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What Is the Course of Bipolar
Episodes of mania and depression typically
recur across the life span. Between episodes, most people with bipolar
disorder are free of symptoms, but as many as one-third of people
have some residual symptoms. A small percentage of people experience
chronic unremitting symptoms despite treatment.
The classic form of the illness, which involves recurrent episodes of
mania and depression, is called bipolar I disorder. Some people, however,
never develop severe mania but instead experience milder episodes of
hypomania that alternate with depression; this form of the illness is
called bipolar II disorder. When 4 or more episodes of illness occur
within a 12-month period, a person is said to have rapid-cycling bipolar
disorder. Some people experience multiple episodes within a single week,
or even within a single day. Rapid cycling tends to develop later in
the course of illness and is more common among women than among men.
People with bipolar disorder can lead healthy and productive lives when
the illness is effectively treated. Without treatment, however, the natural
course of bipolar disorder tends to worsen. Over time a person may suffer
more frequent (more rapid-cycling) and more severe manic and depressive
episodes than those experienced when the illness first appeared. But
in most cases, proper treatment can help reduce the frequency and severity
of episodes and can help people with bipolar disorder maintain good quality
How Is Bipolar Disorder Treated?
Most people with bipolar disorder—even those with the most severe
forms—can achieve substantial stabilization of their mood swings
and related symptoms with proper treatment. Because bipolar disorder
is a recurrent illness, long-term preventive treatment is strongly recommended
and almost always indicated. A strategy that combines medication and
psychosocial treatment is optimal for managing the disorder over time.
In most cases, bipolar disorder is much better controlled if treatment
is continuous than if it is on and off. But even when there are no breaks
in treatment, mood changes can occur and should be reported immediately
to your doctor. The doctor may be able to prevent a full-blown episode
by making adjustments to the treatment plan. Working closely with the
doctor and communicating openly about treatment concerns and options
can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms, treatments, sleep
patterns, and life events may help people with bipolar disorder and their
families to better understand the illness. This chart also can help the
doctor track and treat the illness most effectively.
Medications for bipolar disorder are prescribed by psychiatrists—medical
doctors (M.D.) with expertise in the diagnosis and treatment of mental
disorders. While primary care physicians who do not specialize in psychiatry
also may prescribe these medications, it is recommended that people with
bipolar disorder see a psychiatrist for treatment.
Medications known as "mood stabilizers" usually are prescribed
to help control bipolar disorder. Several different types of mood stabilizers
are available. In general, people with bipolar disorder continue treatment
with mood stabilizers for extended periods of time (years). Other medications
are added when necessary, typically for shorter periods, to treat episodes
of mania or depression that break through despite the mood stabilizer.
Lithium, the first mood-stabilizing medication approved by the U.S. Food
and Drug Administration (FDA) for treatment of mania, is often very effective
in controlling mania and preventing the recurrence of both manic and
Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine
(Tegretol®), also can have mood-stabilizing effects and may be especially
useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved
in 1995 for treatment of mania.
Newer anticonvulsant medications, including lamotrigine (Lamictal®),
gabapentin (Neurontin®), and topiramate (Topamax®), are being
studied to determine how well they work in stabilizing mood cycles
Oxcarbazepine (Trileptal ®), a medication related in many ways to
carbamazepine and used to treat certain seizure disorders, is also an
effective treatment for some patients. Anticonvulsant medications may
be combined with lithium, or with each other, for maximum effect.
Children and adolescents with bipolar disorder generally are treated
with lithium, but valproate and carbamazepine also are used. Researchers
are evaluating the safety and efficacy of these and other psychotropic
medications in children and adolescents. There is some evidence that
valproate may lead to adverse hormone changes in teenage girls and polycystic
ovary syndrome in women who began taking the medication before age 20.Therefore,
young female patients taking valproate should be monitored carefully
by a physician.
Women with bipolar disorder who wish to conceive, or who become pregnant,
face special challenges due to the possible harmful effects of existing
mood stabilizing medications on the developing fetus and the nursing
infant.Therefore, the benefits and risks of all available treatment options
should be discussed with a clinician skilled in this area. New treatments
with reduced risks during pregnancy and lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are at risk of switching
into mania or hypomania, or of developing rapid cycling, during treatment
with antidepressant medication. Therefore, "mood-stabilizing" medications
generally are required, alone or in combination with antidepressants,
to protect people with bipolar disorder from this switch. Lithium
and valproate are the most commonly used mood-stabilizing drugs today.
However, research studies continue to evaluate the potential mood-stabilizing
effects of newer medications.
Atypical antipsychotic medications, including clozapine (Clozaril®),
olanzapine (Zyprexa®), risperidone (Risperdal®), and ziprasidone
(Zeldox®), are being studied as possible treatments for bipolar disorder.
Evidence suggests clozapine may be helpful as a mood stabilizer for people
who do not respond to lithium or anticonvulsants. Other research has
supported the efficacy of olanzapine for acute mania, an indication that
has recently received FDA approval. Olanzapine may also help relieve
If insomnia is a problem, a high-potency benzodiazepine medication such
as clonazepam (Klonopin®) or lorazepam (Ativan®) may be helpful
to promote better sleep. However, since these medications may be habit-forming,
they are best prescribed on a short-term basis. Other types of sedative
medications, such as zolpidem (Ambien®), are sometimes used instead.
Changes to the treatment plan may be needed at various times during the
course of bipolar disorder to manage the illness most effectively. A
psychiatrist should guide any changes in type or dose of medication.
Be sure to tell the psychiatrist about all other prescription drugs,
over-the-counter medications, or natural supplements you may be taking.
This is important because certain medications and supplements taken together
may cause adverse reactions.
To reduce the chance of relapse or of developing a new episode, it is
important to stick to the treatment plan. Talk to your doctor if you
have any concerns about the medications.
People with bipolar disorder often have abnormal thyroid gland function.
Because too much or too little thyroid hormone alone can lead to mood
and energy changes, it is important that thyroid levels are carefully
monitored by a physician.
People with rapid cycling tend to have co-occurring thyroid problems
and may need to take thyroid pills in addition to their medications for
bipolar disorder. Also, lithium treatment may cause low thyroid levels
in some people, resulting in the need for thyroid supplementation.
Medication Side Effects
Before starting a new medication for bipolar disorder, always talk with
your psychiatrist and/or pharmacist about possible side effects. Depending
on the medication, side effects may include weight gain, nausea, tremor,
reduced sexual drive or performance, anxiety, hair loss, movement problems,
or dry mouth. Be sure to tell the doctor about all side effects you notice
during treatment. He or she may be able to change the dose or offer a
different medication to relieve them. Your medication should not be changed
or stopped without the psychiatrist's guidance.
As an addition to medication, psychosocial treatments—including
certain forms of psychotherapy (or "talk" therapy)—are
helpful in providing support, education, and guidance to people with
bipolar disorder and their families. Studies have shown that psychosocial
interventions can lead to increased mood stability, fewer hospitalizations,
and improved functioning in several areas. A licensed psychologist, social
worker, or counselor typically provides these therapies and often works
together with the psychiatrist to monitor a patient's progress. The number,
frequency, and type of sessions should be based on the treatment needs
of each person.
Psychosocial interventions commonly used for bipolar disorder are cognitive
behavioral therapy, psychoeducation, family therapy, and a newer technique,
interpersonal and social rhythm therapy. NIMH researchers are studying
how these interventions compare to one another when added to medication
treatment for bipolar disorder.
Cognitive behavioral therapy helps people with bipolar disorder learn
to change inappropriate or negative thought patterns and behaviors associated
with the illness.
Psychoeducation involves teaching people with bipolar disorder about
the illness and its treatment, and how to recognize signs of relapse
so that early intervention can be sought before a full-blown illness
episode occurs. Psychoeducation also may be helpful for family members.
Family therapy uses strategies to reduce the level of distress within
the family that may either contribute to or result from the ill person's
Interpersonal and social rhythm therapy helps people with bipolar disorder
both to improve interpersonal relationships and to regularize their daily
routines. Regular daily routines and sleep schedules may help protect
against manic episodes.
As with medication, it is important to follow the treatment plan for
any psychosocial intervention to achieve the greatest benefit.
In situations where medication, psychosocial treatment, and the combination
of these interventions prove ineffective, or work too slowly to relieve
severe symptoms such as psychosis or suicidality, electroconvulsive
therapy (ECT) may be considered. ECT may also be considered to treat
acute episodes when medical conditions, including pregnancy, make
the use of medications too risky. ECT is a highly effective treatment
for severe depressive, manic, and/or mixed episodes. The possibility
of long-lasting memory problems, although a concern in the past,
has been significantly reduced with modern ECT techniques. However,
the potential benefits and risks of ECT, and of available alternative
interventions, should be carefully reviewed and discussed with individuals
considering this treatment and, where appropriate, with family or
Herbal or natural supplements, such as St. John's wort (Hypericum perforatum),
have not been well studied, and little is known about their effects on
bipolar disorder. Because the FDA does not regulate their production,
different brands of these supplements can contain different amounts of
active ingredient. Before trying herbal or natural supplements, it is
important to discuss them with your doctor. There is evidence that St.
John's wort can reduce the effectiveness of certain medications ( http://www.nimh.nih.gov/events/stjohnwort.cfm
). In addition, like prescription antidepressants, St. John's wort may
cause a switch into mania in some individuals with bipolar disorder,
especially if no mood stabilizer is being taken.
Omega-3 fatty acids found in fish oil are being studied to determine
their usefulness, alone and when added to conventional medications, for
long-term treatment of bipolar disorder.
A Long-Term Illness That Can
Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it
is important to understand that bipolar disorder is a long-term illness
that currently has no cure. Staying on treatment, even during well times,
can help keep the disease under control and reduce the chance of having
recurrent, worsening episodes.