Acute Phase of Bipolar Treatment

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Selecting a mood stabilizer for an acute manic episode

The first-line drugs for treating a manic episode during the acute phase are lithium and valproate. In choosing between these 2 medications, your doctor will consider your treatment history (whether either of these medicines has worked well for you in the past), the subtype of bipolar disorder you have (e.g., whether you have rapidcycling bipolar disorder), your current mood state (euphoric or mixed mania), and the particular side effects that you are most concerned about.

Lithium and divalproex are each good choices for “pure” mania (euphoric mood without symptoms of depression), while divalproex is preferred for mixed episodes or for patients who have rapid-cycling bipolar disorder. It is not unusual to combine lithium and divalproex to obtain the best possible response. If this combination is still not fully effective, a third mood stabilizer is sometimes added.

Carbamazepine is a good alternative medication after lithium and divalproex. Like divalproex, carbamazepine may be particularly effective in mixed episodes and in the rapid-cycling subtype. It can be easily combined with lithium, although it is more complicated to combine it with divalproex.

The newer anticonvulsants (lamotrigine, gabapentin, and topiramate) are often best reserved as back-up medications to add to firstline medications for mania, or to use instead of the first-line group if there have been difficult side effects.

How quickly do mood stabilizers work?

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It can take a few weeks for a good response to occur with mood stabilizers. However, it is often helpful to combine mood stabilizers with other medications that provide immediate, short-term relief from the insomnia, anxiety, and agitation that often occur during a manic episode. The choices for so-called “adjunctive” medication include:

• antipsychotic medicines, especially if the person is also having psychotic symptoms (see above).

• a sedative called a benzodiazepine. Benzodiazpeines include lorazepam (Ativan), clonazepam (Klonopin), and others. They should be carefully supervised, or avoided, in patients who have a history of drug addiction or alcoholism.

Although both benzodiazepine sedatives and antipsychotic medicines can cause drowsiness, the dosages of these medications can generally be lowered as the person recovers from the acute episode. However, some individuals need to continue taking a sedative for a longer period to control certain symptoms such as insomnia or anxiety. Longer-term treatment with an antipsychotic is sometimes needed to prevent relapse.

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