There are some people that are able to manage bipolar disorder without medication, though not many. Bipolar disorder can be debilitating, and remaining at a functioning level is difficult, even with treatment. Once someone with bipolar disorder is diagnosed, it may take years to find a drug therapy regimen that works, and even that may change over time. Bipolar disorder is fluid. It doesn’t just evoke changes in mood; it affects sleeping patterns, eating patterns, memory, attention and overall health. All of these can shift without warning, though there are identifiable triggers. Patterns of treatment in bipolar disorder are also shifting, though the efficacy may be questionable.
Science didn’t officially begin recognizing bipolar disorder (or manic-depressive illness) until the late-19th century. Treatment for symptoms, however, goes all the way back to ancient Greece and Rome when “agitated or euphoric patients” were treated with water from northern-Italian spas. The water contained lithium, a naturally-occurring salt. Other treatments like bloodletting and witchcraft were also used as treatments, but turned out to be remarkably ineffective. Go figure.
Lithium came back into style in the 1970’s and became the staple for treating bipolar disorder. It works not only as a mood-stabilizer, but may have neuroprotective properties as well. Along with altering neurological pathways, lithium seems to help increase the volume of areas of the brain thought to be related to bipolar disorder. Brain scans of patients taking lithium match more closely to the brain scans of neurotypical patients than patients not receiving treatment. Lithium was the most commonly used drug treatment for bipolar disorder, both acutely and for maintenance, but that has changed in the last decade.
A recent study published in the Bipolar Disorders Journal followed the patterns of prescribed drug treatments for over 3,000 bipolar disorder patients from 2000-2011. In the year 2000, lithium was the most popular drug treatment, prescribed to more than 40% of patients. Second in line were SSRI antidepressants, prescribed to about 25% of patients.
The problem with lithium is that it’s high-maintenance. It can negatively impact kidney and thyroid function, so blood levels have to be carefully monitored. This means patients regularly have to get their blood drawn to make sure levels are high enough to work, but not high enough to cause damage. People with bipolar disorder can be bad at taking medication in the first place, adding that extra step just exacerbates the problem.
Lithium levels in the blood are also affected by a number of factors including hormones, illness, season changes and other medications. It also comes with possible side effects of lithium-induced hypothyroidism, gastrointestinal distress, tremor, chronic thirst and drowsiness.
The problem with antidepressants is that they can induce mania in some patients, especially when used alone or for maintenance.
According to the study authors Kessing, Vradi and Andersen, prescriptions for lithium have been outpaced by those for antipsychotics and antiepileptics.
Antiepileptics are the most prescribed medication for bipolar disorder, especially for maintenance and depression. These are drugs like valproate (brand name: Depacon), gabapentin (Neurontin) and lamotrigine (Lamictal). When your brain is firing off too many signals, it’s thought to cause problems like epilepsy and bipolar disorder symptoms. Antiepileptics decrease the firing rate and also act on neurotransmitters related to mood like serotonin, dopamine and norepinephrine.
These drugs typically do not require blood level monitoring. They do come with side effects like weight changes, drowsiness and tremor. There is also a small of a potentially deadly skin rash. However, the side effects of these drugs are thought to be fewer and easier than those of other drugs for bipolar disorder.
Atypical antipsychotics are now the most prescribed drug for mania and are prescribed to more than 60% of patients during maintenance phases. They are recommended for acute manic and psychotic episodes. These include drugs like olanzapine (Zyprexa) and quetiapine (Seroquel). They are basically tranquilizers. They work on the neurotransmitters serotonin, noradrenaline and, mostly, dopamine. They decrease the overabundant dopamine in the brain thought to bring on psychosis. These are powerful drugs. Side effects include excessive sleepiness, weight gain and sexual disfunction. Patients may need to be monitored for increased glucose levels.
It’s good news that there are multiple drug treatments available to patients with bipolar disorder. Everyone experiences it a little differently and so needs to be able to try different doses and different medications to reach the best result.
However, the results from this study, show that these trends do not conform to general treatment recommendations. Lithium is still recognized as the most effective long-term treatment overall but prescription rates continue to fall. Instead of being the first medicine prescribed to patients, it is often the last.
Photo credit: Nico Paix