If left untreated, episodes of bipolar-related depression or mania can last for between 6-12 months.
On average, someone with bipolar disorder will have five or six episodes over a 20-year period. However, with effective treatment, episodes usually improve within about three months.
The majority of people with bipolar disorder can be treated using a combination of different treatments. These include:
- medicines 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,
- medicines to treat the main symptoms of depression and mania as and when they occur,
- learning to recognise things that trigger an episode of depression or mania
- learning to recognise the signs of an approaching episode.
Medication
A number of medications are available to help stabilise mood swings. These include:
- lithium carbonate
- anti-convulsant medicines
- anti-psychotic medicines
Lithium carbonate
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 and it is usually prescribed for a minimum of six months.
If you are prescribed lithium, stick to the prescribed dose and do not stop taking it suddenly (unless directed to by your doctor).
For lithium to be effective, it is essential that the dosage is correct. If the dose is incorrect, it may cause side effects, such as diarrhoea and vomiting. If you are taking lithium and you have side effects, tell your doctor immediately.
While taking lithium, you will need to have regular blood tests (at least once every three months) to ensure that your levels of lithium are not too high or too low.
Lithium levels are measured in millmoles per litre of blood (a millimole is a measuring unit used to measure very small things like molecules) or mmol/L
If you are being prescribed lithium for the first time then your treatment team will be aiming to achieve a lithium level of between 0.6 and 0.8 mmol/Ls.
If this fails to control your symptoms, or you have a relapse, then your dosage may be increase so you have blood lithium levels of between 0.8 and 1 mmol/Ls.
While lithium levels of above 1 mmol/Ls are usually considered too high so if monitoring detected such levels it is likely that your dosage or medication will need to be adjusted.
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 specifically prescribed by your GP. Your GP can advise you further about this.
In the UK, lithium is currently the only medication that is licensed for use with children who have bipolar disorder (those who are aged 12 or over). However, in 2000, the Royal College of Paediatrics and Child Health stated that unlicensed medicines may be prescribed for children if there are no suitable alternatives, and where their use can be justified by expert consensus (agreement).
Anti-convulsant medicines
Anti-convulsant medicines include:
- valproate,
- carbamazepine, and
- lamotrigine.
These medicines are sometimes used to treat episodes of mania. Like lithium, they are long-term mood stabilisers. Anti-convulsant medicines are often used to treat epilepsy, but they have also been found to be effective in treating bipolar disorder.
A single anti-convulsant medicine may be used or, in cases where the condition does not respond to the use of lithium on its own, they may be used in combination with lithium.
Valproate
Valproate is not usually prescribed for women of child bearing age because it may carry risks to an unborn child. However, if there is no alternative, your GP will need to ensure that 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, before gradually being increased. If you are taking other forms of medication (including the contraceptive pill) your progress will be carefully monitored.
When you start taking carbamazepine, a number of blood tests will be carried out to check the functioning of your liver and kidneys, and then 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 that will be increased gradually.
If you are taking lamotrigine and you develop a rash, visit your GP immediately. You will also need to have an annual health check but other tests will not usually be required.
Women who are taking the contraceptive pill should talk to their GP about changing to a different method of contraception.
Anti-psychotic medicines
Anti-psychotic medicines are sometimes prescribed to treat episodes of mania or hypomania (less severe mania). Anti-psychotic medicines include:
- olanzapine
- quetiapine
- risperidone
Olanzapine may also be used long-term as a mood stabiliser and quetiapine for long-term bipolar depression.
Anti-psychotic medicines can be particularly useful if the symptoms are severe or the behaviour is disturbed. As anti-psychotics can cause side effects, such as blurred vision, dry mouth, constipation and weight gain, the initial dose will usually be kept low.
If you are prescribed an anti-psychotic 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 do not improve, you may be offered lithium and valproate as well.
Stopping medication
If your GP or psychiatrist recommends that you stop taking medication for bipolar disorder, the dose should be gradually reduced over a minimum of four weeks and up to three months if you are taking an anti-psychotic or lithium.
If, for any reason, you have to stop taking lithium, see your GP about taking an anti-psychotic or valproate instead.
Rapid cycling
If you experience rapid cycling (where 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 does not 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 anti-depressant unless an expert in bipolar disorder has specifically recommended it.
Treating depression
If you are already taking medication for bipolar disorder and you developdepression, your GP will check that you are taking the correct dose and, if necessary, they will adjust it.
Episodes of depression in bipolar disorder can be treated in a similar way to clinical depression. This includes the use of anti-depressant medication.
Anti-depressants
Anti-depressants are effective in about 70% of cases. However, it can take time (between two to four weeks) for them to take affect. Therefore, if you are prescribed a course of anti-depressants, you need to be patient and persevere with them.
There are several different types of anti-depressants, some of which have possible side effects. Some common anti-depressants include:
- tricyclic anti-depressants (TCAs): such as amitryptyline, imipramine, and dothiepin
- selective serotonin reuptake inhibitors (SSRIs): such as fluoxetine, sertraline, paroxetine and citalopram
- monoamine oxidase inhibitors (MAOIs): such as phenelzene and isocarboxazid
- newer anti-depressants: such as mirtazapine, venlafaxine and reboxetine.
Learning to recognise triggers
If you have bipolar disorder, it is possible to learn to recognise the warning signs of an approaching episode of mania or depression. This will not prevent the episode occurring, but it will enable you to get help in time.
This may mean making some changes to your treatment, perhaps adding an anti-depressant or anti-psychotic medicine to the mood stabilising medication you are already taking. Your GP or specialist can advise you about this.
Treatment in hospital
Most people with bipolar disorder are able to receive the majority of their treatment without having to stay in hospital.
However, treatment in hospital may be required if your symptoms are very severe, or if you are being treated under the Mental Health Act because there is a danger that you will harm yourself or others.
In some circumstances it may be possible for you to receive treatment in a day hospital and return home at night.
Other useful treatments
Other possible treatments for bipolar disorder include:
- psychological treatment: to help you to deal with your depression and your other symptoms, and to provide you with advice about how to improve your relationships
- regular exercise: has been found to be an effective method of dealing with depression,
- planning activities that you enjoy and that give you a sense of achievement
- dietary advice: particularly in relation to effective weight management.
You may also receive advice about how to ensure that you sleep well.
Pregnant women
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 of Clinical 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 also be developed as soon as possible. The plan should be drawn up in conjunction with the patient, her partner, her obstretician (pregnancy specialist), midwife, GP and health visitor.
The following medication is not routinely prescribed for pregnant women with bipolar disorder:
- valproate: as there is a risk to the foetus and the subsequent development of the child
- carbamazepine: as it has limited effectiveness and there is risk of harm to the foetus
- lithium: as there is a risk of harm to the foetus, such as cardiac problems
- lamotrigine: as there is a risk of harm to the foetus
- paroxetine: as there is a risk of harm to the foetus, such as cardiovascular malformations
- long-term treatment with benzodiazepines: as there are risks during the pregnancy and the immediate postnatal period, such as cleft palate and floppy baby syndrome
See the NICE guidance for bipolar disorder, which also includes information and advice about bipolar disorder and pregnancy.
