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Drug therapy is usually the first-line of therapy used in treating acute episodes of bipolar disorder.

Medications chosen for treatment of bipolar disorder are usually determined by:

• Treatment history
• Type of bipolar disorder
• Severity and current state of mood
• Side effects of each drug

Women who are trying to conceive, who are pregnant, or who are nursing should discuss with their doctors the benefits and risks involved in continuing treatment with any medication.

There are three types of medications utilized in the treatment of bipolar disorder.

• Mood stabilizers
• Antipsychotics
• Antidepressants

Mood Stabilizers

Mood stabilizers are drugs that provide acute relief from mania, provide acute relief from depression, and prevent recurrences of mania or depression.

The most commonly used mood stabilizers are:

• Lithium (Eskalith, Lithobid, Lithonate)
• Divalproex sodium (Depakote)
• Carbamazepine (Tegretol, Carbatrol)
• Oxcarbazepine (Trileptal)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topomax)

Lithium

Lithium is a naturally occurring element. Its efficiency for treatment was discovered in the 1950's and it was approved by the U.S. Food and Drug Administration (FDA) for treating mania in 1995. It is very effective for pure mania and depression and can be combined with other medications for enhanced effect. It is less effective for rapid cycling or mixed episodes. Lithium has also been shown to reduce the risk of suicide.

Studies indicate that up to 64% of bipolar patients do not respond to lithium. Nonresponding patients include those experiencing:

• Mixed states
• Personality disorders
• Comorbid substance abuse
• Mixed cycling
• Previously failed trials of lithium

When lithium is discontinued, there is usually an abrupt rebound effect with an increase in manic or depressive symptoms. The risk is reduced by lowering the dosage of the drug over several months.

Side effects include:

• Weight gain
• Tremor
• Nausea
• Increased urination

Long term side effects may include renal, thyroid, and cardiovascular problems. Side effects can be minimized by regularly monitoring blood levels of lithium and adjusting the medication as needed.

Divalproex Sodium

This drug was used for many decades as an anticonvulsant. It was approved by the FDA for treatment of mania in 1995. Divalproex is also effective for:

• Mania
• Mixed manic episodes
• Rapid cycling
• Comorbid conditions (e.g., substance abuse or anxiety)

Divalproex differs from lithium in that it can be given initially in large doses to achieve a rapid response to acute mania or depression.

Side effects may include:

• Weight gain
• Sedation
• Tremor
• Gastrointestinal disturbances
• Liver inflammation

Monitoring the blood levels and adjusting the medication accordingly can minimize most side effects.

There is some evidence that divalproex may cause hormonal changes in adolescent girls and may be related to the development of Polycystic Ovary Syndrome (PCOS) in women who began taking the drug before the age of 20. Consequently, hormone levels of any young woman taking divalproex must be carefully monitored.

Carbamazepine and Oxcarbazepine

These two closely related drugs (carbamazepine was reformulated into oxcarbazepine) were originally developed as anticonvulsants. They have similar properties to divalproex and are effective for mania and mixed episodes.

Side effects may include:

• Sedation
• Gastrointestinal upset