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Page 1
• Psychotherapy • Research • Training
C
C
I
entre for
linical
nterventions
Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Keeping Your Balance
Module 2
Treatment Options for Bipolar Disorder
2
5
6
8
Keeping Your Balance
The information provided in this document is for information purposes only. Please refer to the
full disclaimer and copyright statements available at www.cci.health.gov.au regarding the
information on this website before making use of such information.
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
MEDICATION TREATMENT FOR BIPOLAR DISORDER
Introduction
The recommended standard treatment for bipolar disorder is medication, which focuses
on controlling or eliminating the symptoms and then maintaining the symptom-free state by
preventing relapse. The effective use of medication requires that you work closely with
your medical practitioner. Some patients may respond well and experience few side effects
with one type of medication, while others may do better with another. Thus, when taking
medication, it is important that you monitor its effects and consult with your doctor.
Principles of Medication Management
1. For medication to be of benefit, you should carefully follow the prescribed treatment and take note of
your symptoms and side effects.
2. If side effects develop, these should be reported to your doctor as soon as possible to
avoid prolonged discomfort. It is strongly advised that you do not stop medication
abruptly before first consulting with your doctor. This could bring on a return of a
manic or depressive episode.
3. Alcohol, illicit drugs, and other prescribed medicines may cause your medication for bipolar disorder
to be ineffective and may increase side effects. You should report all other medications and
substances you are taking to your doctor to ensure that none adversely interact with the medication
prescribed for bipolar disorder. Research has shown that substance use impacts negatively on the
course and outcome of bipolar disorder and may be a contributing factor to relapse and episode
recurrences.
4. Effective medical management of bipolar disorder requires you to monitor your symptoms and side
effects, and work with your doctor to adjust dosages or types of medications.
Phases of Treatment
There are usually three phases to medical treatment for bipolar disorder — acute treatment, continuation
treatment and maintenance treatment. The most important aim, if you are experiencing an episode of
mania, hypomania, or major depression, is to control or eliminate the symptoms so that they can return to
a normal level of day-to-day functioning. The duration of this acute phase of treatment may last from 6
weeks to 6 months. Sometimes, longer periods are necessary in order to find the most effective
medications with minimal side effects.
Continuation treatment, which is the next phase, may last from 4 to 9 months. In this phase, the main
aim is to maintain the symptom-free state by preventing relapse, which is the return of the most recent
mood episode.
The third phase, the maintenance phase, is critical and essential for all patients with bipolar disorder.
The goal for maintenance treatment is to prevent recurrence, that is, to prevent new episodes of mania,
hypomania, or depression from occurring. For bipolar patients, as with other medical conditions such as
diabetes or hypertension, maintenance treatment may last 5 years, 10 years, or a lifetime. But remember,
the more time you can go without symptoms the more chance you will have to get on with the things that
are important to you in life.
For all phases of treatment and all medications, patients must take the prescribed medications on a daily
basis. Unlike medications like paracetamol or antibiotics that are taken only when a person actually
experiences a headache or has an infection, medications for bipolar disorder must be taken regularly – on
both good days and bad days – at the same dosage.
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Types of Medication for Bipolar Disorder
Mood Stabilisers
A mood stabiliser is a medication that is used to decrease the chance of having further episodes of mania or
depression. They are the first line agents for bipolar disorder. Depending on the associated symptoms
with this disorder, antipsychotics or anti-depressants may also be used.
A mood stabiliser is given to a person as a maintenance medication because it regulates mood swings but
doesn’t take away the cause. Feeling well does not mean you can stop taking mood stabilisers, it means the
medication is keeping you stable.
The most common mood stabilisers are:
• lithium carbonate
• sodium valproate
• lamotrigine
Sometimes these medications are used on their own or in combination with other medications.
Antidepressants
Antidepressants can also be used with mood stabilisers in the acute, continuation, and/or maintenance
phases of medical treatment. There is no one particular antidepressant that is more effective than the
others in bipolar disorder. In fact, there is a significant risk for antidepressants to induce or cause a
“switch” to manic or hypomanic episodes, especially if a patient on antidepressants is not taking a mood
stabiliser.
Because all types of antidepressants seem to be equally effective and it takes several weeks to work
effectively, often it is the side-effects that determine which antidepressants are selected for an individual.
In general, if you do not respond well to one type (or class) of antidepressants, you may tolerate and
respond to a different class, or even to one in the same class.
Common antidepressants include:
• Selective serotonin reuptake inhibitors (SSRIs) - including fluoxetine, paroxetine, sertraline
• Serotonin and noradrenaline reuptake inhibitors (SNRIs) - including venlafaxine, duloxetine
Less commonly used or older types of antidepressants include:
• Tricyclics - including imipramine, amitriptyline, desipramine, dothiepin
• Monoamine oxidase inhibitors (MAOIs) - including phenelzine
Side effects of antidepressants will vary depending on the class of antidepressant. Some older patients may
be more sensitive to these side effects. Side effects are usually seen quite early on or when the dosage is
increased. Lower doses commonly have fewer side effects, and generally, the newer medications have
fewer side effects in the short and longer term.
It is important that you distinguish depressive symptoms from side effects of the antidepressant. You
should discuss this with your doctor before you begin taking the medication. Some medications can cause
side effects that are very similar to the depressive symptoms, e.g., difficulty sleeping, and sexual difficulties.
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Antipsychotic Medication
Antipsychotics are often used in the acute phase of the disorder and as a longer term treatment as well.
These can be used in combination with mood stabilisers to assist in controlling psychotic symptoms such as
hallucinations, or delusions, to induce sleep, or decrease irritability or impulsive behaviours. They are also
now used in continuation and maintenance therapy as mood stabilisers to help prevent a relapse of
psychotic or manic symptoms.
There are two main types of antipsychotic agents — more commonly used second generation or
atypical antipsychotic agents (such as olanzapine and quetiapine), and less commonly used first
generation or typical antipsychotics (such as chlorpromazine and haloperidol).
Some side effects of second generation antipsychotic medications include weight gain, drowsiness, dizziness,
stomach upset, dry mouth and constipation. These side effects can be minimised by using the lowest
necessary doses of the medication. It can also be helpful for your doctor to monitor your weight, blood
pressure, blood sugar and cholesterol regularly while you are taking these medications.
Benzodiazepines
Another class of medicines which can be used in treating bipolar disorder is the benzodiazepines (e.g.
clonazepam, diazepam). These medications are sometimes used in combination with other medications
(mood stabilisers and antipsychotics) to aid in inducing sleep, reducing psychomotor agitation, and slowing
racing thoughts and pressured speech. Benzodiazepines are usually used in the short term only — as their
use in the longer term can result in tolerance and dependence. Some side effects of benzodiazepines are
drowsiness, dizziness, a ‘hungover’ feeling and unsteadiness.
Some Other Things to Consider …
These medications work differently for different people. A medication that works well for one person may
be difficult to tolerate or ineffective for another person. The way medications work is affected by many
things (e.g. sex, age, genetics, metabolism) so the choice of medication needs to be customized for each
person. It is particularly important to take into account the following factors …
• To help your doctor choose the most suitable medications for you, they should be made aware of
any other medical conditions you have. Medical conditions can have an impact on which
medications you can take or the doses you will be prescribed.
• It is also important to let your doctor know if you are taking other medications (including over
the counter and natural therapies). There can be interactions between these treatments and the
medications prescribed for your bipolar illness.
• If you are a woman who is planning a pregnancy, it is really important to discuss your medication
options with your doctor.
For up to date information about mood stabilisers, or any of the medications you are prescribed – ask
your doctor or pharmacist for a printout of the Consumer Medicine Information (CMI) for the
medicine you are taking – this will provide you with information about side effects, and
recommendations for how to take the medicine.
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Medication Record
Remember that it is very important that you communicate openly with your prescribing doctor or
psychiatrist. In general, if you don’t respond well to one type of medication, you may tolerate and respond
to a different type. Use this worksheet to record the types of medication you are currently taking, the
dosage, and any side-effects you might be experiencing. You might also want to take note of how you feel
after taking the medication, whether or not it has been effective. Once you’ve recorded all this
information, discuss your medication treatment with your doctor, especially if you are concerned about the
way you feel. This information could also be valuable as a record of the medications you have taken in the
past.
Use the space at the bottom of the page to write down some questions about your medication or illness
you might want to ask your doctor.
Name and Type of
Medication
Dosage Notes
Questions I might have for my doctor/mental health practitioner:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Current
Past
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Psychosocial Treatment for Bipolar Disorder
Why Psychosocial Treatment?
Although effective medications have been found for bipolar disorder, many patients still experience
episode recurrences and relapse. Some experience between-episode symptoms that may not be serious
enough to be considered a full-blown episode, but could still cause some discomfort and interference with
day-to-day activities. A high rate of relapse and episode recurrences could be because of medication non-
compliance, alcohol and drug use, high stress levels, many between-episode symptoms, and poor daily
functioning. These issues have alerted mental health professionals to try psychotherapy and psychosocial
interventions, in addition to medication, to improve illness outcome and quality of life for bipolar
patients.
All psychosocial treatments for bipolar disorder share the aims of helping people understand more about
their bipolar illness, helping people identify their early warning signs and their triggers for episodes and
working with people to develop action plans with the aim of preventing episodes.
Cognitive Behavioural Therapy
A treatment approach that has been well researched for a wide range of adult
psychiatric disorders is cognitive behavioural therapy (CBT). CBT has been
adapted to bipolar disorder after being used for many other psychiatric
disorders including unipolar depression, anxiety disorders, and eating disorders.
This information package is primarily based on a CBT approach.
CBT is a structured and time-limited intervention. It is a comprehensive psychological therapy in which
there is an emphasis on collaboration between therapist and patient, and on active participation by the
patient in achieving therapeutic goals. CBT is also focused on problem solving. The central aim of CBT is
to teach patients how their thoughts and beliefs play an important role in the way they respond to
situations and people. The CBT approach also teaches patients the tools that could them to make their
response more helpful.
CBT can play a role in teaching bipolar patients about their disorder and helping them deal with adjustment
difficulties. CBT can also help patients cope with everyday stressors through active problem solving, and
teach patients to monitor and regulate their own thoughts, moods, and activities, and thus be prepared to
manage between-episode symptoms.
Other Forms of Psychosocial Treatment
Other forms of psychosocial treatment for bipolar disorder have been developed and investigated over the
last twenty years. These include Psychoeducation (where people attend for group sessions focussed on
increasing their understanding of their illness) and Family Focussed Treatment (where people attend for
individual or group treatment with one or more family members).
Research
CBT for bipolar disorder has been evaluated in a controlled trial here at the Centre for Clinical
Interventions. The results of our study showed that CBT for bipolar disorder was effective in helping
patients feel less depressed and more confident about managing their illness. This type of psychosocial
treatment has also been evaluated in a number of studies worldwide with positive outcomes. At CCI we
have also investigated the outcomes of group sessions for carers of people with a bipolar illness. We found
that group sessions for carers can reduce the sense of burden they feel, increase their understanding of
bipolar illness and help them feel more confident in managing their loved one’s bipolar illness.
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
Module Summary
• The recognised standard treatment for bipolar disorder is medication, which focuses on controlling
or eliminating the symptoms and then maintaining the symptom-free state by preventing relapse
• For medication to be of benefit, patients should carefully follow the prescribed treatment and take
note of their symptoms and side effects
• For all phases of treatment and all medications, it is important that patients take the prescribed
medications on a daily basis
• The use of substances other than prescribed medication is not recommended as this could result in
slower time to recovery, poor response to treatment, or more frequent episode recurrences
• The first line medication for bipolar disorder is a mood stabiliser, which is used to decrease the
chance of having further episodes of mania or depression
• Antidepressants can also be used with mood stabilisers in the acute, continuation, and/or
maintenance phases of medical treatment
• Antipsychotics may also be used both in the acute phase of the disorder and sometimes as a longer
term treatment
• Although medication is the first line of defence for bipolar disorder, psychosocial interventions can
help patients learn to better manage their illness
• An adjunctive psychosocial intervention that has had favourable results is cognitive behavioural
therapy, which focuses on helping patients cope with everyday stressors, monitor and regulate
their thoughts and mood, and manage any between-episode symptoms
Coming up next …
In Module 3, we will introduce ways
of self-monitoring mood and start to
identify early warning signs of mood
episodes…
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Module 2: Treatment Options for Bipolar Disorder
Treatment Options for Bipolar Disorder
About The Modules
Contributors
Laura Smith (MPsych
1
)
Centre for Clinical Interventions
Dr Louella Lim (DPsych
2
)
Centre for Clinical Interventions
1
Masters of Psychology (Clinical Psychology)
2
Doctor of Psychology (Clinical Psychology)
Background
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive Behaviour Therapy. CBT for bipolar disorder is based on the approach that
adjunctive psychological treatment is helpful to improve understanding of the illness, medication adherence,
awareness of early warning signs of mood episodes, quality of life and to reduce symptoms.
Acknowledgement
The Graylands Hospital Medication Information Service has made a longstanding contribution to the Bipolar
program at CCI. Clinical Pharmacists from this service have contributed their time and expertise to
providing excellent medication education to people attending the Bipolar Group at CCI. This longstanding
collaboration has guided the information presented in this module.
References
These are some of the professional references that informed the development of modules in this
information package.
Basco, M.R., & Rush, A.J. (2005) Cognitive Behavioral Therapy for Bipolar Disorder (Second Edition). New
York: The Guildford Press
Bauer, M.S. & McBride, L. (2003) Structured Group Psychotherapy for Bipolar Disorder: The Life Goals
Program (Second Edition). New York: Springer Publishing Company
Goodwin, F.K. & Jamison K.R. (1990) Manic Depressive Illness. Oxford; Oxford University Press
Johnson, S.L. & Leahy, R.L. (2004) Psychological Treatment of Bipolar Disorder. New York: The Guildford
Press
Lam, D.H., Jones, S.H., Hayward, P., & Bright, J.A. (1999) Cognitive Therapy for Bipolar Disorder: A
therapist’s guide to concepts, methods and practice. Chichester: John Wiley & Sons Ltd
Miklowitz, D.J. (2001) Bipolar disorder. In David H. Barlow (Ed.) Clinical Handbook of Psychological
Disorders – Third Edition (pp 523-561). New York: Guilford Press
Newman, C.F., Leahy, R.L., Beck, A.T., Reilly-Harrington, N.A., & Gyulai, L. (2002) Bipolar Disorder: A
cognitive therapy approach. Washington: American Psychological Association
“KEEPING YOUR BALANCE”
This module forms part of:
Lim, L., & Smith, L. (2003). Keeping your Balance: Coping with Bipolar Disorder. Perth, Western Australia:
Centre for Clinical Interventions.
ISBN: 9780975198520 Created: March 2003 Revised: July 2019
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