Different medications are used to treat bipolar disorder including mood stabilizers (e.g. lithium carbonate and valproate), antidepressants, antipsychotics and sedative-hypnotics. Mood stabilizers do what the name implies, that is they keep the mood from going up and down between episodes of depressed mood and mania. Antidepressants are often used to treat the depressed phase of bipolar disorder though they also risk causing or ‘inducing’ mania. Antipsychotics are used to treat symptoms of agitation and psychosis which occur frequently in acute mania. Sedative-hypnotics such as lorazepam are used to treat insomnia and agitation.
Antipsychotics, specifically newer second generation antipsychotics (also called ‘atypical antipsychotics’) are currently regarded as the treatments of first choice for bipolar mania with or without psychosis. The therapeutic benefits of antipsychotics and other medications used to treat bipolar disorder are limited by frequent and potentially serious adverse effects. Earlier so-called ‘first generation’ antipsychotics were associated with frequent neurologic adverse effects (e.g. akathisia) in contrast to the newer second generation antipsychotics which cause weight gain and metabolic adverse effects but less often cause neurologic side effects.
After decades of research there is still no consensus on which particular medication should be tried first. Efforts to identify the most effective medication treatments have been hampered by problems in recent systematic reviews of studies on medications used to treat bipolar disorder including, for example, the use of non-representative patient samples, short trial duration, and experimental design flaws that make it difficult to generalize findings between studies.
Determining which medication may be most efficacious for bipolar mania is not at a simple or straight forward process because of large variations in response and tolerance in individuals with the same symptoms treated with the same medication. Diverse genetic and neurobiological causes of bipolar disorder mean that treatment with the same medication results in a wide range of responses and differences in adverse effects. For example the average weight gain seen in individuals taking second generation antipsychotics (the so-called ‘atypical agents’) is a few kilograms however metabolic differences between individuals can increase that amount 10 to 20 fold. A recent systematic review and meta-analysis of drug trials in acute mania included 68 studies on all drug classes and over 16,000 patients. All drugs were found to be moderately superior to placebo and antipsychotics were found to be more effective than other mood stabilizers in general.
In the context of the limitations of available pharmacologic treatments emerging research findings support the use of select natural products in the treatment of bipolar disorder. To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.