Treatments aim to reduce the number and severity of the episodes of depression and mania that characterise bipolar disorder. 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 3 and 6 months. Episodes of depression tend to last longer, between 6 and 12 months.
However, with effective treatment, episodes usually improve within about 3 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 therapy, which help you deal with depression and provide advice on how to improve relationships
- lifestyle advice – such as doing regular exercise, planning activities that you enjoy and 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 because 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.
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 that 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 that 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 that you stop taking medication for bipolar disorder, the dose should be gradually reduced over a 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 (see below).
In the UK, lithium carbonate (often referred to as just lithium) is the medication that is 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, if you have side effects while taking lithium, tell your doctor immediately.
While taking lithium, you will need to have regular blood tests (at least once every three months) 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 2 to 3 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 (see below), 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 state that unlicensed medicines may be prescribed for children if there are no suitable alternatives, and where their use can be justified by expert agreement.
Anticonvulsant medicines include:
These medicines are sometimes used to treat episodes of mania. Like lithium, they are 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, when the condition does not respond to lithium on its own, they may be used in combination with lithium.
Valproate is not usually prescribed for women of child-bearing age because there is a risk that it could damage an unborn baby. However, 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 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. If you're taking other medication (including the contraceptive pill), your progress will be carefully monitored.
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.
If you are prescribed lamotrigine, you will usually be started on a low dose, which will be increased gradually.
If you are taking lamotrigine and develop a rash, see your GP immediately. 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 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 NICE as an option for treating moderate to severe manic episodes in adolescents with bipolar disorder.
If you have rapid cycling (you quickly change from highs to lows without a "normal" period in between), you may be prescribed a combination of lithium and valproate.
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 from occurring, but it will allow you to get help in time.
This may mean making some changes to your treatment, perhaps adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you are already taking. Your GP or specialist can advise you on this.
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 on bipolar disorder
- cognitive behavioural therapy (CBT), which 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.
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 that 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 should 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
- long-term treatment with benzodiazepines – 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.