Bipolar I Disorder

Finding The Right Treatment

Treatment for Bipolar I Disorder

Treatment for bipolar disorder is extremely important. Without treatment, the symptoms continue and they may also intensify over time. Some people with bipolar disorder lose interest in their jobs, their families, and everything else they once cared about when they are in a depressive state. In this pit of despondency, they cannot imagine ever feeling better. In addition, when they are in a manic state, they can engage in activities that are very dangerous and life-altering or even life-ending, such as driving recklessly or going on wild spending or sexual sprees.

The good news is that most people can recover from this disorder with a combination of therapy, medications, and lifestyle modifications, and lead normal, fulfilling lives. There will be times when symptoms may take over again, even when a person is very faithful about taking their medications. But the outlook is far better for the treated person with bipolar I disorder than for the person who is untreated.

Finding a therapist

While medications are often a catalyst for change in individuals with bipolar I disorder, therapy has proven to yield major improvements in the lives of those struggling. Whether it be early recognition of an individual's symptoms that lead to a depressive or manic episode, an understanding of how one's past might have impacted them, or a simple awareness of their thoughts and their triggers, therapy can help people become more content versions of themselves. Many therapists have experience working with adults with bipolar I disorder.

There are different kinds of professionals who can provide effective therapy, including:

• Clinical psychologists (PhD)
• Licensed clinical social workers (LCSW or LMSW)
• Licensed professional counselors (LPC)
• Licensed clinical professional counselors (LCPC)
• Licensed Marriage and Family Therapists (LMFT)
• National certified counselors (NCC)

There are several styles of therapy that can be helpful for bipolar disorder including psychodynamic, interpersonal, and supportive therapy. In recent years, more therapists employ cognitive behavioral therapy (CBT), which is a method that helps the individual identify unhelpful thought patterns, challenge self-destructive cognitions, and replaces them with more constructive thinking. Therapists will also help the individual identify behaviors which may help bring increased pleasure or a return to a sense of confidence.

Many individuals with bipolar disorder find therapy to be one of the best ways to prevent future depressive episodes. It is critical to recognize the triggers and signs of an oncoming episode, and therapy can help one detect them. The natural ups and downs of life can often be triggers for depressive episodes, and a good therapist will partner with the individual to plan accordingly, even aiding in their advocacy for antidepressant dosing adjustments through these difficult periods.

The decision to start therapy

Many people try to cope with their distress on their own, then feel disappointed when they find that this is very difficult to do. Deciding to start therapy can be hard; it takes courage.

For some people, it can take time to warm up to the idea of sharing one’s intimate thoughts or disclosing details of one’s life, especially for those who grew up in a culture where seeking psychological help was frowned upon.

Psychotherapy is increasingly accepted as not only a way to improve mental health symptoms, but also a means for self exploration and personal growth. No problem is too small for a trained therapist: an individual need not worry that others may have it worse. The willingness to reach out for help is increasing: in 2020, one out of every six Americans (men and women) reported seeing a therapist.

Seeing a therapist with whom one feels comfortable, and a sense of connection, and who also participates in their insurance network, is essential. It may take a couple tries to find a therapist who feels like the right fit. If therapy didn't help the first time around, it can be helpful to give another therapist a try because therapeutic styles vary so much from therapist to therapist.

Where to start

Requesting one’s physician to make a referral is often a good place to start. Many health insurance cards have websites or 1-800 numbers to call for a list of in-network providers.

To find a therapist who takes your insurance, the National Institute of Mental Health offers a comprehensive list of resources.

Psychology Today also lists therapists by type, location and insurance.

Determining whether medications will play a role in treatment

Medications often play a central role in the lives of people with bipolar I disorder. Finding the right medication is not straightforward, as individuals metabolize and react to medications differently. Adjusting dosages to manage and prevent manic or depressive episodes can add an additional layer of complexity.

Mood stabilizing medication

In most cases, a mood stabilizing medication is the first type of drug used to treat bipolar I disorder. Lithium is the most commonly-used medication for bipolar disorder. Lithium is a naturally-occurring element and a different form of lithium is used in some batteries.

If an individual takes lithium, they will need periodic blood tests to determine if the lithium is at a therapeutic level in their blood. Based on the findings of the blood test, they may need a higher or lower dose of lithium. As one's mood stabilizes on lithium, the blood tests become less frequent but periodic checks are still recommended, at a schedule determined by their doctor. The down side of lithium is that the drug may cause a serious weight gain. This is not a problem for everyone who takes lithium but it has been reported by many people taking this medication.

It is also important to drink plenty of fluids–at least 8-12 cups per day–while taking lithium because otherwise, it is possible to become dangerously dehydrated.

If lithium is not effective for a person with bipolar I disorder or causes too many side effects, there are other drugs that are mood stabilizing.

Antipsychotic medications

When psychotic features are present, which often happens at least at some point with bipolar I disorder, the individual will need a prescription for an antipsychotic medication. There are many antipsychotics and most physicians prefer the newer “second generation” or “atypical” antipsychotics available today, which are longer-acting and are also less likely to have side effects than medications that were popular twenty years ago. However, side effects do occur with many antipsychotics and the primary side effect is weight gain of many of these drugs. See the table for a listing of many key antipsychotics.

Antidepressants

Many people with bipolar I disorder also need an antidepressant as an adjunctive treatment to the mood stabilizer. As a result, the person may take medication in the selective serotonin reuptake inhibitor (SSRI or SRI) class, which include fluoxetine (Prozac), escitalopram (Lexapro), and a few others. Research has shown that there is a relationship between depression levels and the amount of serotonin available in the brain; So, these medications prevent serotonin from being taken out of the system too quickly (reuptake inhibition). The other group of commonly used medications are classified as serotonin norepinephrine inhibitors (SNRIs). Both of these classes of drugs modulate the levels of these neurotransmitters in the brain. As a class of medications, antidepressants often take 10 days to two weeks to begin working. The full effect of the medication is not realized for two months.

If one of the “first-line” medications does not initially work, a prescriber has many options. The first is to ensure that the SSRI/SNRI is dosed adequately. For this reason, we have included the maximum recommended doses. Before abandoning a “first-line” treatment, it is prudent that these high doses are given a chance. Sometimes, however, high doses are not tolerated due to side effects.

Second-line treatment

A large percentage of people who take antidepressants either do not tolerate the SSRIs/SNRIs or do not see clinical benefit. In these situations, prescribers turn to bupropion (Wellbutrin). Bupropion is a dopamine and norepinephrine reuptake inhibitor (DNRI). It has significant antidepressant properties, particularly as the dose increases from the starting dose of 150 mg to the maximum dose of 450 mg. Bupropion does not have serotonin properties, and for this reason, it does not cause sexual side effects. On the downside, bupropion is not as effective against anxiety as some of the SSRIs/SNRIs.

Bupropion can be used alone, and in these situations, a higher dose is recommended (300 mg - 450 mg). Not uncommonly, bupropion is added to an SSRI/SNRI. When used in combination, dosages are usually between 150 mg to 300 mg.

Next-level treatment

The strategies discussed above are considered “first-line” treatments. Most of the medications described are generic, and consequently, they are less expensive than new “brand name” medications. The techniques of combining the medications are well established, and can be done in the primary care setting. The majority of patients receiving treatment for depression are given one of these “first-line” options. Fortunately, other options exist for the large swath of individuals who don’t respond to them.

Vortioxetine (Trintellix) works by a combination effect of decreasing serotonin reuptake and interacting with selective serotonin receptors, thus increasing the level of circulating serotonin. Just remember this: more serotonin generally = better mood. Vortioxetine is highly effective in combating symptoms of depression. It is distinguished because it is associated with less weight gain and sexual dysfunction than the SRIs/SNRIs. A small number of individuals taking vortioxetine (Trintellix) notice significant nausea early on, and the medicine should be taken with one's largest meal of the day. While its effectiveness and minimal side effects are noteworthy, vortioxetine (Trintellix) is a more expensive agent, and therefore, protocols suggest trials of SSRIs/SNRIs first.

Vilazadome (Vybriid) also works as a serotonin reuptake inhibitor, and a selective serotonin agonist. It is distinguished from the SSRIs/SNRIs in that it causes less emotional blunting, meaning the people who take it report experiencing a full range of emotions. Like Tryntellix, it has a favorable side effect profile, causing less weight gain and sexual dysfunction than SSRIs/SNRIs. Nausea is associated with Vybriid, although it typically diminishes within the first week. The medication should not be discontinued abruptly.

Healthcare providers that can prescribe medications

Psychiatrists, psychiatric nurse practitioners, and physician assistants are practitioners who are trained to diagnose and treat mental health conditions by prescribing medications. Sometimes it's hard to find a psychiatric provider because there are so many people who need them. So, individuals often choose to see a different kind of provider who can prescribe. This could be a doctor they already see, like a primary care doctor, family doctor or OB/GYN, or a new primary doctor.

FDA warning about suicide risk with antidepressants

Some research exists that, occasionally, newly initiated anti-depressants may increase the risk of suicide. If an individual begins to have these thoughts after starting an anti-depressant, please stop this medicine and contact a prescriber immediately. This risk is more evident in children, adolescents, and young adults.

Dietary supplements

There are an increasing number of supplements, such as an herb, vitamin, mineral, and other supplements claiming to improve sleep, depression, stress, restlessness, or anxiety. While it is possible for a supplement to improve one’s symptoms, their effects are often unproven.

Be aware that dietary supplements are not controlled by the FDA and, therefore, are not subject to the standards of quality, uniformity, and testing for efficacy and safety as regulated medications. It is important to share a list of all medications and supplements with one's treating provider because some of them may interact with the medications they prescribe.