Bipolar Affective Disorder Medication

  • Author: Stephen Soreff, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Apr 17, 2012
 

Medication Summary

Appropriate medication depends on the stage of the bipolar disorder the patient is experiencing. The choice of agent depends on the presence of symptoms such as psychotic symptoms, agitation, aggression, and sleep disturbance. Drug categories include mood stabilizers, anticonvulsants, and antipsychotics.

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Anxiolytics, Benzodiazepines

Class Summary

By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and the action of other inhibitory transmitters.

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Lorazepam (Ativan)

 

Lorazepam is a sedative hypnotic with a short onset of effects and a relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, it may depress all levels of the CNS, including the limbic and reticular formation. Monitor the patient's blood pressure after administering a dose of lorazepam. Adjust the dose as necessary.

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Clonazepam (Klonopin)

 

Clonazepam is a long-acting benzodiazepine that increases presynaptic GABA inhibition and reduces monosynaptic and polysynaptic reflexes. It suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters.

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Mood stabilizers

Class Summary

Clinical experiences have shown that patients with bipolar disorder have fewer episodes of mania and depression when treated with mood-stabilizing drugs.[57] These medications serve to stabilize the patient’s mood, as the name implies. They also can dampen extremes of mania or depression.

Lithium is the drug commonly used for prophylaxis and treatment of manic episodes. A recent study suggests that lithium may also have a neuroprotective role.

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Lithium carbonate (Lithobid)

 

Lithium is considered a first-line agent for long-term prophylaxis in bipolar illness, especially for classic bipolar disorder with euphoric mania. It also can be used to treat acute mania, though it cannot be titrated up to an effective level as quickly as valproate can. Evidence suggests that lithium, unlike any other mood stabilizer, may have a specific antisuicide effect. Monitoring blood levels is critical with this medication.

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Anticonvulsants

Class Summary

Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers. For the depressed phase, mood stabilizers, such as lithium and lamotrigine, are preferred because antidepressants may propel a patient into a manic episode or exacerbate irritability in mixed-symptom mania. Gabapentin, although not a mood stabilizer, also may have anxiolytic properties.

The most widely used anticonvulsants have been carbamazepine, valproate, and lamotrigine. More recently, topiramate and oxcarbazepine also are being tried.

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Carbamazepine (Equetro)

 

Carbamazepine is effective in patients who have not responded to lithium therapy. It also can act to inhibit seizures induced through the kindling effect, which is thought to occur by way of repeated limbic stimulation. Carbamazepine has been effective in treating patients who have rapid-cycling bipolar disorder or those who have not been responsive to lithium therapy.

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Valproate sodium, valproic acid, divalproex sodium (Depakene, Depakote, Depakote ER, Depacon, Stavzor)

 

Valproate has proven effectiveness in treating and preventing mania. It is classified as a mood stabilizer and can be used alone or in combination with lithium. It is useful in treating patients with rapid-cycling bipolar disorders and has been used to treat aggressive or behavioral disorders. A combination of valproic acid and valproate has been effective in treating persons in manic phase, with a success rate of 49%.

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Lamotrigine (Lamictal, Lamictal ODT)

 

Lamotrigine is an anticonvulsant that appears to be effective in the treatment of the depressed phase in bipolar disorders. It is used for the maintenance treatment of bipolar I disorder to delay the time to occurrence of mood episodes (depression, mania, hypomania, mixed episodes) in adults treated for acute mood episodes with standard therapy.

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Atypical Antipsychotics

Class Summary

Atypical antipsychotics are being used increasingly for treatment of both acute mania and mood stabilization.

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Asenapine (Saphris)

 

Asenapine's mechanism of action is unknown. It is indicated as monotherapy for the acute treatment of manic or mixed episodes that are associated with bipolar I disorder. Asenapine is also indicated as adjunctive therapy with lithium or valproate. Its efficacy thought to be mediated through a combination of antagonist activity at dopamine 2 and serotonin (5-HT2) receptors. Asenapine exhibits high affinity for serotonin 5-HT1A, 5-HT1B, 5-HT2A, 5-HT2B, 5-HT2C, 5-HT5, 5-HT6, and 5-HT7 receptors; dopamine D2, D3, D4, and D1 receptors; alpha-1 and alpha-2 adrenergic receptors; and histamine H1 receptors, with moderate affinity for H2 receptors.

In vitro assays suggest antagonistic activity elicited at these receptors. Asenapine is indicated for acute treatment of manic or mixed episodes associated with bipolar I disorder (with or without psychotic features).

The prescribing information was updated in September 2011 to include data from 52 reports of type 1 hypersensitivity reactions.

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Ziprasidone (Geodon)

 

Ziprasidone is an atypical antipsychotic that is approved for the treatment of acute or mixed episodes that are associated with bipolar disorder. It can be used as maintenance treatment as an adjunct to lithium or valproate.

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Quetiapine (Seroquel, Seroquel XR)

 

Quetiapine is indicated for acute treatment of manic episodes that are associated with bipolar I disorder. It can be used as monotherapy or adjunctively with agents such as lithium or divalproex.

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Risperidone (Risperdal, Risperdal Consta, Risperdal M-Tab)

 

Risperidone is indicated for short-term treatment of acute manic or mixed episodes that are associated with bipolar I disorder. It can be used alone or in combination with lithium or valproate. Risperidone can be used in adults and adolescents aged 10-17 years with bipolar I disorder.

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Aripiprazole (Abilify, Abilify Discmelt)

 

Aripiprazole is an atypical antipsychotic used for the acute and maintenance treatment of manic or mixed episodes associated with bipolar I disorder. It can be used alone or in combination with lithium or valproate.

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Olanzapine (Zyprexa, Zyprexa Zydis)

 

Olanzapine is used for the acute and maintenance treatment of manic or mixed episodes associated with bipolar I disorder. It can be used alone or in combination with lithium or valproate. It can be used in adults and adolescents aged 13-17 years with bipolar I disorder.

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Olanzapine and fluoxetine (Symbyax)

 

The drug combination includes olanzapine, an atypical antipsychotic, and fluoxetine, a selective serotonin reuptake inhibitor. This drug is indicated for the acute treatment of depressive episodes associated with bipolar I disorder in adults. The clinical effects of this agent have not been studied in patients younger than 18 years.

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Contributor Information and Disclosures
Author

Stephen Soreff, MD  President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA

Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Lynne Alison McInnes, MD, MS  Associate Clinical Professor of Psychiatry, University of California, San Francisco, School of Medicine; Associate Adjunct Professor of Psychiatry and Genetics and Genomic Sciences, Department of Psychiatry and Human Genetics, Mount Sinai School of Medicine

Lynne Alison McInnes, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Psychiatric Association, and American Society of Human Genetics

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Table. FDA-Approved Bipolar Treatment Regimens
Generic NameTrade NameManicMixedMaintenanceDepression
ValproateDepakoteX
Carbamazepine extended releaseEquetroXX
LamotrigineLamictalX
LithiumXX
AripiprazoleAbilifyXXX
ZiprasidoneGeodonXX
RisperidoneRisperdalXX
AsenapineSaphrisXX
QuetiapineSeroquelXX
ChlorpromazineThorazineX
OlanzapineZyprexaXXX
Olanzapine/fluoxetine combinationSymbyaxX
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