Your definitive bipolar treatment cheat sheet.

by John McManamy


What is bipolar disorder treatment?

In a wide sense, we are talking about everything likely to get you well and keep you well. In a narrow sense, we are tend to focus on medical treatment and talking therapies. On this website, I distinguish between treatment and recovery. The distinction is artificial, but it is useful in helping readers find what they are looking for and to figure out their own strategies for managing their illness and related issues.

So how do you distinguish between treatment and recovery?

In treatment, we are guided by a professional, be it a family doctor, a psychiatrist, a psychologist, an MSW, or other clinician. The focus tends to be on treating the disease. In recovery, the focus is more on what you need to do to get the most out of life. Again, the two are related.

What are the areas you cover in bipolar treatment?

Medications are regarded as the foundation of bipolar treatment. (Check out talking therapyECT, and nutritional supplements in the Depression Treatment FAQ.) Typically, doctors employ meds in two stages: 1) To get us out of crisis and into a state of stabilization, typically referred to as the "acute" phase of treatment; 2) To keep the illness from relapsing or recurring over the long term, referred to as "maintenance" treatment.

Tell me about the acute phase of bipolar treatment.

In mania, this is when we are out-of-control and at grave risk of harming ourselves or others. In this state of crisis, over-medicating us is the rational and compassionate treatment. The goal is short-term - to get us out of danger and into a reasonably stable and safe state. This is a very different consideration than the long-term.

Tell me about the maintenance phase of bipolar treatment.

Long-term is where the trouble starts, as doctors and patients tend to have opposing viewpoints. Doctors tend to regard a treatment "success" as keeping us from being rehospitalized, even if we are not well and are unable to lead full lives. Patients, naturally, want to be well.


Nearly all the studies for treating mania are based on treating patients on very high doses in crisis situations in the short term. But there are virtually no studies for long-term treatment, and the few we have involve exceptionally high drop-out rates. Yet, doctors often persist on keeping us on high doses over the long term, as if we are still in crisis. The result is we often feel worse, not better, not ourselves, overmedicated, laboring under onerous side effects, in no shape to implement our own recovery practices.

So what is the optimum long-term treatment strategy?

Since there is no firm scientific evidence base, I cannot give an authoritative answer. "Successful" patients I have talked to, however, seem to do better on low dose meds. Some are able to function well with no regular doses, but have them on hand on a PRN or "as needed" basis. But for a low or no-dose meds strategy to work, high-dose recovery strategies are mandatory, and we don't learn these overnight. Also, our living situations need to be stable (such as work and relationships). Again, we can't just change our world overnight.

This implies there is a "medium-term" strategy.

Very true. For a certain period, until we can master such recovery techniques as mindfulness and otherwise get our lives in order, it is wise to let our meds do most of the heavy lifting, even at the expense of putting up with side effects and feeling a bit cognitively and emotionally blunted. Over time, as we gain more confidence in our ability to lead more disciplined and stress-free lives, we can work on gradually lowering our meds, but with the proviso we can raise them should we begin to feel we are losing control.

Which leads to the long-term ...

In the long-term, I would say meds are a complement to recovery practices, rather than the other way around. By this stage, we have learned what is likely to trigger a mood episode (such as losing sleep) and know how to avoid or manage these situations. Psychiatrists would disagree with this point of view. My answer to this is that psychiatrists are trained to manage crisis situations, not work with us toward recovery. The scientific evidence base for meds treatment is only authoritative in the crisis stage of the illness. The information you hear from "successful" patients, anecdotal it may be, is the best information we have.

What about patients who need to stay on high-dose meds?

Bipolar is one of the most devastating illnesses on the planet. On top of this, bipolar tends to come pre-loaded with complications such as anxiety or psychosis. Many individuals may have to remain on high-dose meds all their lives, and on more than one med. Nevertheless, in virtually all these cases, even high doses can be lower than the doses administered in the crisis phase. Additionally, these patients benefit enormously from implementing their own recovery practices.



What kind of meds are used to treat bipolar?

The two main classes are mood stabilizers and antipsychotics. Sleep meds and anti-anxiety meds are often indispensable in certain situations. In addition, meds for improving cognition and promoting wakefulness may be pressed into service.

Tell me about mood stabilizers.

Mood stabilizers are something of a misnomer, as they mainly keep mania in check by slowing down the brain. These include the common salt lithium, as well as the anti-seizure meds Depakote, Tegretol, and Trileptal. Another anti-seizure med, Lamictal, appears to have better efficacy for treating the depressive side of bipolar. Because of their less onerous side effects profiles (when compared to antipsychotics) these are the preferred long-term meds.

Tell me about antipsychotics.

Ironically, antipsychotics have a better claim to being mood stabilizers than so-called mood stabilizers. Zyprexa, Abilify, and Seroquel each have evidence of antidepressant efficacy as well as being effective for treating mania. Their first use was to treat psychosis in schizophrenia, then they were found useful for bipolar. The catch is owing to their burdensome side effects profile, they are only recommended for long-term treatment if symptoms persist.




Tell me about meds side effects.

Both mood stabilizers and antipsychotics can be highly sedating, especially in high doses. Moreover, they can blunt emotions and cognition. These effects may go away or at least be tolerable in lower doses, though this may raise the risk of a return to symptoms. In addition, mood stabilizers and antipsychotics come with a range of metabolic and other side effects. These vary from med to med and individual to individual, but the bottom line is that over the long term, onerous side effects should not be considered a fair trade-off for a reduction in mood symptoms. In the final analysis, onerous side effects (such as excessive weight gain, messed-up sleep, cognitive dulling, and sexual dysfunction) are only going to make you feel emotionally worse in the long term, which will sabotage your recovery.

What about pregnancy and breast-feeding?

Please check with your psychiatrist, as well as the doctor treating you for your pregnancy. In general, the first trimester is the danger period for fetal development. You want to be stable during the last trimester, as the risk for postpartum mental illness skyrockets when unstable. Every decision carries a risk.

What about anti-anxiety and sleep meds?

Stress and anxiety can often trigger a mood episode. Likewise, so can lack of sleep. Accordingly, it makes sense to have these meds on hand on an "as needed" basis. Benzodiazepines (such as Klonopin) may serve double duty as sleep aids and "chill pills."

What about meds to improve cognition or improve wakefulness?

Various meds to boot up the dopamine and related systems may help us in our anergic states. In addition, many of us with bipolar may feel cognitively blunted, even if we are not on sedating meds. Moreover, there appears to be a link between cognition and wakefulness. A smart doctor can work with you in finding a novel meds strategy that works.

You haven't mentioned antidepressants.

The best evidence we have is that antidepressants may worsen bipolar and that they do not help our depressions. There may be exceptions to this, but you need to work with a smart doctor who knows what he or she is doing. The reality is too many doctors who indiscriminately over-prescribe these medications.

So how do we treat bipolar depression?

Lamictal, Seroquel, Zyprexa, and Abilify have some evidence of efficacy for bipolar depression. In the case of Lamictal and Seroquel, the FDA indication is as a single agent. For Zyprexa and Abilify, the FDA indication is in combination with an antidepressant. Because of the high side effects profile of antipsychotics, it is advisable to consider Seroquel, Zyprexa, and Abilify for short-term use, though long-term use may be justified.



Are there any other considerations to treating bipolar?

Yes. Since bipolar is a cycling illness, we cannot treat episodes in isolation. This is why antidepressant treatment may be dangerous, as antidepressants may speed up the cycle and kickstart mania. Likewise, an anti-mania med may make dealing with depression far more problematic. Often, the best strategy is to treat the cycle rather than the "symptom du jour."

How does my psychiatrist fit into the picture?

I would love to be able to tell you to trust your doctor. But his or her idea of long-term success is likely to be different than yours, with the goal of keeping you from slipping back rather than moving you forward. This makes a true partnership highly problematic. The issue is compounded by the fact that doctors have hardly any time to spend with us.

That sounds exceptionally bleak.

True, but an educated patient and one who shows up to appointments well-prepared is in a position to get the most out of a smart doctor (but the onus is on you to find a smart one who listens). In a sense, psychiatrists have abdicated their authority over to you. This can be very frightening, but it is also very empowering. YOU are in charge.

So what should I expect from meds?

There are no magic bullets. Meds are imperfect agents at best, but good results are possible when you employ smart strategies. Moreover, they can give you a vital leg up in implementing your own recovery practices. Don't expect miracles. But don't sell yourself short, either. You are entitled to full recovery, but be active in your recovery and don't wait for things to happen.

What about medical marijuana?

Our scientific knowledge is limited, but a number of patients do report that tiny doses - well short of recreational - may be helpful in calming down the brain. The catch is, in light of the potential for abuse, can we trust ourselves on small doses? Like all treatment decisions, medical marijuana carries risks.

I just read a book that warns me against the evils of meds and psychiatry. Would I be better off not seeing a psychiatrist and not being on meds?

This is your choice. Psychiatry and Pharma have been complicit in over-selling the benefits of meds and down-playing the things we can do for ourselves, such as practicing mindfulness. As a result, psychiatry is facing an extreme credibility crisis, and it is wise to be highly skeptical of their claims.

The book you read undoubtedly gives the impression that you should stay away from meds completely. The opposite extreme is that pushed by psychiatry - that you need to be on meds the rest of your life, typically at doses that sabotage your recovery.

The articles on this site, instead, come from the point of view that it is wise to acknowledge the limits of meds and their risk of doing harm, and taking charge in a treatment-recovery strategy that works for you.

Keep in mind, everyone has an agenda: Psychiatry, other clinicians, Pharma, plus those who are critical of psychiatry or offer alternatives to psychiatry. The voice that tends to get left out is you - the patient or loved one. In the final analysis, our interest is the only valid one in the whole equation: To get well and stay well.

And the only one standing up for your interest is you. This can be extremely frightening, but it is also mightily empowering.

See also: Bipolar FAQRecovery FAQ

For answers to questions on talking therapy, ECT, and supplements see: Depression Treatment FAQ

Reviewed July 6, 2016


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