About bipolar Information leaflets Introduction to medical treatment Always seek a doctor's advice when making decisions about medication Medications are the cornerstone of treating bipolar disorder, though there are many other aspects to keeping well. We’ve compiled this short resource guide for information only. There is a range of different medications used to treat bipolar. Many different medications are used to treat bipolar. Which medications are used will depend on the nature and degree of your symptoms and the phase of the illness you are in. For example, when bipolar is associated with other problems such as sleep disturbance additional medication may be needed. Medications commonly used fall into these categories: Mood stabilisation or mood maintenance For use when high (hypomania/mania) For bipolar depression For associated conditions, such as sleep difficulties and anxiety Scientific evidence shows that how effective an individual or a combination of medications is can vary significantly. People can respond differently to the same medication and an individual’s response to a medication can change over time. There are a variety of side effects and different people will experience these in different ways. There are also new medications being developed for bipolar all the time. 1. Medications for mood stabilisation or mood maintenance Your doctor may prescribe one of these for your condition. Each of these medications acts in a different way in the brain to prevent your mood becoming unstable. They may also act to improve your mood if depressed or calm you down if high. Lithium Divalproex Carbamazepine Valproic acid Olanzapine Quetiapine How do they work? Their exact mechanism is not known and they probably work in different ways. They may have a common action to change the level of mood changing chemicals and boost levels of a “brain fertiliser hormone” called Brain Derived Neurotrophic Factor (BDNF). This is boosted particularly in critical areas of the brain responsible for mood regulation, or an area known as the limbic system and prefrontal cortex. Blood monitoring Many of the mood stabilisers require some kind of regular blood monitoring to check the medication’s plasma level. Lithium can affect organs such as the kidney, thyroid and liver. Regular blood tests can monitor this and are vital in preventing damage.. Physical health When you start on a mood stabiliser or antipsychotic you may have tests before and then at regular intervals afterwards. Olanzapine and quetiapine can cause changes in your metabolism leading to weight gain, diabetes or raised cholesterol. Initially your weight gain, blood pressure and blood will be tested every three months for the first year and then each year thereafter. It is important that these tests are done to detect changes early and treat them. 2. Medications used when high (hypomania/mania) Antipsychotics Antipsychotics are the most commonly used type of medication to treat a manic episode. They are divided into groups based on their potential side effects. No medication has a more tolerable side effect, but rather they have different side effects. Newer medications are equally effective in treating bipolar but all have different side effects that are not necessarily less troublesome than older ones. Psychiatrists use the wider range of antipsychotics available to suit individual patients. Antipsychotics have been shown to act as mood stabilisers in some cases. Some of the mood stabilisers are effective in treating a manic episode if given at higher doses. The following is a list of common antipsychotics that your psychiatrist may use: Aripiprazole Haloperidol Olanzapine Quetiapine Risperidone Clozapine Other anti-manic medications that are not antipsychotics include clonazepam, lorazepam, lithium and valproate. Other medications Other medications may also be used to prevent or treat mania, but there is less evidence for their effectiveness. These include topiramate, lamotrigine, levetiracetam, oxcarbazepine, ritanserin, ziprasidone and gabapentin. How does bipolar medication work? The exact mechanism is not known. They have a sedative effect on the brain and alter the balance of a brain chemical called dopamine which is known to be abnormal in mania and psychosis. 3. Medications used for bipolar depression The following medications are established treatments for bipolar depression: Lithium Lithium plus antidepressants Lamotrigine Olanzapine plus fluoxetine Quetiapine There are many groups and types of antidepressants, too many to list in completeness here. Those commonly prescribed today are the SSRIs (selective serotonin reuptake inhibitors) and include fluoxetine, paroxetine and citalopram. They work by altering the balance of the brain chemical serotonin in parts of the brain. Antidepressants alone without a mood stabiliser are avoided in bipolar depression as there is a risk of inducing a hypomania or rapid cycling. Other treatments, but with less scientific evidence for effectiveness in bipolar depression, include valproate, carbamazepine, aripiprazole and gabapentin. Treatment resistant bipolar depression This can be disabling and your doctor will have to weigh the risk of inducing a high or rapid cycling in you if using multiple treatments. Your doctor may, by combining medication types, boost their effectiveness. Combinations your doctor may investigate include multiple mood stabilisers, two antidepressants or lithium plus lamotrigine. In severe cases electroconvulsive therapy (ECT) may be necessary. The law governing the use of ECT is very strict in the UK and it is used infrequently. 4. Medications used for associated conditions Sleeping tablets From time to time people with bipolar suffer from sleep difficulties. Managing your sleep by keeping regular patterns and habits will aid good sleep. This is essential in keeping your moods stable. Avoiding stimulants like coffee in the afternoon and evening is a good example. If you are struggling to sleep it may be wise to take a sleeping tablet with your doctor’s agreement as when you have bipolar you can become more sensitive to sleep loss. Don’t take herbal supplements or other sleep aids without first consulting your doctor. Your doctor may be cautious about giving you too many sleeping tablets too often as they can become addictive. When stopping them you may have difficulty sleeping for a night or two and have vivid dreams. The most commonly used prescription sleeping tablets are zolpidem and zopiclone. Anxiety medications Anxiety problems with bipolar are common. Generalised anxiety, panic attacks and social anxiety are all more common in bipolar than in those without the condition. Anxiety problems are more likely just before, during or after a period of instability of mood. Most of the medications used to treat bipolar may help anxiety. However some of the side effects may make it worse or may seem like anxiety. For example some antipsychotics can induce a restlessness called akathisia (Greek for “can’t sit still”). It is important to report your symptoms in detail to your doctor so he/she may provide the right treatment. There are many psychological and other non-medication treatments for anxiety. Commonly used medications include antidepressants, beta-blockers, valproate and gabapentin. How do they work? They have a varied mechanism but benzodiazepines act like a key on large receptors on the surface of brain cells causing the cells to be less likely to activate, therefore mildly sedating them. 5. Women and Sodium valproate Valproate is a medication used to treat bipolar, other mental health conditions and epilepsy. It’s associated with a risk of birth defects and development disorders in children born to women who have taken Valproate during pregnancy. It is vital that women and girls are aware of the risks of this medication. Women should receive a patient booklet and alert card from their doctor or pharmacist. Nobody should stop taking Valproate without discussing it with their doctor or psychiatrist. You can search for Valproate on our website for more information. There are medications that are safer to take during pregnancy than others. We recommend that you speak with your doctor and midwife to ensure that you are getting the safest treatment for you and your pregnancy. For more information, we have produced a booklet with Action on Postpartum Psychosis (APP) which is available upon request. We hope you’ve found this leaflet useful. Medication is the cornerstone of treating bipolar, but there are many other aspects to keeping well including diet, physical exercise and complementary therapies. If you look after yourself, you are better equipped to understand bipolar and monitor variations in your mood swings. Check out our Medication and treatment blog for more stories and information Other links UK Psychiatric Pharmacy Group – This site offers a group of frequently asked questions about medications. The Royal College of Psychiatrists – This site offers a range of detailed information leaflets for a variety of mental health issues. The Institute of Psychiatry, King’s College – This site carries a comprehensive list of medications and their side effects plus helpful videos. Please do not hesitate to contact your doctor or mental health professional for specialist advice. Download this information as a PDF