How Is Bipolar Disorder Treated?
Most people with bipolar disorder—even those with the most severe
achieve substantial stabilization of their mood swings and related symptoms
with proper treatment. Because bipolar disorder is a recurrent
illness, long-term preventive treatment is strongly recommended
and almost always indicated. A strategy that combines medication
and psychosocial treatment is optimal for managing the disorder
In most cases, bipolar disorder is much better controlled
if treatment is continuous than if it is on and off. But even
when there are no breaks in treatment, mood changes can occur
and should be reported immediately to your doctor. The doctor
may be able to prevent a full-blown episode by making adjustments
to the treatment plan. Working closely with the doctor and communicating
openly about treatment concerns and options can make a difference
in treatment effectiveness.
In addition, keeping a chart of daily
mood symptoms, treatments, sleep patterns, and life events may
help people with bipolar disorder and their families to better
understand the illness. This chart also can help the doctor track
and treat the illness most effectively.
Medications for bipolar disorder are prescribed
doctors (M.D.) with expertise in the diagnosis and treatment of mental
disorders. While primary care physicians who do not specialize in
psychiatry also may prescribe these medications, it is recommended
that people with bipolar disorder see a psychiatrist for treatment.
Medications known as "mood stabilizers" usually
are prescribed to help control bipolar disorder.11 Several
different types of mood stabilizers are available. In general, people
with bipolar disorder continue treatment with mood stabilizers for
extended periods of time (years). Other medications are added when
necessary, typically for shorter periods, to treat episodes of mania
or depression that break through despite the mood stabilizer.
- Lithium, the first mood-stabilizing medication approved by the
U.S. Food and Drug Administration (FDA) for treatment of mania,
is often very effective in controlling mania and preventing the
recurrence of both manic and depressive episodes.
- Anticonvulsant medications, such as valproate
or carbamazepine (Tegretol®), also can have mood-stabilizing
effects and may be especially useful for difficult-to-treat bipolar
episodes. Valproate was FDA-approved in 1995 for treatment of mania.
- Newer anticonvulsant medications, including
gabapentin (Neurontin®), and topiramate (Topamax®), are
being studied to determine how well they work in stabilizing mood
- Anticonvulsant medications may be combined with lithium, or with
each other, for maximum effect.
- Children and adolescents with bipolar disorder generally are
treated with lithium, but valproate and carbamazepine also are
used. Researchers are evaluating the safety and efficacy of these
and other psychotropic medications in children and adolescents.
There is some evidence that valproate may lead to adverse hormone
changes in teenage girls and polycystic ovary syndrome in women
who began taking the medication before age 20. Therefore,
young female patients taking valproate should be monitored carefully
by a physician.
- Women with bipolar disorder who wish to conceive,
or who become pregnant, face special challenges due to the possible
harmful effects of existing mood stabilizing medications on the
developing fetus and the nursing infant. Therefore,
the benefits and risks of all available treatment options should
be discussed with a clinician skilled in this area. New treatments
with reduced risks during pregnancy and lactation are under study.
of Bipolar Depression
Research has shown that people with bipolar disorder are at risk of
switching into mania or hypomania, or of developing rapid cycling, during
treatment with antidepressant medication.16 Therefore, "mood-stabilizing" medications
generally are required, alone or in combination with antidepressants, to
protect people with bipolar disorder from this switch. Lithium and valproate
are the most commonly used mood-stabilizing drugs today. However, research
studies continue to evaluate the potential mood-stabilizing effects of newer
- Atypical antipsychotic medications, including
olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine
(Seroquel®), and ziprasidone (Geodon®), are being studied
as possible treatments for bipolar disorder. Evidence suggests
clozapine may be helpful as a mood stabilizer for people who do
not respond to lithium or anticonvulsants.17 Other
research has supported the efficacy of olanzapine for acute mania,
an indication that has recently received FDA approval. Olanzapine
may also help relieve psychotic depression.19
- If insomnia is a problem, a high-potency
benzodiazepine medication such as clonazepam (Klonopin®) or lorazepam (Ativan®)
may be helpful to promote better sleep. However, since these medications
may be habit-forming, they are best prescribed on a short-term
basis. Other types of sedative medications, such as zolpidem (Ambien®),
are sometimes used instead.
- Changes to the treatment plan may be needed at various times
during the course of bipolar disorder to manage the illness most
effectively. A psychiatrist should guide any changes in type or
dose of medication.
- Be sure to tell the psychiatrist about all other prescription
drugs, over-the-counter medications, or natural supplements you
may be taking. This is important because certain medications and
supplements taken together may cause adverse reactions.
- To reduce
the chance of relapse or of developing a new episode, it is
important to stick to the treatment plan. Talk to your doctor
if you have any concerns about the medications.
People with bipolar disorder often have abnormal thyroid gland function.5 Because
too much or too little thyroid hormone alone can lead to mood and energy changes,
it is important that thyroid levels are carefully monitored by a physician.
with rapid cycling tend to have co-occurring thyroid problems and may need to
take thyroid pills in addition to their medications for bipolar disorder. Also,
lithium treatment may cause low thyroid levels in some people, resulting in the
need for thyroid supplementation.
Medication Side Effects
Before starting a new medication for bipolar disorder, always talk with your
psychiatrist and/or pharmacist about possible side effects. Depending on the
medication, side effects may include weight gain, nausea, tremor, reduced sexual
drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be
sure to tell the doctor about all side effects you notice during treatment. He
or she may be able to change the dose or offer a different medication to relieve
them. Your medication should not be changed or stopped without the psychiatrist's
As an addition to medication, psychosocial treatments—including
certain forms of psychotherapy (or "talk" therapy)—are
helpful in providing support, education, and guidance to people
with bipolar disorder and their families. Studies have shown that
psychosocial interventions can lead to increased mood stability,
fewer hospitalizations, and improved functioning in several areas.13 A
licensed psychologist, social worker, or counselor typically provides
these therapies and often works together with the psychiatrist to
monitor a patient's progress. The number, frequency, and type of
sessions should be based on the treatment needs of each person.
interventions commonly used for bipolar disorder are cognitive behavioral
therapy, psychoeducation, family therapy, and a newer technique,
interpersonal and social rhythm therapy. NIMH researchers are studying
how these interventions compare to one another when added to medication
treatment for bipolar disorder.
- Cognitive behavioral therapy helps people with bipolar disorder
learn to change inappropriate or negative thought patterns and
behaviors associated with the illness.
- Psychoeducation involves teaching people with bipolar disorder
about the illness and its treatment, and how to recognize signs
of relapse so that early intervention can be sought before a full-blown
illness episode occurs. Psychoeducation also may be helpful for
- Family therapy uses strategies to reduce the level of distress
within the family that may either contribute to or result from
the ill person's symptoms.
- Interpersonal and social rhythm therapy helps people with bipolar
disorder both to improve interpersonal relationships and to regularize
their daily routines. Regular daily routines and sleep schedules
may help protect against manic episodes.
- As with medication, it
is important to follow the treatment plan for any psychosocial
intervention to achieve the greatest benefit.
- In situations where medication, psychosocial treatment, and
the combination of these interventions prove ineffective, or work
too slowly to relieve severe symptoms such as psychosis or suicidality,
electroconvulsive therapy (ECT) may be considered. ECT may also
be considered to treat acute episodes when medical conditions,
including pregnancy, make the use of medications too risky. ECT
is a highly effective treatment for severe depressive, manic,
and/or mixed episodes. The possibility of long-lasting memory
problems, although a concern in the past, has been significantly
reduced with modern ECT techniques. However, the potential benefits
and risks of ECT, and of available alternative interventions,
should be carefully reviewed and discussed with individuals considering
this treatment and, where appropriate, with family or friends.20
- Herbal or natural supplements, such as St. John's wort (Hypericum
perforatum), have not been well studied, and little is known about
their effects on bipolar disorder. Because the FDA does not regulate
their production, different brands of these supplements can contain
different amounts of active ingredient. Before trying herbal or
natural supplements, it is important to discuss them with your
doctor. There is evidence that St. John's wort can reduce the
effectiveness of certain medications.21 In
addition, like prescription antidepressants, St. John's wort may
cause a switch into mania in some individuals with bipolar disorder,
especially if no mood stabilizer is being taken.
fatty acids found in fish oil are being studied to determine
their usefulness, alone and when added to conventional medications,
for long-term treatment of bipolar disorder.
Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it is important
to understand that bipolar disorder is a long-term illness that currently has
no cure. Staying on treatment, even during well times, can help keep the disease
under control and reduce the chance of having recurrent, worsening episodes.
Do Other Illnesses Co-occur
with Bipolar Disorder?
Alcohol and drug abuse are very common among people with bipolar disorder.
Research findings suggest that many factors may contribute to these
substance abuse problems, including self-medication of symptoms, mood
symptoms either brought on or perpetuated by substance abuse, and risk
factors that may influence the occurrence of both bipolar disorder
and substance use disorders. Treatment
for co-occurring substance abuse, when present, is an important part
of the overall treatment plan.
Anxiety disorders, such as post-traumatic
stress disorder and obsessive-compulsive disorder, also may be common
in people with bipolar disorder. Co-occurring
anxiety disorders may respond to the treatments used for bipolar disorder,
or they may require separate treatment. For more information on anxiety
disorders, contact NIMH (see below).
How Can Individuals and Families Get Help for Bipolar Disorder?
with bipolar disorder should be under the care of a psychiatrist skilled
in the diagnosis and treatment of this disease. Other mental health
professionals, such as psychologists, psychiatric social workers, and
psychiatric nurses, can assist in providing the person and family with
additional approaches to treatment.
Help can be found at:
- University—or medical school—affiliated
- Hospital departments of psychiatry
- Private psychiatric offices and clinics
- Health maintenance organizations (HMOs)
- Offices of family physicians, internists, and pediatricians
community mental health centers
People with bipolar disorder may need help to get help
What About Clinical Studies for Bipolar Disorder?
- Often people with bipolar disorder do not realize how impaired
they are, or they blame their problems on some cause other than mental
- A person with bipolar disorder may need strong encouragement from
family and friends to seek treatment. Family physicians can play
an important role in providing referral to a mental health professional.
- Sometimes a family member or friend may need to take the person
with bipolar disorder for proper mental health evaluation and treatment.
- A person who is in the midst of a severe episode may need to be
hospitalized for his or her own protection and for much-needed treatment.
There may be times when the person must be hospitalized against his
or her wishes.
- Ongoing encouragement and support are needed after a person obtains
treatment, because it may take a while to find the best treatment
plan for each individual.
- In some cases, individuals with bipolar disorder may agree, when
the disorder is under good control, to a preferred course of action
in the event of a future manic or depressive relapse.
- Like other serious illnesses, bipolar disorder is also hard on
spouses, family members, friends, and employers.
- Family members of someone with bipolar disorder often have to cope
with the person's serious behavioral problems, such as wild spending
sprees during mania or extreme withdrawal from others during depression,
and the lasting consequences of these behaviors.
- Many people with bipolar disorder benefit from joining support
groups such as those sponsored by the National Depressive and Manic
Depressive Association (NDMDA), the National Alliance for the Mentally
Ill (NAMI), and the National Mental Health Association (NMHA). Families
and friends can also benefit from support groups offered by these
organizations. For contact information, see the "For
More Information" section at the back of this booklet.
Some people with
bipolar disorder receive medication and/or psychosocial therapy by
volunteering to participate in clinical studies (clinical trials).
Clinical studies involve the scientific investigation of illness and
treatment of illness in humans. Clinical studies in mental health
can yield information about the efficacy of a medication or a combination
of treatments, the usefulness of a behavioral intervention or type
of psychotherapy, the reliability of a diagnostic procedure, or the
success of a prevention method. Clinical studies also guide scientists
in learning how illness develops, progresses, lessens, and affects
both mind and body. Millions of Americans diagnosed with mental illness
lead healthy, productive lives because of information discovered through
clinical studies. These studies are not always right for everyone,
however. It is important for each individual to consider carefully
the possible risks and benefits of a clinical study before making a
decision to participate.
In recent years, NIMH has introduced a new generation
of "real-world" clinical
studies. They are called "real-world" studies for several
reasons. Unlike traditional clinical trials, they offer multiple different
treatments and treatment combinations. In addition, they aim to include
large numbers of people with mental disorders living in communities
throughout the U.S. and receiving treatment across a wide variety of
settings. Individuals with more than one mental disorder, as well as
those with co-occurring physical illnesses, are encouraged to consider
participating in these new studies. The main goal of the real-world
studies is to improve treatment strategies and outcomes for all people
with these disorders. In addition to measuring improvement in illness
symptoms, the studies will evaluate how treatments influence other
important, real-world issues such as quality of life, ability to work,
and social functioning. They also will assess the cost-effectiveness
of different treatments and factors that affect how well people stay
on their treatment plans.
The Systematic Treatment Enhancement Program
for Bipolar Disorder (STEP-BD) is seeking participants for the largest-ever, "real-world" study
of treatments for bipolar disorder. To learn more about STEP-BD or
other clinical studies, see the Clinical Trials page on the NIMH
Web site, visit
the National Library of Medicine's
clinical trials database, or