 months, but possibly more often, particularly if you have diabetes.

If your symptoms do not improve, you may be offered lithium and valproate as well.

Rapid cycling

You may be prescribed a combination of lithium and valproate if you experience rapid cycling, where you quickly change from highs to lows without a "normal" period in between.

If this does not help, you may be offered lithium on its own, or a combination of lithium, valproate and lamotrigine.

But you will not usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognise triggers

If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.

A community mental health worker, such as a psychiatric nurse, may be able to help you identify your early signs of relapse from your history.

This will not prevent the episode occurring, but it'll allow you to get help in time.

This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you're already taking.

Your GP or specialist can advise you on this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medicine in between episodes of mania or depression.

This may include:

• psychoeducation – to find out more about bipolar disorder
• cognitive behavioural therapy (CBT) – this is most useful when treating depression
• family therapy – a type of talking therapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of 6 to 9 months.

Pregnancy and bipolar medicines

One of the main problems is that the risks of taking bipolar medicines during pregnancy are not well understood.

If you're pregnant and you have bipolar disorder, a written plan for your treatment should be developed as soon as possible.

The plan should be drawn up with you, your partner, your obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medicines are not routinely prescribed for pregnant women with bipolar disorder, as they may harm the baby:

• valproate
• carbamazepine
• lithium
• lamotrigine
• paroxetine
• benzodiazepines (tranquillisers), such as diazepam (Valium) and lorazepam (Ativan)

If you become pregnant while taking medicine that's been prescribed for bipolar disorder, it's important that you do not stop taking it until you have discussed it with your doctor.

If bipolar medicine is prescribed for bipolar disorder after the baby's born, it may also affect your decision whether to breastfeed.

Your pharmacist, midwife or mental health team can give you advice based on your circumstances.