Bipolar disorder: What are the different treatments?

Bipolar disorder: A brief review

Bipolar disorder is a severe psychiatric disorder previously known as "manic depression". It is characterised by a disproportion both in intensity and in duration of felt emotions. The majority of the initial symptoms appear between the ages of 15 and 25 (or 15 and 19, depending on the source), in both men and women, regardless of the standard of living. According to the World Health Organization (WHO), bipolar disorder is one of the 10 most incapacitating disorders worldwide.  

Bipolarity manifests as follows: 

• Manic (excessive euphoria) or hypomanic (manic episodes with less intensity) episodes
• Depressive episodes
• Mixed episodes (with both manic and depressive symptoms)

These episodes can sometimes be interspersed with phases of normal behaviour. 

Bipolar disorder should not be mistaken with cyclothymia: a more or less regular cycle of happiness and sadness, which is not considered an illness as quality of life is not impacted. 

A difficult diagnosis

There are many causes of bipolar disorder, including high stress, alcoholism, smoking, drug abuse, head injury and not least the hereditary factor. Indeed, the risk increases if a close family member is affected by bipolar disorder. 

Diagnosis of bipolar disorder remains difficult, as it is often confused with "standard" depression during a medical consultation. This can be explained either by the greater number of depressive episodes or by the difficulty of identifying manic, but especially hypomanic, disorders on the part of the doctor and the patient. 

In addition, sudden mood fluctuations are also symptoms of other conditions. They can occur, for example, with brain tumours, thyroid disorders or as a result of certain medications such as corticosteroids and amphetamines.

On average, it takes 10 years between the first episode, diagnosis and subsequent treatment. Without treatment, episodes occur more frequently and with greater intensity.

Treatments

Drug treatments: 

Several classes of medication can be used to treat this complex condition, often on a long-term or even life-long basis.

Mood stabilisers:

The most commonly used is lithium (PRIADELⓇ). A first-line treatment for manic episodes and relapse prevention, it has the advantage of having no effect in subjects who don't have bipolar disorder. 

However, lithium must be used under strict surveillance and caution. Indeed, a lithium test (to measure of the level of lithium in the blood) must be carried out regularly (every 5 days at the beginning of treatment, then the frequency decreases). This is to avoid an overdose, which can have serious consequences, but also to maintain a minimum effective concentration (MEC). The dosage should be personalised for each patient according to the concentrations and the clinical response observed. 

One must also pay close attention to water loss (through sweat or diuretic substances such as coffee, tea or certain medications) or sodium, which increase lithium levels. In addition, alcohol consumption increases drowsiness and fluctuations in lithium levels.

The most common symptoms of overdose are (but are not limited to): drowsiness, dizziness, convulsion and coma.

Lithium is also contraindicated in pregnant women as it crosses the foeto-placental barrier and has teratogenic effects (meaning it can cause birth defects). 

Anticonvulsants:

Anti-epileptic drugs made of mainly sodium valproate, and its derivatives (DEPAKOTEⓇ), but also others such as carbamazepine (TEGRETOLⓇ) and lamotrigine (LAMICTALⓇ) may be prescribed. The former two regulate mood while the latter is used in the prevention of depressive episodes. However, precautions should be taken with the use of sodium valproate which has teratogenic properties.

Antidepressants:

Antidepressants are used with caution (only in cases of major depressive episode and suicidal risk). Most often, SSRIs (selective serotonin reuptake inhibitors) are prescribed. These molecules are more active and better tolerated than the other families of antidepressants. Frequently prescribed antidepressants for bipolar disorder include: mention paroxetine, fluoxetine, citalopram, escitalopram. However, antidepressants take a bit time take effect (usually around 3 to 4 weeks).   

Additionally, mood stabilisers are more effective without antidepressants. 

Antipsychotics (neuroleptics):

Atypical neuroleptics can also be used for this condition. They are prescribed to treat manic episodes, and most particularly for their sedative effect.

Some examples include: risperidone (RISPERDALⓇ), quetiapine (SEROQUELⓇ), aripiprazole (ABILIFYⓇ).  

Non-drug treatments: 

Patients can also benefit from non-drug treatments: 

Cognitive and behavioural psychotherapies have little effect on the disorder itself, but allow the patient to work on him or herself. 

Psychoeducation (PE) allows a better compliance with treatments by explaining the disorder and treatments to the patient and his or her loved ones.

Finally, electroconvulsive therapy is used to relieve the patient during acute manic or depressive phases. The aim is to trigger a seizure by passing an electric current between the temples (under general anaesthetic). Despite its poor public image, it has few side-effects apart from headaches, confusion, nausea and brief memory problems (which tend to disappear within a few days or weeks).

Was this article helpful to you? Would you like to learn more? Read our article dedicated to bipolar disorder here!  

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