Just a few of the sites I found for you, but as always I recomend that you TALK TO YOUR DOCTOR, your doctor will tell you which forms of treatment will work best for you and will work with you to change treatment should initial treatment fail. Please consult your doctor befor following any medical advice, they don't just add this because of liability issues in ads...they do this because it is your health and you need to take an active role in maintianing good health.
How is bipolar disorder treated?
Bipolar disorder can be treated by your family doctor. Your family doctor may want you to see a psychiatrist too. You and your doctors will work together to control your mood swings and make sure you stay well.
Bipolar disorder is treated with medicines to stop the mood swings. Mood stabilizers are used to even out highs and lows in your mood. Antidepressant medicine can help reduce the symptoms of depression. Your doctor may add other medicines as you need them. These medicines don't start to work right away, but you will start to notice a difference in your moods after a few weeks. Be sure to take your medicines just as your doctor tells you.
Counseling can help you with stress, family concerns and relationship problems. It's important to get counseling if you have bipolar disorder
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Treating Bipolar Disorder: Toward the Third Millennium
by Heather S. Hopkins and Alan J. Gelenberg, M.D.
February 2001, Vol. XVIII, Issue 2
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(This is the first part of a series of articles discussing treatments for bipolar disorder--Ed.)
Although lithium is still the only drug approved by the U.S. Food and Drug Administration for both the treatment of acute mania and the maintenance treatment of bipolar disorder (BD), it is not efficacious for many people with BD, and its side effects are problematic for many others. The search for alternative treatments for the 20% to 40% of "classic" patients who do not respond adequately to lithium or cannot tolerate it continues. Even more, nonclassic patients (for example, rapid-cyclers, patients with mixed and dysphoric mania, and those with comorbid substance abuse) seem even less likely to respond adequately to lithium. Because a minority of patients with BD remain euthymic on lithium alone, adjunctive treatments are also being studied.
Divalproex (Depakote) and olanzapine (Zyprexa) are approved for the treatment of acute mania, but no trial has shown their efficacy in prophylaxis. Carbamazepine (Tegretol) continues to be employed for acute mania, bipolar depression and maintenance treatment, but rigorous studies have not produced consistent, positive results. Investigators are now looking at newer anticonvulsants, such as lamotrigine (Lamictal), gabapentin (Neurontin), topiramate (Topamax) and tiagabine (Gabitril).
In contrast with prescribing practices in many other countries, where doctors primarily use lithium, many doctors in the United States are prescribing these newer therapies to their patients before rigorous studies have proven their effectiveness.
Lithium
Many double-blind studies have shown lithium to be more efficacious than placebo in the long-term treatment of BD (Goodwin and Jamison, 1990). Some recent studies, however, have obtained less favorable results (Silverstone et al., 1998; Gershon and Soares, 1997; Moncrieff, 1995). To test the hypothesis that the effectiveness of lithium in BD has diminished over the past 30 years, Baldessarini and Tondo (2000) reviewed the medical literature from 1970 to 1996 and analyzed 360 patients with BD who had started maintenance lithium treatment during this time period. They found no indication that benefits from lithium treatment in BD have decreased and suggest that less favorable results with lithium may be due to the inclusion in clinical trials of more patients with atypical, treatment-unresponsive illness. Gitlin and Altshuler (1997) agreed that a change in the type of patients treated in clinical settings (including more patients with comorbid disorders), as well as problems with compliance, contribute to the disparity between results from controlled studies and naturalistic data. Schou (1993) cited "insufficient information, support, and supervision" as a cause of poor results with lithium, but Maj and colleagues (1998) found a high dropout rate (almost 30%)-despite efforts to optimize compliance-in 402 patients who started lithium prophylaxis at a lithium clinic.
Patients with a classical presentation of BD-clear-cut onset and recovery from episodes, and an absence of comorbid complications-appear to respond better to lithium treatment than do patients with complicating factors. Grof and colleagues studied "excellent responders" to lithium to identify determining characteristics (as cited in Friedrich, 1999). They found that these patients experienced full remissions between episodes and no loss of efficacy over time. In contrast to theories of discontinuation-induced refractoriness (Post et al., 1992), patients who discontinued lithium in this study experienced no loss of efficacy when they restarted treatment (Grof et al., as cited in Friedrich, 1999). Coryell and co-authors (1998) also found no evidence that discontinuing lithium caused a worse future response.
There may be two different groups of patients with BD: those who are responsive to lithium versus those who are more responsive to anticonvulsants or other agents (Goodwin and Ghaemi, 1998; Swann et al., 1997). A potential problem, however, is that anticonvulsants may not have the same ability to protect against suicide. Approximately 19% of patients with BD commit suicide (Goodwin and Jamison, 1990). There is about a sevenfold reduction in suicidal behavior with lithium treatment compared with no treatment (Baldessarini et al., 1999), and lithium may decrease the suicide rate in patients with mood disorders, even when it does not decrease the number of mood episodes.
In a multicenter, controlled trial in Germany comparing lithium with carbamazepine over 2.5 years in 378 patients with bipolar or schizoaffective disorder, no patient taking lithium committed suicide. While taking carbamazepine, however, five patients attempted suicide and nine committed suicide (Thies-Flechtner et al., 1996). In two independent analyses, patients at high risk for suicide showed reduced suicide rates after taking lithium, whether their response to lithium in terms of episode prevention was good, fair or poor (Friedrich, 1999). Conceivably, lithium could be an antisuicide adjunct for patients with BD, even if they are stable on other medications.
Anticonvulsants
Divalproex has overtaken lithium in the United States as a treatment for bipolar disorder. In particular, it and other anticonvulsants are used alone or in conjunction with lithium and/or other agents in patients with dysphoric or mixed episodes, rapid cycling, neurologic histories or comorbid substance abuse.
Divalproex and carbamazepine. Divalproex has been shown to be efficacious for the treatment of acute mania and is approved by the U.S. Food and Drug Administration for this indication. The study by Bowden et al. (1994) found that patients with acute mania who had a history of poor response to lithium were more likely to improve with divalproex. Patients with multiple prior episodes also did better with divalproex than with lithium. A recent one-year study did not establish a statistically significant superiority of divalproex over placebo for maintenance therapy, but it did show a trend for a maintenance effect (Bowden et al., in press). Results from a small study suggest that adding divalproex to lithium for the continuation and maintenance treatment of patients with BD may enhance efficacy, although it also increases the risk of adverse reactions (Solomon et al., 1997). The combination of lithium and valproate led to increased serum lithium levels in one-third of patients in one case series (Sharma et al., 1993) and in laboratory rats, who also showed a decrease in plasma valproate levels (Vargas et al., 1996).
Carbamazepine is considered a second- or third-line treatment for acute mania or maintenance therapy, but conclusive evidence for its efficacy is lacking. Recent studies have continued to show that it may be effective in some patients but not as effective as lithium. In Germany, Greil and others (1997) found no statistically significant differences between lithium and carbamazepine on survival analyses regarding hospitalizations and recurrences. Carbamazepine-treated subjects, however, required significantly more comedication with antidepressants or neuroleptics, and more dropped out of treatment due to severe side effects.
In another study, patients were randomly assigned to one-year sequential treatment with carbamazepine, lithium and the combination (Denicoff et al., 1997b). Many of the subjects had a history of psychosis and/or rapid cycling. Patients had the same number of episodes during the carbamazepine year (seven manic, six depressive) as during the lithium year (four manic, nine depressive), but fewer during the year of combination treatment (three manic, four depressive). Patients from this study who did not respond to either lithium or carbamazepine were enrolled in another crossover study (Denicoff et al., 1997a). After one year, six of 18 had moderate to marked responses to lithium plus divalproex, and three of seven responded to therapy with lithium, divalproex and carbamazepine. In a small open trial of carbamazepine for bipolar patients in a depressive or mixed episode, 63% of patients were considered to have entered remission after three weeks of treatment (Dilsaver et al., 1996).
In a study of young women with epilepsy, 43% on valproate monotherapy and 50% of those taking valproate and carbamazepine had polycystic ovary (PCO) syndrome (Isojýrvi et al., 1993). A cross-sectional pilot study failed to find an association between divalproex and PCO syndrome in women with BD, but did find high rates of menstrual disturbances in women taking both divalproex and lithium (Rasgon et al., 2000). Therefore, although data are lacking in young women taking this drug for mood stabilization, there is a possible risk for PCO and menstrual disturbances.
Gabapentin and lamotrigine. Open-label studies, case series and individual reports have indicated that gabapentin and lamotrigine may be efficacious in the treatment of BD and that they might be considered as alternatives for primary or adjunctive therapy when more established treatments are ineffective or poorly tolerated (Bennett et al., 1997; Fatemi et al., 1997; Fogelson and Sternbach, 1997). Gabapentin may be superior to divalproex and carbamazepine for anxiety and agitation, whereas lamotrigine may have more antidepressant potency.
In one double-blind study, lamotrigine monotherapy at both 50 mg and 200 mg was found to be significantly superior to placebo for bipolar depression (Calabrese et al., 1999). Bowden and others (1999) found significant improvement among both rapid-cycling and non-rapid-cycling treatment-resistant patients in both depressive and manic symptomatology in an open trial of lamotrigine as monotherapy or in combination with other drugs. Informal reports suggest lack of efficacy for gabapentin in rigorously designed trials. An analogous agent, pregabalin, may undergo study.
Topiramate. Topiramate was approved as an adjunctive antiepileptic treatment by the FDA in late 1996. As with gabapentin and lamotrigine, it has not been systematically studied as a treatment for bipolar disorder. A few reports suggest it may be efficacious as an adjunctive treatment for patients with BD unresponsive to more standard treatments, including patients with rapid cycling (Chengappa et al., 1999; Marcotte, 1998; Marcotte et al., 1998). Suppes et al. (1998) found that 35% of patients who were hypomanic or manic and 50% of patients who were depressed were much or very much improved after one month of adjunctive treatment with topiramate. Coadministration of carbamazepine or divalproex lowers topiramate serum levels and plasma levels of divalproex. The side effects of topiramate include dizziness, somnolence, psychomotor slowing, ataxia and-in contrast to most other antiseizure medications-weight loss. Conceivably, it could be an adjunct to the many other antimanic agents and mood stabilizers that increase weight.
Tiagabine. Because the anticonvulsant tiagabine has a mechanism of action similar to divalproex, as well as antikindling properties, it might be another treatment for acute mania. In one small open trial, however, it produced only mild improvement in a few patients (Grunze et al., 1999).
Conclusion
For patients with BD who do not respond to or cannot tolerate lithium, there are now many alternatives, although few have adequate scientific support of their benefit in a large number of patients, in long-term treatment and in medication combinations. It seems prudent at this stage to use an evidence-based approach, starting with the medications whose efficacy is best established by large, rigorously designed trials. Treatment needs to be tailored to the individual patient, based on personal and family history of response and characteristics of the illness. Polypharmacy may be the answer for many patients, and psychotherapy can help provide long-term stability. The multicenter, collaborative Systematic Enhancement Program for Bipolar Disorder (STEP-BD) project, sponsored by the National Institute for Mental Health, may help tease apart the current confusion among treatment options.
Ms. Hopkins is general partner with Arizona Editors, a writing and editing company in Tucson. She has been the assistant editor of Biological Therapies in Psychiatry for 10 years.
Dr. Gelenberg is professor and chair of the department of psychiatry at the University of Arizona Health Sciences Center in Tucson.
References
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Baldessarini RJ, Tondo L, Hennen J (1999), Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar manic-depressive disorders. J Clin Pyschiatry 60(suppl 2):77-84.
Bennett J, Goldman WT, Suppes T (1997), Gabapentin for treatment of bipolar and schizoaffective disorders. J Clin Psychopharmacol 17(2):141-142 [letter].
Bowden CL, Brugger AM, Swann AC et al. (1994), Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. [Published erratum appears in JAMA 271(23):1830.] JAMA 271(12):918-924 [see comment].
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Bowden CL, McElroy SL, Calabrese JR et al. (in press), Efficacy of divalproex vs. lithium and placebo in the prophylactic treatment of bipolar disorder. Arch Gen Psychiatry.
Calabrese JR, Bowden CL, Sachs GS et al. (1999), A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin Psychiatry 60(2):79-88.
Chengappa KNR, Rathore D, Levine J et al. (1999), Topiramate as add-on adjunctive treatment for patients with bipolar I or schizoaffective bipolar type disorder experiencing either a manic or mixed episode. Poster 76. Presented at the 39th Annual Meeting of the New Clinical Drug Evaluation Unit, Boca Raton, Fla.; June 1-4.
Coryell W, Solomon D, Leon AC et al. (1998), Lithium discontinuation and subsequent effectiveness. Am J Psychiatry 155(7):895-898 [see comment].
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Denicoff KD, Smith-Jackson EE, Disney ER et al. (1997b), Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder. J Clin Psychiatry 58(11):470-478.
Dilsaver SC, Swann SC, Chen YW et al. (1996), Treatment of bipolar depression with carbamazepine: results of an open study. Biol Psychiatry 40(9):935-937.
Fatemi SH, Rapport DJ, Calabrese JR, Thuras P (1997), Lamotrigine in rapid-cycling bipolar disorder. J Clin Psychiatry 58(12):522-527.
Fogelson DL, Sternbach H (1997), Lamotrigine treatment of refractory bipolar disorder. J Clin Psychiatry 58(6):271-273 [letter].
Friedrich MJ (1999), Lithium: proving its mettle for 50 years. JAMA 281(24):2271-2273 [news].
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Greil W, Ludwig-Mayerhofer W, Erazo N et al. (1997), Lithium versus carbamazepine in the maintenance treatment of bipolar disorders-a randomised study. J Affect Disord 43(2):151-161.
Grunze H, Erfurth A, Marcuse A et al. (1999), Tiagabine appears not to be efficacious in the treatment of acute mania. J Clin Psychiatry 60(11):759-762.
Isojýrvi JI, Laatikainen TJ, Pakarinen AJ et al. (1993), Polycystic ovaries and hyperandrogenism in women taking valproate for epilepsy. N Engl J Med 329(19):1383-1388.
Maj M, Pirozzi R, Magliano L, Bartoli L (1998), Long-term outcome of lithium prophylaxis in bipolar disorder: a 5-year prospective study of 402 patients at a lithium clinic. Am J Psychiatry 155(1):30-35.
Marcotte D (1998), Use of topiramate, a new anti-epileptic as a mood stabilizer. J Affect Disord 50(23):245-251.
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Treatment
Treatment for bipolar disorder includes medication, psychotherapy, and, when necessary, electroconvulsive shock therapy (ECT). Treating the acute episode is similar to treating the underlying mood disorder (continual), though there are differences between the two approaches.
Acute Treatment of Manic Episode
The following drugs may be used to treat manic episodes:
Lithium (Eskalith®)
Valproate (Depakote®)
Carbamazepine (Tegretol®)
Olanzapine (Zyprexa®)
Ziprasidone (Geodon®)
These medications control mood swings and acute symptoms, manage recurrences, reduce the risk of suicide, and restore a sense of well-being.
Lithium revolutionized psychiatry when first introduced as a drug of treatment in the 1950s. The use of a simple salt to effectively treat mental illness supported the theory that chemical imbalances caused the disorders and dispelled beliefs that bad parenting or neglect were the only causes. Lithium is the mainstay of bipolar treatment, and the condition can often be controlled with lithium alone. It effectively treats both manic and depressive episodes and prevents devastating relapses. It typically takes 1 to 2 weeks for lithium to be effective.
There is a high rate of suicide among people with untreated bipolar disorder, and studies show that lithium treatment significantly reduces this risk. Conversely, patients who discontinue lithium treatment are 20 times as likely to commit suicide during the first 6 months following discontinuation.
Common side effects of lithium treatment include the following:
Blurred vision
Dry mouth
Fine hand tremor
Frequent urination
Mild nausea, occasional vomiting
Long-term effects include weight gain, possible hypothyroidism, and kidney dysfunction. Patients who have kidney disease should not take lithium. Levels of lithium in the blood are monitored regularly to ensure that the proper concentration is maintained.
Lithium may cause birth defects and pregnant women should discuss the risks of taking the drug during pregnancy with their health care providers.
Valproate, which was initially used to treat seizures, is also approved to treat bipolar disorder. This drug is more effective than lithium in treating rapid-cycling bipolar disorder. Blood levels of valproate must be monitored regularly because high levels can be toxic. Common side effects of valproate include the following:
Dizziness
Drowsiness
Nausea
Tremor
Long-term effects include weight gain and possible liver dysfunction. Patients with liver disease should not take this medication.
Carbamazapine is also an antiseizure drug. Although not approved by the FDA for the treatment of bipolar disorder, it can be used to control mania and depression in patients with the disorder. Common side effects include the following:
Dizziness
Drowsiness
Nausea and occasional vomiting
Rash
Long-term effects include reduced white blood cell count (leukopenia) and liver dysfunction. Patients who have liver disease should not take this drug. Blood levels of carbamazapine are monitored regularly.
Carbamazepine may cause birth defects and pregnant women should discuss the risks of taking the drug during pregnancy with their health care providers. Carbamazepine may cause oral contraceptive (i.e., birth control pill) failure. To avoid becoming pregnant, another form of birth control should be used while taking the drug.
Antipsychotic medications (e.g., olanzapine [Zyprexa®]) can be used to treat psychosis when it occurs in a manic episode. Symbyax combines olanzapine with fluoxetine hydrochloride (the active ingredient in Prozac®) to treat bipolar disorder. Antipsychotic medications may cause serious long-term side effects (e.g., tardive dyskinesia) and should be used at the lowest effective dose and discontinued as soon as symptoms resolve.
Patients taking antipsychotic medications should be evaluated periodically to assess the need for maintenance therapy (see treatment of schizophrenia). Side effects include the following:
Blurred vision
Drowsiness
Dry mouth
Weight gain
Ziprasidone (Geodon®) is an antipsychotic medication that recently has been approved by the FDA to treat manic episodes. This medication, which also is used to treat schizophrenia, is prescribed at higher doses to treat bipolar disorder. Side effects include the following:
Constipation
Cough
Diarrhea
Difficulty swallowing
Extreme tiredness
Increased or decreased body temperature
Low blood pressure (dizziness, increased heart rate, fainting)
Muscle spasms
Nausea
Seizures
Studies indicate that ziprasidone may cause fewer side effects (e.g., weight gain, movement disorders) than other medications.
Benzodiazepines are used to treat anxiety or agitation during a manic episode.
Risperidone (Risperdal®) has been approved by the Food and Drug Administration (FDA) as short-term treatment for acute mania associated with bipolar I disorder. This drug, which also is used to treat schizophrenia, may be used alone (called monotherapy) or in combination with lithium or valproate.
Side effects include the following:
Agitation
Anxiety
Dizziness
Excessive sleepiness (somnolence)
Headache
Acute Treatment of Depressive Episode
Treating the depressive episode in bipolar disorder is controversial for two main reasons. First, antidepressant medication may send a person into a manic or hypomanic episode. Second, antidepressants may cause rapid cycling. A person may recover more quickly from depression, but may experience the next episode sooner.
To reduce these risks, most psychiatrists prescribe mood stabilizers (e.g., lithium, valproate) in combination with antidepressants. Once the symptoms of the depressive episode resolve, the dosage of the antidepressant medication is tapered down over several weeks and finally discontinued.
If psychotic symptoms are present during an acute depressive episode, antipsychotic medication is prescribed. This medication is not used for maintenance therapy because of serious side effects that develop over the long term.
Otherwise, treating an episode of depression in bipolar disorder is the same as major depressive disorder (see treatment of depression).
Chronic Treatment (Prophylaxis) of Bipolar Disorder
Once bipolar disorder is diagnosed, it is necessary to continue treatment indefinitely. Various mood stabilizers are typically used for continual treatment, alone or combined. In some cases, an antidepressant or antipsychotic drug is used in the combination.
Patients require lifelong lithium therapy to prevent relapses. When lithium treatment stops, relapses occur within 6 months in 90% of patients, and subsequent lithium treatment and other treatments are less likely to be effective.
Chronic treatment with more than one type of medication requires close monitoring to ensure that the proper concentrations of the drugs are maintained and to make any necessary adjustments (e.g., change medications or dosages) to alleviate side effects.
Ongoing psychotherapy is necessary for the following reasons:
Ensures compliance with the schedule of medication
Helps patients deal with effects of the disorder on their social and work relationships
Helps patients maintain a positive self-image
Support groups are beneficial for patients, their families, and close friends. Patients receive encouragement, learn coping skills from others, share their concerns, and feel less isolated. Family members and friends acquire a better understanding of the illness, share their concerns, and learn how to support their loved ones.
Hospitalization
Hospitalization is required for severe episodes of mania and depression to protect patients from injuring themselves or others.
Electroconvulsive therapy (ECT) is used primarily as an acute treatment for hospitalized patients who are suicidal, psychotic, or dangerous to others. It is effective in nearly 75% of patients who undergo this treatment. Receiving ECT during pregnancy is considered safe.