Bipolar II Disorder

Finding The Right Treatment

Treatment for Bipolar II Disorder

Treatment for bipolar II disorder is extremely important. Without treatment, depression lingers for a longer period, and hypomania periodically crops up. In addition, sometimes symptoms intensify over time. Some people with bipolar disorder lose interest in their jobs, their families, and everything else they once cared about. In this pit of despondency, they cannot imagine ever feeling better. The good news is that most people with this disorder do well with therapy, medications, and lifestyle modifications, and lead normal, fulfilling lives.

Medication is generally considered to be the cornerstone of treatment for bipolar type II disorder; however, eating a nutritious diet, exercising regularly and getting enough sleep are also important, as are minimizing the use of alcohol/caffeine and avoiding illicit drug use. 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 II disorder than for the person who is untreated.

Finding a therapist

While medications are often a catalyst for change in people with bipolar disorder, therapy has been proven to yield major improvements in the lives of those struggling. Whether it be new ways to work with symptoms, an understanding of how one's past might have impacted them, or a simple awareness of one's thoughts and their triggers, therapy can help people become more content versions of themselves.

Many therapists have experience working with adults with bipolar disorder. There are several styles of therapy that can be helpful, 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 and challenge self-destructive cognitions, and replaces them with more constructive thinking.

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.

Medications

Medications play a central role in the lives of people with bipolar disorder. When we think about how to manage the symptoms of bipolar disorder it can be helpful to picture a seesaw with depression being on one side and hypomania being on the other - and through using certain medications we can balance both sides of the seesaw in order for someone’s mood to be “stable”.

The medications most commonly used to treat bipolar type II disorder are called “mood stabilizers” because they do just that by lowering the highs of hypomania and lifting the lows of depression. The three types of medications that are used as mood stabilizers are Lithium, anti-seizure medications, and antipsychotic medications. At times an antidepressant medication, when used in combination with a mood stabilizer, may also be prescribed for the treatment of bipolar II disorder.

Finding the right medication is not straightforward, as individuals metabolize and react to medications differently, and it can take several weeks after starting the medication for it to be at optimal effectiveness. The need to adjust dosages, or find an optimal medication combination, to manage and prevent hypomanic or depressive episodes can add an additional layer of complexity.

Lithium (lithium carbonate or lithium citrate)

Lithium is an element found in nature and is also present in small amounts in the human body. Lithium is used to treat hypomanic symptoms, reduce suicidal thoughts, and prevent future episodes of hypomania or depression from developing. Finding the right lithium dose is based on assessing how someone is responding to treatment and drawing blood to test the amount lithium in their blood. Blood samples are taken at regular intervals and the lithium dose may be adjusted to make sure that the lithium blood level is in a therapeutic range – neither too high or too low. The amount of lithium in the body can increase to dangerous levels when a person becomes severely dehydrated or is taking too high a dose. It is important to stay hydrated when taking lithium and avoid changing the amount of salt in the diet as the amount of salt used can affect lithium levels.

Common side-effects of lithium include upset stomach/nausea, increased thirst and urination, weight gain. and mild trembling of the hands. Less common side-effects can include fatigue, vomiting and diarrhea, blurred vision, difficulty concentrating, impaired memory, acne/dry skin, or mild muscle weakness. These side effects are generally mild and reduce as treatment continues. If, however, any of these effects are severe, they should be reported to the prescribing clinician immediately. In some people, lithium can affect their thyroid or kidney function and this must be monitored regularly by the prescribing clinician.

Anti-seizure mood stabilizers

Certain anti-seizure medications can be used in the treatment of bipolar II disorder as they appear to calm overly-excited parts in the brain - which then seems to allow the mood to be more steady and less likely to cycle into hypomania/depression. Due to these medications calming this excitability in the brain they are also used to treat epilepsy, prevent migraines, and treat other neurological conditions. The anti-seizure medications most often prescribed for managing bipolar II disorder are Lamotrigine (Lamictal), Valproic Acid (Depakote, Divalproex, or valproate) , and Carbamazepine (Tegretol).

Lamotrigine (Lamictal)

Lamotrigine is very effective in reducing depressive symptoms for someone with bipolar disorder. The starting dose of lamotrigine should be very low and increased very slowly over four weeks or more. This approach decreases the risk of a severe rash—a rare but potentially dangerous side-effect of this drug. Any rashes that begin in the first few weeks of starting lamotrigine, or after increasing the dose, should be reported immediately to the prescribing clinician.

Common side-effects of lamotrigine are usually temporary and reduce with time. Possible side effects include fever, aches, drowsiness, dizziness, blurred vision, nausea, vomiting, stomach upset, headache and skin rash.

Valproic Acid (Depakote, Divalproex, or Valproate)

Valproic acid is used to reduce the occurrence of manic/hypomanic episodes in the future. Valproic acid should not be taken by people who are pregnant due to risk of birth defects.

Common side-effects of divalproex include drowsiness, dizziness, nausea and blurred vision. Less common side-effects are vomiting or mild cramps, muscle tremor, mild hair loss, weight gain, bruising or bleeding, liver problems, and changes in the menstrual cycle.

Carbamazepine

Carbamazepine is used to treat manic/hypomanic symptoms, rapid cycling (a pattern of multiple manic or depressive episodes within one year), and mixed states (concurrent manic and depressive symptoms).

Common side-effects of carbamazepine include dizziness, drowsiness, blurred vision, confusion, muscle tremor, nausea, vomiting or mild cramps, increased sensitivity to sun, skin sensitivity and rashes, and poor coordination. A rare but dangerous side-effect of carbamazepine is reduced blood cell counts. People taking carbamazepine need to avoid grapefruit juice as it can increase carbamazepine levels in the body.

Atypical antipsychotic medications

The class of medications referred to as “antipsychotics” have emerged in recent years as a mainstay treatment for bipolar disorder. Antipsychotics have mood stabilizing properties and can fend off impending manic or depressive episodes. Importantly, they can be used to treat symptoms of psychosis such as paranoia, delusional thinking or hallucinations. In people with bipolar disorder who have both mood and psychotic symptoms antipsychotic drugs serve double duty. Many healthcare providers prefer the newer “second generation” or “atypical” antipsychotics available today, which are longer-acting and are also less likely to have side effects compared to older “first generation” antipsychotics that were introduced decades ago. The side effect profiles of the available atypical antipsychotic medications vary widely with the most common side effects being risk of weight gain, fatigue, glucose intolerance, or other metabolic disturbances. See the table for a listing of many key antipsychotics.

Antidepressants

Many people with bipolar II disorder may wonder if antidepressant medications are also considered mood stabilizers since they help lift mood in people with a depressive disorder. However, antidepressants are not mood stabilizing medications as they lift depression but do not address hypomanic symptoms. This has the potential risk of worsening mood destabilization (onset of mania, rapid cycling, worsening depression, or cause suicidal thoughts) in someone with bipolar II disorder. Because of that risk, the best treatment options for bipolar II disorder are mood stabilizing medications.

For those who are already taking a mood stabilizer, but still have breakthrough symptoms of depression, an antidepressant could be cautiously added as an adjunct to the mood stabilizer as this may further address depression while carrying less risk for mood destabilization. Examples of antidepressant medications that might be used as an adjunct to a mood stabilizer include fluoxetine (Prozac), escitalopram (Lexapro), sertraline (Zoloft), and buproprion (Wellbutrin).

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.

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.