Bipolar disorder - Treatment 

Treating bipolar disorder 

NICE guidance

According to the National Institute for Health and Care Excellence (NICE), good care for people with bipolar disorder should include:

  • working with patients and their families to develop a collaborative relationship
  • providing written information at every stage of the process, including information about medications
  • encouraging patients and their families and carers to join self-help and support groups
  • advising patients about monitoring their own symptoms, looking out for triggers and early warning signs
  • offering lifestyle advice, including good sleeping habits and coping strategies
  • writing advance statements, with patients and their families and carers if they agree, about their mental and physical healthcare, especially if they have severe episodes or have been treated under the Mental Health Act (these should be included in the care plans and circulated to the healthcare team)
  • taking into account the needs of the patient's family or carers, including their physical, social and mental needs, and being accessible in times of crisis

Read the NICE guidelines for the management of bipolar disorder.

For more information, take a look at the national service framework and strategy for mental health.

Find out how your local NHS manages bipolar disorder care

Treatment for bipolar disorder aims to reduce the number and severity of the episodes of depression and mania that characterise the condition. In doing so, a person can live as normal a life as possible.

Treatment options for bipolar disorder

If a person is not treated, episodes of bipolar-related mania can last for between three and six months. Episodes of depression tend to last longer, for between 6 and 12 months.

However, with effective treatment, episodes usually improve within about three months.

Most people with bipolar disorder can be treated using a combination of different treatments. These can include one or more of the following:

  • medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day on a long-term basis
  • medication to treat the main symptoms of depression and mania when they occur
  • learning to recognise the triggers and signs of an episode of depression or mania
  • psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
  • lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep

Read more about living with bipolar disorder.

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.

However, hospital treatment may be needed if your symptoms are severe, or if you are being treated under the Mental Health Act, as there is a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

Several medications are available to help stabilise mood swings. These are commonly referred to as mood stabilisers and include:

If you are already taking medication for bipolar disorder and you develop depression, your GP will check you are taking the correct dose. If you aren't, they will change it.

Episodes of depression are treated slightly differently in bipolar disorder, as the use of antidepressants alone may lead to a hypomanic relapse.

Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabiliser. However, antidepressants are commonly used alongside a mood stabiliser or antipsychotic.

Read more about antidepressants.

If your GP or psychiatrist recommends you stop taking medication for bipolar disorder, the dose should be gradually reduced over at least four weeks, and up to three months if you are taking an antipsychotic or lithium.

If you have to stop taking lithium for any reason, see your GP about taking an antipsychotic or valproate instead.

Lithium carbonate

In the UK, lithium carbonate (often referred to as just lithium) is the medication most commonly used to treat bipolar disorder.

Lithium is a long-term method of treatment for episodes of mania, hypomania and depression. It is usually prescribed for at least six months.

If you are prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly (unless told to by your doctor).

For lithium to be effective, the dosage must be correct. If it is incorrect, you may get side effects such as diarrhoea and vomiting. However, tell your doctor immediately if you have side effects while taking lithium.

You will need to have regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels are not too high or too low.

Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you are taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they are prescribed by your GP. 

In the UK, lithium and the antipsychotic medicine aripiprazole are currently the only medications licensed for use in adolescents with bipolar disorder who are aged 13 or over.

However, the Royal College of Paediatrics and Child Health states that unlicensed medicines may be prescribed for children if there are no suitable alternatives and their use can be justified by expert agreement.

Anticonvulsant medicines

Anticonvulsant medicines include:

These medicines are sometimes used to treat episodes of mania. They are also long-term mood stabilisers.

Anticonvulsant medicines are often used to treat epilepsy, but they are also effective in treating bipolar disorder.

A single anticonvulsant medicine may be used, or they may be used in combination with lithium when the condition does not respond to lithium on its own.

Valproate

Valproate is not usually prescribed for women of childbearing age because there is a risk it could damage an unborn baby.

It can be used if there is no alternative, although your GP will need to check you are using a reliable form of contraception.

If you are prescribed valproate, you will need to visit your GP to have a blood count when you begin the medication, and then again six months later.

Carbamazepine

Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.

Your progress will be carefully monitored if you're taking other medication, including the contraceptive pill.

Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine, and again after six months.

You will also need to have a blood count at the start and after six months, and you may also have your weight and height monitored.  

Lamotrigine

If you are prescribed lamotrigine, you will usually be started on a low dose, which will be increased gradually.

See your GP immediately if you are taking lamotrigine and develop a rash. You will need to have an annual health check, but other tests are not usually needed.

Women who are taking the contraceptive pill should talk to their GP about taking a different method of contraception.

Antipsychotic medicines

Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include: 

They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.

Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed. As antipsychotics can cause side effects – such as blurred vision, dry mouth, constipation and weight gain – the initial dose will usually be low.

If you are prescribed an antipsychotic medicine, you will need to have regular health checks at least every three months, but possibly more often, particularly if you have diabetes. If your symptoms don't improve, you may be offered lithium and valproate as well.

Aripiprazole is also recommended by the National Institute for Health and Care Excellence (NICE) as an option for treating moderate to severe manic episodes in adolescents with bipolar disorder.

Rapid cycling

You may be prescribed a combination of lithium and valproate if you experience rapid cycling (where you quickly change from highs to lows without a "normal" period in between).

If this doesn't help, you may be offered lithium on its own or a combination of lithium, valproate and lamotrigine.

However, you will not usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.

Learning to recognise triggers

If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.

This will not prevent the episode occurring, but it will allow you to get help in time.

This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you are already taking. Your GP or specialist can advise you on this.

Psychological treatment

Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:

  • psychoeducation – to find out more about bipolar disorder
  • cognitive behavioural therapy (CBT) – this is most useful when treating depression
  • family therapy – a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health

Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of six to nine months.

Pregnancy

The management of bipolar disorder in women who are pregnant, or those who are trying to conceive, is complex and challenging.

One of the main problems is the risks of taking medication during pregnancy are not always that well understood.

The National Institute for Health and Care Excellence (NICE) recommends that the risks of treating or not treating women with bipolar disorder during pregnancy should be fully discussed.

NICE also recommends that specialist mental health services work closely with maternity services.

A written plan for managing the treatment of a pregnant woman with bipolar disorder should be developed as soon as possible.

The plan should be drawn up with the patient, her partner, her obstetrician (pregnancy specialist), midwife, GP and health visitor.

The following medication is not routinely prescribed for pregnant women with bipolar disorder:

  • valproate – there is a risk to the foetus and the subsequent development of the child
  • carbamazepine – it has limited effectiveness and there is risk of harm to the foetus
  • lithium – there is a risk of harm to the foetus, such as cardiac problems
  • lamotrigine – there is a risk of harm to the foetus
  • paroxetine – there is a risk of harm to the foetus, such as cardiovascular malformations
  • benzodiazepines – if used long term, there are risks during the pregnancy and immediately after the birth, such as cleft palate and floppy baby syndrome

If medication is prescribed for bipolar disorder after the baby is born, it may also affect a mother's decision to breastfeed her child.

Page last reviewed: 08/04/2014

Next review due: 08/04/2016

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Comments

The 6 comments posted are personal views. Any information they give has not been checked and may not be accurate.

supporthealer said on 23 July 2013

@AlexisGreen-your mum may be in denial as she has lost her son and she will live in fear that one of her other children suffers from bipolar.
The mind is fascinating and we must try to take control of how it works and not let the mind take control over us. Difficult I know, but techniques such as meditation and Mindfulness will help you to take time out and let your mind recover from all the stimuli. You have been very brave to self diagnose and the fact that you want to seek help is very reassuring and a positive aspect which suggests that you are intelligent and you will take control of your illness, something your brother was not fortunate enough to do All the best.

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AlexisGreen said on 06 December 2012

Since my brother died two years ago (took his own life) I have been having these symptoms, I tried to tell my mum but its hard how can I tell her that two out of four of her kids are potentially mental ill, she already lost my brother, it's getting hard and harder to hide how I am feeling from her now,I'm very sure I have bipolar and I'm having a downer at the moment which means I haven't been to bed yet what should I do because my mum doesn't want to hear it when I tell her I need help she always tells me it's part of being a 15year old girl & dealing with my brothers death but its not I just know that I'm not right shall I get someone to take me doctors other than my mum & tell her if I do have it once the doctors say I do? Will it stop me from chasing my dreams like my brother ? He had depression but since feeling the way I feel and research bipolar I have become sure he had it too and I'm very sure I have it I don't want it but there's nothing I can do. Advise please anyone? Thank you

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LeeJ23 said on 13 September 2012

I've not yet been diagnosed as having bipolar disorder but I am being treated for it and have been told that it's likely to be causing my symptoms. I am taking carbamazepine 400mg and it's my fourth attempt at finding a 'good' antidepressant.
I have heard that being diagnosed can take a very long time. The illnesses (both bipolar and severe depression)have had such a large impact on my life over the last year and I've hit rock-bottom so many times with the rapid cycling of my moods.
Carbamazepine has had some useful interactions and has partly controlled my elevated moods, but I've found that now my moods are far more mixed between elevated and depressive within one day but are less severe than before I begun taking carbamazepine. I don't know if this is normal?

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bermudj said on 25 December 2011

I am Bipolar-I and I manage the illness without any medication what so ever. I disagree with your statement that recognising the trigger will not prevent the onset of the illness. Furthermore from my experience once the illness has began to creep on me medication has never stopped the progress of the illness. What has helped is that what triggers the illness has been indentified and this removed. Basically the stimulus has been taken away. You can contact me on this.

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Ponting said on 11 January 2011

The particular causes of bipolar disorder are unknown. While the genetic factors and stress of life are involved in triggering it. According to the experts the underlying imbalance of brain chemicals produces this kind of symptoms. When the levels of these chemicals are too high, mania occurs. When levels are low, there is depression. The best treatment for bipolar disorder is the combination of medication and counseling.
http://www.biblehealth.com/bipolar-disorder/bipolar-disorder-treatment-know-about-them.html

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STAVROS said on 24 February 2010

i am allso suffering from bipolar disorder.but the other thing is that im not taking any of these drugs above me why is that.can anyone outhere help me and tell me why im not taking any drugs only for depression

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