8.3 Treatments for Bipolar Disorders

Bipolar disorder is often a lifelong illness, and episodes of mania and depression typically recur. Between episodes, many people with bipolar disorder are free of mood disruption, but some people have lingering symptoms. Long-term, continuous treatment can help people manage symptoms and prevent relapse. An effective treatment plan for bipolar disorder typically includes a combination of medications and psychotherapy.[1]

Medications

Medications used to treat bipolar disorder include mood stabilizers, anti-seizure medications, and second-generation (“atypical”) antipsychotics. Treatment plans may also include medications that target sleep disruption or anxiety. Antidepressant medication may be used to treat depressive episodes in bipolar disorder in combination with a mood stabilizer and/or antipsychotic to prevent precipitating a manic episode.[2] See Table 8.3 for a list of common medications used to treat bipolar disorders.[3] Review information about the associated neurotransmitters in the “Psychotropic Medications” chapter.

Table 8.3 Common Medications Used to Treat Bipolar Disorders

Medication Class Nursing Considerations Common Side Effects

(*Indicates medical emergency)
Mood Stabilizers Used to treat symptoms of mania and mood lability.
Lithium Used as a first-line mood stabilizing agent to treat mania when symptoms are acute or as maintenance therapy

Improved tolerance with food and better drug absorption

Recommended water intake is 1.5 – 3 liters/day

Given in divided doses if gastrointestinal distress occurs

NSAIDs are not recommended because they increase lithium levels

Therapeutic blood levels are required. Blood levels are drawn 10-12 hours after the last dose taken. The therapeutic lithium serum level is 0.6-1.2 mEq/L

 Lithium blocks ADH, so monitor for symptoms of diabetes insipidus (i.e., excessive thirst and urination)

Long-term use increases risk for hypothyroidism, hyperparathyroidism, and impaired kidney functioning

*Lithium toxicity (notify the health care provider)

Early signs (<1.5 mEq/L): nausea, vomiting, diarrhea, thirst, polyuria, slurred speech, muscle weakness, or fine tremors

Moderate signs (1.6-1.9 mEq/L): coarse hand tremors, mental confusion, persistent GI complaints, muscle hyperirritability, EEG changes, or uncoordinated movements

Severe signs (>2.0  mEq/L): ataxia, blurred vision, large output of dilute urine, severe hypotension, clonic movements, overt confusion, cardiac dysrhythmias, proteinuria, or death secondary to pulmonary complications

*Lithium levels > 2.5 mEq/L constitute a medical emergency, even if the client is asymptomatic.

Treatments for toxicity:

  • Notify the health care provider for any level of toxicity
  • Hold the lithium
  • Encourage fluids; IV fluids may be required
  • Gastric lavage
  • May require urea, mannitol, aminophylline, or dialysis to hasten the excretion of the drug in severe cases
Anti-seizure Medications Used to treat mania and other symptoms.
Valproic Acid (Depakote) Used for rapid cycling in acute manic phase when not responding to other mood stabilizers

Require periodic therapeutic serum valproic acid blood levels. Therapeutic range is 50-125 mcg/mL

Require laboratory monitoring, including liver function tests, amylase, and lipase and platelet levels due to higher risk for blood dyscrasias and pancreatitis
  • Weight gain
  • Sedation
  • Nausea and/or vomiting
  • Hair loss
  • Tremors
  • Gastrointestinal discomfort

*Signs of toxicity (notify the health care provider):

  • Abdominal pain
  • Dark colored urine
  • Jaundice
Carbamazepine (Tegretol) Used in combination with lithium and antipsychotic drugs for resistive symptoms

Used when treatment resistant due to rapid cycling, paranoia, and extreme hyperactivity

Requires routine laboratory monitoring, including white blood cells and liver function tests because it can cause bone marrow suppression and liver damage

Therapeutic serum blood levels are 4-12 mcg/mL
  • Risk for hyponatremia
  • Fatigue
  • Blurred vision
  • Nausea
  • Ataxia

Risk for toxicity if tegretol blood level is >20 mcg/mL. If suspect toxicity, hold the drug and notify the health care provider.
Lamotrigine (Lamictal) Used with acute mania or as maintenance therapy

Therapeutic serum blood level is 2.5 to 15 mcg/mL

Improved tolerance in divided doses
  • Stevens-Johnson syndrome (A rare but potentially life-threatening reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters.)
Topiramate (Topamax)

Oxcarbazepine (Oxtellar)

 Used for treatment resistant mania Topiramate

  • Weight loss
  • Fatigue
  • Visual disturbances

Oxcarbazepine

  • Hyponatremia
Antipsychotics Medications Used to treat symptoms of psychosis, agitation, insomnia, or anxiety.
Olanzapine (Zyprexa)

Risperidone (Risperdal)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Aripiprazole (Abilify)

Clozapine (Clozaril)

 Help stabilize mood and slow down hyperactive motor activity

Several drugs come in oral, parental, liquid, oral disintegrating tablets, and long-acting injections

 Review common adverse effects in the “Schizophrenia” section of the “Psychosis and Schizophrenia” chapter.
Antianxiety Medications Used to treat symptoms of anxiety and irritability.
Benzodiazepines

Lorazepam (Ativan)

Alprazolam (Xanax)

Other

Gabapentin (Neurontin)

Buspirone (Buspar)

 Help reduce the level of hyperactivity during an acute manic phase as a supplement with mood stabilizing drugs

Avoid in patients with substance use disorders due to high risk of addiction

 Review common adverse effects in the “Treatments for Anxiety” section of the “Anxiety Disorders” chapter.
Antidepressants Medications Used to treat symptoms of depressive episodes.
Medication Classes:

SSRIs

SNRIs

TCAs

MAOIs

 Can precipitate a manic episode if not used in combination with a mood stabilizer and/or antipsychotic. Review common adverse effects in the “Treatments for Depression” section of the “Depressive Disorders” chapter.

 

Lithium

When administered to a client experiencing a manic episode, lithium may reduce symptoms within 1 to 3 weeks. It also possesses unique antisuicidal properties that sets it apart from antidepressants.[4],[5]

Black Box Warning

A Black Box Warning for lithium states that lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy.[6]

Adverse/Side Effects

Lithium must be closely monitored with routine blood work because it has a narrow therapeutic range of 0.8 to 1.2 mEq/L. Levels above this range cause lithium toxicity. Lithium levels > 2.5 mEq/L constitute a medical emergency, even if the client is asymptomatic. Signs of early lithium toxicity include diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. At higher levels giddiness, ataxia, blurred vision, tinnitus, and a large output of dilute urine may be seen. Treatment of lithium toxicity includes withholding the lithium and pushing fluids; IV fluids may be required. In severe cases, gastric lavage, mannitol, urea, aminophylline, or dialysis may be used to hasten the excretion of the drug. Lithium is contraindicated in clients with renal or cardiovascular disease, severe dehydration or sodium depletion, and those receiving diuretics because these conditions increase the risk of lithium toxicity.[7],[8]

Fine hand tremor, polyuria, and mild thirst may persist throughout treatment. Lithium can cause abnormal electrocardiographic (ECG) findings and risk of sudden death. Clients should be advised to seek immediate emergency assistance if they experience fainting, light-headedness, abnormal heartbeats, or shortness of breath.[9]

Renal function is adversely affected by lithium and requires routine laboratory testing including urinalysis, blood urea nitrogen, and creatinine. Thyroid and parathyroid functioning can also be adversely affected by lithium, requiring routine laboratory testing including thyroid function studies and calcium levels.[10]

Lithium can cause fetal harm in pregnant women. Safety has not been established for children under 12 and is not recommended.[11]

Patient Education for Lithium

Lithium must be taken as prescribed or serious side effects can occur. Blood tests to measure lithium levels will be ordered regularly by the provider. The provider should be immediately notified of symptoms of elevated levels of lithium, including diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination, ringing in the ears (tinnitus), or large amounts of dilute urine.  Driving or operating heavy machinery should be avoided when first starting lithium because it can impair mental alertness.  Lithium should not be taken during pregnancy or while breastfeeding unless it is determined that the benefits to the mother outweigh the potential risks to the baby.[12]

Psychotherapy

Psychotherapy is a term for a variety of treatment techniques that help an individual identify and change troubling emotions, thoughts, and behaviors. Treatment may include therapies such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and psychoeducation. Read more information about CBT and DBT in the “Treatments for Depression” section in the “Depressive Disorders” chapter.

Treatment may also include newer therapies designed specifically for the treatment of bipolar disorder, including Interpersonal and Social Rhythm Therapy (IPSRT) and family-focused therapy. IPSRT emphasizes the importance of establishing stable daily routines such as sleeping, waking up, working, and eating meals. Family-focused therapy focuses on psychoeducation, communication enhancement training, and problem-solving skills. It includes attention to family dynamics and relationships as contributing factors to the client’s mood.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is used to treat bipolar disorders. ECT is a brain stimulation procedure delivered under general anesthesia. It can be effective in treating severe depressive and manic episodes when medication and psychotherapy are not effective. ECT can also be effective when a rapid response is needed, as in the case of suicide risk or catatonia (a state of unresponsiveness). Read more about electroconvulsive therapy (ECT) in the “Depressive Disorders” chapter.

Self-Help and Coping

Regular aerobic exercise, such as jogging, brisk walking, swimming, or bicycling, helps with depression and anxiety, promotes better sleep, and is healthy for the heart and brain. There is also some evidence that anaerobic exercise such as weightlifting, yoga, and Pilates can be helpful.[13]

Even with proper treatment, mood changes can occur. Treatment is more effective when a patient and health care provider work together and talk openly about concerns and choices. Keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events can help clients and health care providers track and treat bipolar disorder over time. Clients can easily share data collected via smartphone apps – including self-reports, self-ratings, and activity data – with their health care providers and therapists.[14]

Take the American Psychiatric Association’s free course: The Treatment of Bipolar Depression: From Pills to Words.

  1. National Institute of Mental Health. (2020, January). Bipolar disorder. National Institutes of Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
  2. National Institute of Mental Health. (2020, January). Bipolar disorder. National Institutes of Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
  3. Post, R. M. (2022, May 17). Bipolar treatment in adults: Choosing maintenance treatment. UpToDate. Retrieved July 13, 2022, from https://www.uptodate.com/ ↵
  4. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  5. Malhi, G. S., Tanious, M., Das, P., Coulston, C. M., & Berk, M. (2013). Potential mechanisms of action of lithium in bipolar disorder. Current understanding. CNS Drugs, 27(2), 135–153. https://doi.org/10.1007/s40263-013-0039-0 ↵
  6. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  7. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  8. Janicak, P. G. (2022). Bipolar disorder in adults and lithium: Pharmacology, administration, and management of adverse effects. UpToDate. Retrieved July 14, 2022, from https://www.uptodate.com ↵
  9. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  10. Janicak, P. G. (2021, January 19). Bipolar disorder in adults and lithium pharmacology, administration, and management of adverse effects. UpToDate. Retrieved July 13, 2022, from https://www.uptodate.com/ ↵
  11. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  12. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  13. National Institute of Mental Health. (2020, January). Bipolar disorder. National Institutes of Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
  14. National Institute of Mental Health. (2020, January). Bipolar disorder. National Institutes of Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
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