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Bipolar Disorder: Treatment Part 2

Bipolar disorder is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe, but it can be treated, and people with this illness can lead full and productive lives.

What are the side effects of these medications?

Before starting a new medication, people with bipolar disorder should talk to their doctor about the possible risks and benefits. The psychiatrist prescribing the medication or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than earlier treatments. However, everyone responds differently to medications. In some cases, side effects may not appear until a person has taken a medication for some time.

If the person with bipolar disorder develops any severe side effects from a medication, he or she should talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. People being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to rebound, or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but they may have unintentional effects on some people, especially in adolescents and young adults. The U.S. Food and Drug Administration (FDA) warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor.

Mood Stabilizers

In some cases, lithium can cause side effects such as

• Restlessness
• Dry mouth
• Bloating or indigestion
• Acne
• Unusual discomfort to cold temperatures
• Joint or muscle pain
• Brittle nails or hair

Lithium also causes side effects not listed here. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

If a person with bipolar disorder is being treated with lithium, it is important to make regular visits to the treating doctor. The doctor needs to check the levels of lithium in the person's blood, as well as kidney and thyroid function.

These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking.

Common side effects of other mood stabilizing medications include

• Drowsiness
• Dizziness
• Headache
• Diarrhea
• Constipation
• Heartburn
• Mood swings
• Stuffed or runny nose, or other cold-like symptoms

Atypical Antipsychotics

Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days, and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women

Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these moments. TD can range from mild to severe, and it cannot always be cured. Some people with TD recover partially or fully after they stop taking the drug.

Antidepressants

The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include

• Headache, which usually goes away within a few days
• Nausea, which usually goes away within a few days
• Sleep problems, such as sleeplessness or drowsiness. This may happen during the first few weeks but then go away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
• Agitation or feeling jittery
• Sexual problems, which can affect both men and women. These include reduced sex drive, and problems having and enjoying sex.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

Should women who are pregnant or may become pregnant take medication for bipolar disorder?

Women with bipolar disorder who are pregnant or may become pregnant face special challenges. The mood stabilizing medications in use today can harm a developing fetus or nursing infant. But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy.

Scientists are not sure yet, but lithium is likely the preferred mood stabilizing medication for pregnant women with bipolar disorder. However, lithium can lead to heart problems in the fetus. Women need to know that most bipolar medications are passed on through breast milk. Pregnant women and nursing mothers should talk to their doctors about the benefits and risks of all available treatments.

Psychotherapy

In addition to medication, psychotherapy, or talk therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include

• Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
• Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.
• Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
• Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

A licensed psychologist, social worker, or counselor typically provides these therapies. This mental health professional often works with the psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. As with medication, following the doctor's instructions for any psychotherapy will provide the greatest benefit.

Recently, NIMH funded a clinical trial called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). This was the largest treatment study ever conducted for bipolar disorder. In a study on psychotherapies, STEP-BD researchers compared people in two groups. The first group was treated with collaborative care (three sessions of psychoeducation over six weeks). The second group was treated with medication and intensive psychotherapy (30 sessions over nine months of CBT, interpersonal and social rhythm therapy, or family-focused therapy). Researchers found that the second group had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plans. They were also more likely to get well faster and stay well longer.

NIMH is supporting more research on which combinations of psychotherapy and medication work best. The goal is to help people with bipolar disorder live symptom free for longer periods and to recover from episodes more quickly. Researchers also hope to determine whether psychotherapy helps delay the start of bipolar disorder in children at high risk for the illness.

Other Treatments

Electroconvulsive Therapy (ECT)

For cases in which medication or psychotherapy does not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as shock therapy, once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30-90 seconds. People who have ECT usually recover after 5-15 minutes and are able to go home the same day.

Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes, but is generally not a first line treatment.

ECT may cause some short term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.

Sleep Medications

People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, the doctor may suggest a change in medications. If the problems still continue, the doctor may prescribe sedatives or other sleep medications.

People with bipolar disorder should tell their doctor about all prescription drugs, over-the-counter medications, or supplements they are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

Herbal Supplements

In general, there is not much research about herbal or natural supplements. Little is known about their effects on bipolar disorder. An herb called St. John's wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder. St. John's wort can also make other medications less effective, including some antidepressant and anticonvulsant medications. Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long term treatment of bipolar disorder. It is important to talk with a doctor before taking any herbal or natural supplements because of the serious risk of interactions with other medications.

What can people with bipolar disorder expect from treatment?

Bipolar disorder has no cure, but can be effectively treated over the long term. It is best controlled when treatment is continuous, rather than on and off. In the STEP-BD study, a little more than half of the people treated for bipolar disorder recovered over one year's time. For this study, recovery meant having two or fewer symptoms of the disorder for at least eight weeks.

However, even with proper treatment, mood changes can occur. In the STEP-BD study, almost half of those who recovered still had lingering symptoms. These people experienced a relapse or recurrence that was usually a return to a depressive state. If a person had a mental illness in addition to bipolar disorder, he or she was more likely to experience a relapse. Scientists are unsure, however, how these other illnesses or lingering symptoms increase the chance of relapse. For some people, combining psychotherapy with medication may help to prevent or delay relapse.

Treatment may be more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can help a doctor assess a person's response to treatments. Sometimes the doctor needs to change a treatment plan to make sure symptoms are controlled most effectively. A psychiatrist should guide any changes in type or dose of medication.