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Mood, like the weather, is always changing. For most people, the emotional climate remains within predictable limits—not too high and not too low. For a person with bipolar disorder the barometer of life will at times seem to fall from a temperate normal mood, to the bleak chill of depression. It can also shoot up to the bright heights of hypomania or beyond to the brilliant blaze of mania.

Bipolar Disorder, as its name suggests, is a condition characterized by periods of high mood in addition to the low moods that occur in the more common “unipolar” depression. Studies show that 1.5% of the population will have at least one hypomanic or manic episode in their adult lives.

When a person is hypomanic, they may feel unusually good and competent, or simply irritable. Their thoughts race and consequently their speech is often pressured; they may be distractible and flit from topic to topic. They apply their heightened energy to multiple projects. Sleep seems less necessary. There is a drive for pleasurable activities with uncharacteristic disregard for risk. Friends and relatives who know the person recognize that they are behaving differently—out of character. If the symptoms are so severe that they cause marked impairment in work or social functioning, then the condition is called mania.

Depression, the other pole of Bipolar Disorder, may also vary in severity from a relative decrease in enjoyment and interest, to a complete and painful lack of pleasure in anything. Often there are disturbances in concentration, sleep, appetite and energy as well as paralysis of decision making. Guilt and low self-esteem are common.

Without treatment, bipolar disorder can be devastating. People with this condition divorce 2-3 times more commonly and show decline in occupational functioning twice as commonly as the average population. Proper treatment can lower the elevated suicide mortality rate in this group.

Fortunately, there are a number of good treatments available for Bipolar Disorder. The first step in treatment is appropriate evaluation and diagnosis. Usually medication can help control the mood swings. It is essential to develop a trusting relationship between the psychiatrist and patient, especially since many patients initially don’t recognize or don’t want to recognize the danger of an elevated mood. If a strong alliance is present, medication can often be started sooner—before a crisis develops—and prevent a full-blown mood swing. It is often a turning point in treatment when the patient accepts the need to monitor their own mood and to ask for help early on.

Medication Treatment for Bipolar Disorder

Glenn Brynes, PhD, MD

Bipolar Disorder (or Manic Depressive Illness) involves prominent mood swings. The individual has periods of depression, and periods when they feel either unusually good or pressured and irritable. It affects 1-2% of the population. Genetics plays a significant role. About 15% of children with one bipolar parent develop the disorder.

Treatments include medication, supportive psychotherapy and occasionally ECT. Medications include lithium, anticonvulsant drugs (carbamazepine (Tegretol), valproate (Depakote), gabapentin (Neurontin) and lamotrigine Lamictal), antidepressants (such as bupropion (Wellbutrin)or sertraline (Zoloft)), neuroleptics (e.g. haloperidol) and benzodiazepines (e.g. lorazepam) Treatment choices depend on the type and phase of the illness. There is growing evidence that patients with less frequent and more intense mood swings respond best to lithium, while those with more than 4 mood swings per year respond best to the ‘anticonvulsant’ mood stabilizers. When a person is acutely manic, they may require hospitalization. Lithium or an anticonvulsant mood stabilizer can be quite effective, but may take several days or weeks to take effect. Antipsychotic and antianxiety drugs can help control symptoms during this period.

The depressive phase may not respond as well to lithium and most anticonvulsants. While antidepressants can help, they carry a moderate risk of overshooting into mania; thus they are generally used with a mood stabilizer. One promising drug, lamotrigine (Lamictal), may have specific antidepressant in addition to anti-manic properties. Lamotrigine is usually increased slowly to minimize the chance that it might cause a rash. 

ECT helps severe depression or mania. It is most often used when medication doesn’t work or is unsafe.

Lithium is a top choice for acute mania and for maintenance in ‘classic’ bipolar disorder. Because of its narrow therapeutic range, blood levels must be monitored; also heart and kidney function (EKG, blood and urine tests). Medications such as diuretics, that block its excretion require caution.

Anticonvulsants have an edge with rapid-cycling and mixed mood states (e.g. depression with racing thoughts). Except for gabapentin (Neurontin) and lamotrigine (Lamictal), they require blood tests. Carbamazepine (Tegretol) is monitored with blood levels; also CBC, platelets and liver function tests. Valproate (Depakote) requires CBC, platelet count and liver function tests; blood levels may be helpful. Lamotrigine (Lamictal) requires caution because of its association with a rare but dangerous skin rash (exfoliative dermatitis); risk can be minimized by starting with low doses and increasing gradually. Use lower doses with medications that slow lamotrigine metabolism (e.g. valproate). Gabapentin is generally safe and does not require blood tests.

It is not unusual for patients to need more than one mood stabilizing medication for best results.

Because bipolar disorders are generally recurrent, maintenance treatment is usually needed. This is especially true when there have been multiple episodes, a clear family history of bipolar disorder or symptom onset before age 18. Effective maintenance requires full doses of mood stabilizing medications and ongoing medical monitoring. Psychotherapy can help patients and their families understand the illness, can teach the importance of early relapse detection, and ensure compliance with medication. In therapy, patients can deal with past instability and prepare constructively for the future.

Selected References:

Gershon ES: Genetics, in Manic-Depressive Illness. Edited by Goodwin FK, Jamison KR. New York, Oxford University Press, 1990, pp 373—401 APA Textbook of Psychiatry 2nd Ed. Ch. 27


(Dunner and Fieve 1974; Prien et al. 1984; Wehr et al. 1988).
Dunner DL, Fieve RR: Clinical factors in lithium carbonate prophylaxis failure. Arch Gen Psychiatry 30:229–233, 1974

Kukopulos A, Caliari B, Tundo A, et al: Rapid cyclers, temperament, and antidepressants. Compr Psychiatry 24: 249–258, 1983

Most professionals agree that Bipolar Disorder is a biologically-based mental illness. Medication is a critical part of the treatment. However, the emotional swings, the medication side effects, the disruptions in work or school all take place within an individual-and that individual usually lives in a family.

An episode of mania or depression can make a familiar family member seem like a stranger. The experience can be frightening and disorganizing for the entire family. In such a state, the family members may become hostile, fearful and controlling. They may blame themselves or the affected individual.

Bipolar disorder may involve long periods of remission between episodes. Everyone can be lulled into a false sense of security. This fosters denial of the illness and premature medication cessation. Some individuals who are usually quite responsible may temporarily lose their insight during the early stages of an acute episode.

Family therapy can help the entire family unit regain healthy relationships after a period of mania or depression. It can help the patient and family identify and deal with the stresses that may trigger acute episodes. The patient and family may need to distinguish the patient’s long-term personality traits from an exacerbation of the bipolar disorder. On one hand, the patient and family need to work through denial and learn to accept this as a biological condition. However, excessive vigilance, relating every personality quirk to the illness, can be counterproductive.

Families do not cause bipolar disorder, but they can do a lot to support treatment, speed recovery, and help the individual identify early recurrence.

Which came first, the chicken or the egg?

Which came first, the drugs or the mood swings? Too often, I have to figure this out. His parents or teachers sent him to see me because he have had mood swings, verbal explosions and sleep problems. The drug screen comes back positive for cocaine and marijuana, and the garbage can search reveals empty wine bottles.

He has a problem with drugs and alcohol. He has mood swings. Drugs can cause mood swings. On the other hand, someone with depression or mania may use drugs to take away the pain of uncontrollable mood changes. Figuring out the answer often requires some expert detective work. He need to open up and give me a detailed, honest history. His family members must also be frank about their own drug and psychiatric histories. No more secrets.

Adolescents may abuse drugs for a variety of reasons. These often include peer group pressure, parental drug and alcohol use, depression or just a desire for a new experience.

No adolescent should use alcohol or illegal drugs. However, there are certain individuals who are at increased risk. These individuals should be cautious even as adults. Some people can drink for quite a while before running into problems. Others have problems after that first drink. If close family members have had problems with drugs or alcohol, you are at increased risk. If you are depressed or already have trouble with mood swings, you are more likely to become addicted, and may have more trouble getting off drugs. There is evidence that drug use may cause an individual with a biological tendency toward bipolar disorder to develop the illness earlier in life. High school is difficult enough; you don’t need this too. Talk to a trusted adult and get help early.

Carol E. Watkins, M.D.

Links related to Depression and Bipolar Disorder

• Common side effects of medications used for bipolar disorder.
  This site includes a long list of first, second and third-line medications and their more common side effects.

• Child and Adolescent Bipolar Foundation
  Information and advocacy for families affected by pediatric Bipolar Disorder

• Depression
  Recommended books for children. Also see Psychotherapy Section

• Seasonal Affective Disorder