An Overview of Treatment Options for Bipolar Disorder

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Lori Altshuler, M.D.
Lori Altshuler, M.D.

Bipolar disorder is characterized by cycles of mania and depression. Although the manic state is more dramatic, the depressed state is experienced three times more frequently.  A number of medications and modalities are used in the treatment of bipolar depression with varying rates of effectiveness. At present, there is no test to predict which treatment will work best for an individual patient, an area of intense interest to bipolar disorder clinicians and researchers like Dr. Altshuler, and to researchers in virtually all areas of mental illness.

Lithium, which has been in long use for treating mania, has been shown to be effective in treating bipolar depression as well as to greatly reduce suicide, a very great risk among people with bipolar disorder. The anticonvulsant drugs lamotrigine (Lamictal) and valproate are used with lithium as mood stabilizers, but evidence points to possible effectiveness of lamotrigine alone as a treatment option.

Agents that are moderately effective for both depression and mania are the antipsychotic quetiapine (Seroquil), and a medication sold under the trade name Synbyax that combines the antipsychotic olanzapine (Zyprexa) with the antidepressant fluoxetine (Prozac), the antipsychotic Aripiprazole (Abilify), also provides good mood stabilization when combined with an antidepressant.

Some research has shown that antidepressants can help bipolar disorder depression on their own or in combination with a sub-therapeutic level of lithium. A recent study found that bipolar patients on an antidepressant combined with pramipexole, a drug used for Parkinson’s disease, showed improvement, but the study sample was too small to be definitive. There is some evidence of effectiveness for the B vitamin folate as an adjunct to an antidepressant. Oral folate does not cross the blood-brain barrier, but a newer folate formulation, sold under the trade name Deplin, does enter the brain and aids in the synthesis of neurotransmitters involved in mood.

Among other options that have shown some promise is modafinil (Provigil), a drug developed to treat daytime sleepiness.  Light therapy can help, and some reports support the use of omega-3 fatty acids. Brain stimulation techniques have been introduced in recent years for relieving unipolar depression that does not respond to antidepressant medication. One form, repetitive transcranial magnetic stimulation (rTMS), in which magnetic current stimulates a target area of the brain, is safe and noninvasive and appears to be effective for some patients for treating bipolar disorder depression.

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Please note that researchers cannot give specific recommendations or advice about treatment; diagnosis and treatment are complex and highly individualized processes that require comprehensive face-to- face assessment. Please visit our "Ask an Expert" section to see a list of Q & A with NARSAD Grantees.
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