PsychEducation.org 

TREATMENT  
(original 2001; revised 12/2010, minor update 4/2012)

• What are the basics of bipolar disorder treatment?
• Which mood stabilizer should I start with? 
• Specific guidelines for lamotrigine, lithium and valproate
• Do I really have to stop my antidepressant?
• How long should someone stay on mood stabilizer medications?
• Can I really do this with my primary care doctor?
• A "Dear Doctor" letter for your provider

What are the basics of bipolar disorder treatment?
(Wait a minute, before you start treatment, you and your doctor should be sure that you don’t have thyroid changes causing your mood problem. This can be done with a simple test called "TSH", which measures the level of "thyroid stimulating hormone". Usually your doctor will also order other tests at this time, if you have not had a recent check of cell counts and blood chemicals, to make sure you don’t have other potential medical causes for your mood problems. Because it is not very common to find a problem using these tests, treatment can start even before the results are back. The doctor is just making sure she/he doesn’t miss something unusual. (Thyroid hormone has also been shown to act as a treatment for bipolar disorder in some cases, so it is important to know just where your "TSH" is)). 

Now, the three most important principles, in my view, of bipolar treatment:  

1. Maximize non-medication approaches. This will include at least 3 basics for anyone with a bipolar mood problem.  
2. Medications: start with the ones that have evidence for being effective. These are generally called mood stabilizers.
3. Beware of antidepressants  (but do not stop yours now!; you must work with your doctor, perhaps using some ideas below) 
   

Read through this page first, for an overview of treatment.  Then skim through again and take some of the links in each section for more details on concepts of particular interest to you. 

Principle A: Maximize Non-Medication Approaches
Brace yourself. 

The good news: here come lots of non-medication options for treatment. The bad news: they all take at least a little work on your part. Some take a lot. But almost all are virtually risk free and cheap. Hard to beat that. I wish they were easier for most people. Some are hard for people without symptoms to do! But if you maximize these, you'll almost certainly need less medication; and -- importantly -- the opposite is also true: if you don't, you're likely to need more medication.  

Here are a few details for some of the not-obvious treatment components above . One approach that is crucial for most patients with bipolar disorder is to maintain a regular daily schedule, especially regular patterns of sleep.  An entire therapy for bipolar disorder is organized around this daily schedule idea ("social rhythm therapy") -- especially around having a regular time to go to sleep, and a regular time to wake up and get out of bed.  Yes, sorry to say, it would be best to do that same routine even on weekends.  

Talk about lifestyle change!  This idea of a regular sleep schedule could be very difficult for some people. Unfortunately, the most important steps you can take, without medications, can seem quite restrictive. Many people resist these restrictions, which is understandable.  But that often means they will have to rely more heavily on medications, which can mean having to deal with more side effects or risks.

For many people, a very important part of bipolar disorder treatment is getting help coming to terms with having the illness at all.   Accepting the illness, and accepting some limitations in order to deal with it -- sometimes getting some help with this makes a huge difference.  Call it "psychotherapy", or just call it getting some help:  either way, it can make this important step much easier. I hope this is obvious:  if you are still spending all your energy trying to resist the fact that you have a mood problem, you won't be able to accept some of the lifestyle changes that could make your mood problem much easier to manage.

In fact, multiple research studies have shown that using a therapist to help you with this acceptance stage, and then with making some of the necessary changes in your routines, leads to much better long-term outcomes. Three major forms of bipolar-specific psychotherapy emphasize this process of acceptance and change. All of them are variations on techniques which have been around for a long time: cognitive behavioral therapy, interpersonal therapy, and family therapy.  Most therapists you can find will be familiar with one or several of these techniques. The bipolar-specific versions simply incorporate some special features pertinent to people with bipolar disorder.

Unfortunately, most psychotherapists (as of 2008) are not specifically trained in the bipolar-specific versions of these therapies.  Unless you live near one of the training centers for these methods, you may not be able to find a therapist who who has had specific training on using such an approach.  Worse yet, the training manuals for these therapies, which are easily obtained, tend to focus on Bipolar I.  The emphasis is on preventing subsequent severe episodes of mania or depression.  For people with Bipolar II, these psychotherapies require some adaptation.  For now, the easiest way to do this is to work closely with a good therapist, emphasizing the following (you can even point out to your therapist where to find more information on these, using the resources in the right-hand column):

The research behind these approaches has been summarized on a separate page on this website, Psychotherapies for Bipolar Disorder.     

Principle B:  Medications -- use evidence-based Mood Stabilizers

In addition to these non-medication approaches, most people with bipolar disorder also need to use medications -- although if more people were really rigorous about the non-medication approaches, and I mean really rigorous, perhaps we'd be able to use less medications. But that's really tough, especially since motivation goes missing during bipolar depression, and most of those approaches require either motivation or a really good system of habits.  

The main medications for bipolar disorder are called "mood stabilizers".   There are at least 5 options, and the list continues to grow.  Your doctor will choose, or help you choose, based on her/his sense of what will work best for your set of symptoms; or what has worked for others in your family, which is often a huge clue; or based on your preferences, looking at the potential side effects and risks.  

You might think "whoa, I'm being offered medications they use for people with serious mental illnesses -- look, there's lithium!"  But you didn't know that lithium is commonly used as a booster for antidepressants in plain old depression.  It even works by itself as an antidepressant.  So taking lithium is not a marker for "serious" mental illnesses (whatever that means. Here's my little essay about "Normal -- or Mentally Ill?" ).  But what about side effect risks from mood stabilizers?  Are they worse than antidepressants?  

Some mood stabilizer options carry significant risks, unfortunately. Many doctors shy away from talking about bipolar disorder as a possible diagnosis because the think the risks of the treatments are much greater than the risks of antidepressants, for example. But if you read Prozac Backlash, which offers an extreme view of the possible risks of antidepressants, you'd probably think at least some of the mood stabilizers look better, by comparison.  If you include the risk of antidepressants making bipolar disorder worse, then the risks of the mood stabilizers could be regarded as roughly in the same realm as the risks of antidepressants.  Update 7/2006: when I wrote that last sentence, this view was pretty radical. But listen to this statement from one of the most widely respected bipolar experts in the world, Dr. Fred Goodwin, who said that doctors and patients tend to think of antidepressants: 

"...as light, easy uncomplicated drugs; and mood stabilizers as heavy drugs that should be reserved for use as a last resort. But in fact, recent data suggest that we may have to reverse that order of preference, or at least put them on an equal plane."   (interview, Primary Psychiatry, 2005)

Dr. Goodwin is saying the same thing I've been saying for over 5 years -- but neither of us has very solid data to go on, unfortunately. We're worrying, more than we're saying we know. 

Ahem, back to the mood stabilizer options. While your mind may leap to considering the risks, you should step back first and consider the evidence for effectiveness, of any treatment you're considering. Will it work? If that evidence isn't very strong, then the risk side of the equation may not matter much -- unless the treatment is cheap, harmless, and may have other benefits. There are several such options, it turns out. But you won't like the sound of them, when described. Too bad. 

Wait a minute, wait a minute. What is he talking about: cheap, harmless, other benefits? Okay, try this one: "exercise" (it's like invoking the name of the devil, in some circles, to say that). Or this one: "sleep" . Or rather, "about 8 hours of sleep on a regular schedule", that's the hard part. Even good old fish oil has remarkably good evidence for a "mood stabilizer" effect, but you have to take a lot. So it's not entirely "cheap". But it does appear to be nearly harmless and have other benefits. 

Ahem again (why is this so hard to stay on track here? Well, there is just so much to say about all this. You won't see them all but this website now has about 300 pages, many on very specific topics with only a single path that will take you there. So I've buried a lot of information. Let's get back to the basics, shall we?) 

My main point about choosing a medication: become familiar with at least some of the evidence for the options you're being offered, or should be offered. Some doctors don't keep up with that evidence; or are too swayed by pharmaceutical company pitches; or just use what they are comfortable with. The more you learn the more you'll be in a position to help determine your own treatment. (Not that it will be an easy negotiation with your doctor all the time. Read my hints about Talking with Doctors.)  

Principle C:  Beware of Antidepressants

Depression is the big problem in non-manic versions of bipolar disorder (these versions include Bipolar II, and "softer" versions, as described in the Diagnosis section of this website). Thus many people with bipolar mood problems are offered antidepressants at some point. Seems logical, yet research does not strongly support this approach. Worse yet, antidepressants can make some people with bipolar disorder worse. Therefore most mood experts recommend using antidepressants only when one or several of the mainstay medications, the "mood stabilizers" discussed below, have not been able to prevent or relieve a bipolar depression.  In other words, there is general agreement that antidepressants are not the first thing to turn to in the treatment of bipolar depression.

However, beyond that general agreement, controversy abounds. Some experts think that antidepressants do not have a role at all in treating bipolar depression, except perhaps as a maneuver of last resort. Such experts point either to the lack of evidence for sustained benefit, or the several lines of evidence that they can do harm. More details about the role of antidepressants in bipolar disorder treatment, including links to relevant articles that form the basis of my view, and a summary of an alternative point of view, can be found on the Antidepressant Controversies page. 

Because antidepressants are so widely used, I will take this opportunity here to make sure that you are familiar with the concerns about antidepressants.  First let us look at the generally agreed upon risks of antidepressants-- although even these are somewhat controversial, because some doctors think they are not common; and some think that if they occur, then one simply treats them and continues the antidepressant.    

1. Antidepressants can cause  "rapid cycling".  Technically this means more than 4 mood episodes per year, of any type (depressed or manic or mixed), but cycles can be as often as every day or few days and a few people can go even faster, so-called "ultradian (more than one per day) cycling".   
2. Antidepressants can cause hypomanic or manic symptoms (sometimes called "switching", meaning from depressed to manic). Overall, this is thought to occur between 20 and 40% of the time when a depressed patient with bipolar disorder is given an antidepressant. Though one review found much smaller percentages, the first study dedicated to looking for this rate came out with a switch rate of 20-30% in the first 10 weeks.^Leverich  
3. Antidepressants can cause  "mixed states".  Remember, bipolar disorder is not like the north and south pole;  hypo/manic symptoms can occur while depressed symptoms are also present.  In a way, this is the same problem as #2 above, except that instead of switching from one state to another, you have both at the same time.  Usually this looks like agitation or anxiety, or irritability; and difficulty sleeping; and depression, all at the same time.  

Secondly, here are the more controversial risks. 

1. Antidepressants may cause "mood destabilizing" -- increasing cycle frequency over a longer period of time; in other words, having more mood episodes than before, or more rapid switches from one mood state to another.  This is regarded as worsening the mood condition overall, making it less stable.  This is one of the main concerns expressed by one of the lead experts on this issue, Dr. Ghaemi, whose work is cited extensively in the Antidepressant Controversies essay. 
    
2. Finally, could antidepressants cause "kindling", in which the illness worsens more quickly with time than it might have if antidepressants weren't there?  I don't hear too many other experts fretting about this as I do, so I won't worry you with it here.  If you'd like to hear some more of my concerns, there is a section on "kindling" on the AD controversy page.

Whatever you do with antidepressants, you really need to work closely with your doctor on this.  DO NOT STOP your antidepressant.  It must be tapered at minimum, if you're going off, or you could -- for sure; I'm not making this up -- actually end up quickly worse.  You have to plan this out with your doctor.  If you have trouble getting your concerns or ideas heard, here are some ideas on talking with doctors. 

Meanwhile, however, the good news is that we have at least ten different ways of treating depression in bipolar disorder, without using antidepressants.  These are summarized on the page entitled Antidepressants That Aren't "Antidepressants".   Most of these are ingredients in basic treatment, outlined in the next two sections B and C below. 

Which mood stabilizer should I start with? 
There are several options, shown by generic name in the diagram below. How do you decide which to use?  Here's a very simplified view to start; then we'll look at some other ways to choose; and finally, we will look in detail at the most commonly used medications. 

(For women of child-bearing age: I am sorry to say, all of these medication approaches carry significant risks in pregnancy. It is generally recommended that women take very effective precautions against becoming pregnant while taking these medications.  It is possible to have a child, but it must be a planned pregnancy.  Before stopping your birth control methods, you should have a very solid treatment relationship developed with a competent psychiatrist. With her or him you will work out a detailed plan, including:  how you will taper off your current medications; how your symptoms will be controlled during the pregnancy, if they return; how those medications will be adjusted as you near the end of your pregnancy; and what medications you'll either be taking, or resume, after delivery.  Guys can help out here:  use condoms, they're effective and she doesn't get side effects -- as long as you don't grumble about using them.)

After I show patients the whole "menu" of mood stabilizers, they almost always end up choosing one based on some combination of these factors: 

However, some of these medications have been around longer, so we know much more about their benefits and risks (those whose role is in some doubt have a question mark in the figure above).  We'll start by looking at what mood experts have suggested.  

Expert agreement: "first line" medications
Lithium and valproate/divalproex/Depakote used to be the  "first line" options according to "expert consensus".  This means that mood experts agree these are the best choices as a place to start if you've never taken a mood stabilizer before. Basic information on using lithium and valproate follows below.  But since those consensus guidelines were written up, most of the new recommendations focus on the non-medication options above. There is little new, in terms of medications; except a lot more controversy about the role of antidepressants. You're welcome to see for yourself: here's an introduction to Canadian, European, and U.S. guidelines.     

It Depends On Where You're Starting From
For people whose predominant symptom is depression, as is almost always the case in Bipolar II, then their "mood stabilizer" ought to have plenty of antidepressant "oomph" (a peculiar American term meaning clout, or ability to knock the air out of your lungs, reflecting our peculiar passion for violent versions of football). Here are some mood stabilizers that have well-accepted antidepressant "oomph", yet are not antidepressants themselves.  

• lithium
• lamotrigine (formerly Lamictal, now generic)
• olanzapine/Zyprexa (capitalized means the U.S. trade names; no capitalized name means a generic is routinely used)
• quetiapine/Seroquel
• omega-3 fatty acids (fish oil), perhaps? 
• some authors would include risperidone and aripiprazole/Abilify  (more on those, and why I don't include them, here).

Careful now -- you will soon discover that olanzapine and quetiapine are new-generation "antipsychotics".  Wow, the idea of lithium was freaky enough, and now we're talking antipsychotics? Aren't those the "big guns"? If that worries you, see my little essay about the term antipsychotic; it might reassure you a little bit. 

But as you can see, I emphasize lithium and lamotrigine over the rest.  This helps avoid the "atypical antipsychotic" group, which includes olanzapine/Zyprexa and quetiapine/Seroquel, as well as risperidone and aripiprazole/Abilify, because my patients usually don't like to stay on these medications long-term, for two reasons.  First, even these new "second generation" or "atypical" antipsychotics still feel like antipsychotics to a lot of people:  they slow down thinking, especially.  Sometimes that's a very good thing, and when that effect is necessary, these are great options.  But I generally prefer to use medications that when they are working well are basically "invisible" to the person taking the medication:  you feel "normal", not "drugged" in the least.  

Secondly, all of these antipsychotics sometimes cause weight gain and can raise the risk of diabetes.  Zyprexa is worst in this respect^Leslie  and risperidone and quetiapine are thought to be intermediate.  Aripiprazole causes less weight gain, but it can still cause this problem just like the rest; and ziprasidone perhaps least, maybe only rarely doing so (unfortunately ziprasidone is the trickiest to use; after years of fooling with it I still have trouble prescribing it, so don't expect your primary care doctor to be suggesting it, despite the better risk profile regarding weight). 

Not first line but worth a serious look in some cases
Omega-3 fatty acids from fish oil have several studies supporting their use (too bad there's no company going to make millions by studying this more closely, as that would move the research on O-3's along faster).  The reason for looking closely at fish oil is not the great results in research trials, although there are some; but rather the complete lack of any risk known at this point.  In fact, there's even a potential for lowering cholesterol levels.  So, it's cheap; it has no long term risk; it has almost no side effects; it's available without a prescription -- hey, if it actually worked, that would be sort of a bonus! (That's a joke, mind you.  Usually we start by looking at benefits of medications, since if they have no evidence for benefit, the evidence about risks doesn't matter much, right?  I'd like to hear a resounding RIGHT there, folks...)  Here are the research studies showing it may indeed work, at least to some degree, and links to more detail about fish oil.  Even if it does work, though, it appears to take over a month, probably closer to two.  So if you have symptoms that are really getting in your way now, don't rely on fish oil alone.  (For sure do not go off some other medication and onto fish oil instead; that must be discussed with your doctor.)

Finally, there are add-on  medications as well (not mood stabilizers themselves, as such). These include benzodiazepines (U.S.: Valium, Librium, Xanax, Ativan), which work well at first but usually lose some of their effectiveness over time, with the possible exception of clonazepam (Klonopin). 

Thyroid hormone has a specific role, especially when a person's thyroid hormone is already low, or on the low side of normal -- and perhaps especially if there are a lot of people in the family who have both thyroid and mood problems.  Recent research suggests that thyroid hormone, which is very inexpensive, may be both an antidepressant and a mood stabilizer, at least in women (2010); this has been under study for years, but with recent emerging evidence has climbed much higher on my list of options.  For details, first read basics about thyroid and bipolar disorder; then see my page on high-dose thyroid hormone.

Another add-on: verapamil has been around for a long time but has received renewed interest as an option during pregancy^Wisner, and for women at risk of weight gain and metabolic changes from other mood stabilizers; it may only work when added to lithium, though.^Mallinger  

In any case, you can see there are a lot of medications you might consider.  Here's a master list with several other ways of looking at the options.  You might end up trying quite a few looking for the best one for you.  And you'll need to be keeping track of your symptoms to know how you're doing on each one.  So you may as well start right now with the tracking.  Although of course "there's an app for it" , for most folks, a good paper and pencil chart will do (this one is from the Harvard mood clinic, modified with permission from Dr. Sachs; here's an example of how it looks if you stay at it).  Parents and significant others can keep such a chart, even if there are a lot of missing data-days, if the patient her/himself is not doing so.  I strongly recommend that.  

Specific guidelines for lamotrigine and lithium (and valproate)

As these got longer, I moved them to my mood stabilizer page; here is a link to the section on these medications.

What should I do with my antidepressant?

What if you are currently on an antidepressant?

• If you're doing well, maybe continue it.  This is controversial. 
• If you've just been diagnosed as bipolar, most doctors will add a mood stabilizer to your antidepressant.  
  • If things clearly get better, and you're doing well, again it's controversial what to do.  
  • If things get better but still you're cycling up and down, just not as much, then in my opinion it's clear:  you should talk to your doctor about tapering off the antidepressant (very slowly! Take at least several months to get to zero).  
• If you're currently on a mood stabilizer and not doing well, then in my view you need to ask your doctor what risks she sees in tapering off the antidepressant. 

Please note the emphasis on talking with your doctor.  Some of my colleagues have expressed their concern to me that their patients will read this website and stop their antidepressants.  If that was really happening very often, I'd have to consider shutting down the site.  The intent here is not to undermine other doctors, just to educate those who wish to learn more than their doctors have time to teach. 

There is strong consensus that antidepressants can -- in some people --  make bipolar disorder worse (e.g. see another expert's summary). The depression gets better, but the "manic" side symptoms (remember, this can include sleep problems, anxiety/agitation, irritability, and difficulty concentrating) get worse.  The whole mess can start to "cycle" more frequently, even though the depression is better.  In many people, eventually a full depression episode occurs again, despite being on an antidepressant, even one that "worked" before!  For some people, you can even say that the antidepressant is causing depression, by making the cycling continue, including cycling into depression.  

In that case, even if a mood stabilizer does not have antidepressant effects by itself (there is debate about valproate and carbamazepine in this respect, compared to lithium) it can "work" as an antidepressant very well, by stopping the cycling.  I have seen this happen many, many times:  so many, in fact, that I routinely rely on the mood stabilizers to help depressed people, and taper off their antidepressants, even while they are depressed.  Many times it’s the only way out of the problem (though usually I’ll start the mood stabilizer along with their antidepressant, then taper off the antidepressant when it’s clear the person is getting better).

Gary Sachs, the Harvard bipolar expert, jokes that he tell bipolar patients who experience a very strong antidepressant response: "great, let’s celebrate, let’s lower the dose of your antidepressant!"^Sachs(a)  Note how different an approach this is than in unipolar depression, where continuing an effective antidepressant for 6 months is the standard advice .  However, there is no clear consensus on how to handle antidepressants in bipolar disorder.

I advise patients that they have not had an adequate trial of mood stabilizers if they were simultaneously on an antidepressant at the time. If we try almost everything and the patient still does not improve, eventually she/he will need to try the same mood stabilizers again without an antidepressant on board.

Should I show you that link to controversies regarding antidepressant use one more time? (the language is more complex but I hope you'll find the concepts fairly clear).  Yeesh, this Phelps guy really seems to have a thing about antidepressants, doesn't he?  

How long should someone stay on mood stabilizer medications?

Most people ask: "will I have to take this for the rest of my life?"  I generally answer this by suggesting that first we should see whether the medication seems to work; later, if it does, we’ll discuss how long to continue it.  People often seem to grasp intuitively that if they have had symptoms for many years, they will probably require medications to "normalize their brain chemistry" for many years.

Bipolar I is a long-term illness that usually requires lifelong preventive strategies, at least after several manic or depressed phases have occurred.  Bipolar II is less well defined but intuition is generally correct:  the longer people have had symptoms, the longer it makes sense to continue the medication before a trial of tapering it off.  In any case, "taper" is the most important concept. There are several studies in Bipolar I which seem to indicate that rapidly discontinuing lithium leads to rapid relapse, where tapering off does not present that risk.  For lithium at least, stopping should take months, decreasing by 150mg increments all the way to zero; and this probably applies, by extension (for the moment, at least, until we have some data to go on), to other mood stabilizers.

However, you obviously have ultimate control over how your medication is managed — you’re the one that has to put the pills in your mouth every day.  If you decided to, you could just stop doing that. So you really ought to know about any risks that might come with doing that, and there are some.  At minimum, if your symptoms have been severe in the past, you should have some sort of a "safety net" if you’re going to stop the medications: a partner, or parent, or several close friends and a work acquaintance.  Somehow there should be a group who’s going to easily notice if you’re "slipping", including someone who can take charge of getting you help, if you are not able to do so yourself.

Be aware that you cannot expect the medications will "work" again if you stop taking them, then start again.  Bipolar disorder in many cases seems to progress, as though each cycle was increasing the likelihood and the severity of yet more cycles. Left uncontrolled for a period of time, it can worsen so that previously effective treatments are no longer adequate.  

The thoughtful reader may have wondered: "is there any evidence that starting mood stabilizers then stopping them is worse than never having started them at all?"  There is no evidence of this that I know of.  We should worry about it, though.  I have seen about three patients where it looked to me as though this might have occurred (out of roughly two thousand), but there are so many variables involved it is impossible to be at all certain.  The fact that I have yet to encounter other experts writing about this possibility is somewhat reassuring.  

I have seen mood stabilizers seem to make people more depressed than they were before they started, so that is worth watching for (we stopped the medication and things got better; then tried other approaches).  This has occurred particularly with divalproex/Depakote, oxcarbazepine/Trileptal, and carbamazepine/Tegretol, though it's very uncommon, perhaps 1 in a hundred or so by my estimate.  I've not seen other mood experts describe this problem.  Nor have I seen it with lithium or lamotrigine or thyroid, all of which have some "built-in" antidepressant potential.  

Can I really do this with my primary care doctor?

You should do this with a psychiatrist who knows about bipolar II if you possibly can, even if it means traveling a long way. If it is impossible for you to find a psychiatrist, obviously you and your primary care provider may be stuck trying whatever you can.  Hopefully this website will help you decide if bipolar II should be considered, and help with trying some basic treatments if you decide bipolar II has the "power" to explain your experience.

Primary care providers are being bombarded with material from the internet.  They don’t have time to read it all.  Invite them to read this site, which actually has all the references I'd want to present to a primary care provider.  You might be able to convince her to do so, if you say something like:

"I know you’re trying to help me, and I wish I had a simpler problem to deal with. I found a site on the internet that made a lot of sense to me, and might help us help me. Here’s a letter from the doctor who wrote it."

Then hand her a Dear Doctor letter -- or use any approach you think might work to get her to the doctors’ site!

But please remember: most doctors have not been well-trained in this area.  Asking them to do something outside their training will make many providers very anxious. They may resist this, and in some cases they may resist in odd ways. If they are frustrated at not being able to help you, which is probably true, their frustration can sometimes seem like it’s aimed at you. It should be aimed at the symptoms, of course. Give him room to "say no" gracefully -- which may save both of you some discomfort.  After that, if you need it, here are those thoughts about how to talk to doctors.  

Congratulations, that’s it for the basics of treatment. From here you can review, or you can select from brief essays on more treatment details.