Bipolar Depression Treatment
Treatment of Bipolar Depression and detailed explanation of medications for Bipolar Depression.
Antidepressant medication treatment for depression is often more successful than medication treatment for bipolar depression- simply because researchers know more about the depressed brain than the bipolar brain. Medications are developed from brain research- not the other way around. Antidepressants that are clearly established as effective treatments for depression, generally do not successfully treat bipolar depression, and in many instances can make it worse. The biggest concern is that antidepressants can cause mania. A further complication of antidepressant use in bipolar depression is the chance of rapid cycling where, over a period of time, episodes of mania and depression become more frequent. As researchers better understand the bipolar brain, they can come closer to creating antidepressants that don't cause mania. That will be a great day for all people with bipolar depression!
Depression and Bipolar Depression Medication Categories
There are four main medication categories used to treat depression and bipolar depression. The medications are sometimes used interchangeably for each depression, but bipolar depression almost always requires more medications in order to keep all of the symptoms under control without igniting mania. Treatment is complicated, but it's not difficult to learn the medication categories used to treat mood disorders.
Mood Stabilizers: There are four mood stabilizers used to treat Bipolar disorder:
In reality, only Lithium is a true mood stabilizer. The other three are anticonvulsants that were created for epilepsy and just happened to work on mood disorders. Lithium, Depakote and Tegretol often work miracles with mania, but only Lamictal is used to manage depression.
Antipsychotics: These are medications used to manage the psychosis that can come with depression, mania and mixed episodes. These are more commonly used for Bipolar Depression treatment than Depression. You may remember the old antipsychotics such as Thorazine or Haldol. There is now a new category called atypical antipsychotics that have less side-effects- though many people will tell you they can still have plenty! These include:
One of these drugs, Seroquel, has recently been found to be very effective in treating BIPOLAR depression, even when there are no psychotic symptoms.
Antidepressants: The most familiar antidepressants are the SSRI's such as Prozac, and Celexa. There is a second category called SNRI's, such as Effexor, that also work very well to manage Depression. As said before, the problem is that ALL of these drugs can ignite mania. There are no exceptions. This doesn't mean that people with Bipolar Depression can't take antidepressants. Many do, but to be safe, they should always be used with a mood stabilizer or antipsychotic that prevents mania. As you can imagine, this can get very complicated and it's essential you have vigilant medical management any time a new drug is tried.
Benzodiazapines (Antianxiety Medications): These are used to manage the anxiety that is very common with both types of depression. They are also used as a sleep aid. These include:
Yes, there is a risk of addiction with these drugs, but many use these drugs for anxiety and sleep with no addiction problems.
Most people with Bipolar Depression who are successfully treated often take several drugs simultaneously. Results from a recent Bipolar Disorder research project called the STEP-BD Project found that 89% of those successfully treated for Bipolar Disorder required, on average, three medications from the above categories. According to the recent STAR-D research project, people with Depression who don't respond fully to one antidepressant often respond successfully to two or more medications. My Gold Standard Treatment articles for Depression and Bipolar Disorder mentioned at the beginning of this article give more in-depth information on the successful medication treatment of mood disorders.
Here is how David, a 28 year old man with Bipolar Disorder explains the difficulties in treating Bipolar Depression.
BIPOLAR depression can come and go multiple times a day-rapid cycling. It can also be clouded by other Bipolar Disorder symptoms that can exacerbate the condition. For instance, if you are already experiencing OCD as a BIPOLAR symptom along with mild mania, and then Bipolar depression strikes, the manifestation in behavior and actions are much more dramatic. You now have two or more distinct mood swings at work that can be tough to identify since they are co-mingled. Together they can present as agitated mania, paranoia or anxiety. It can be equally as difficult to pinpoint which mood swing came first or which is the root cause of the other; the OCD symptoms, mania or the depression. This can make the job of friends, family members and even healthcare professionals all the more difficult in determining accurate current-state diagnosis and medicine treatment for the patient. When you are already anxious, for example, and then the Bipolar depression hits, the effects seem to be twice as devastating in terms of managing thoughts and perceptions. Example, one broken arm is much easier to manage than a broken arm AND a concurrent broken leg.
When you read the above story, what medications do you think David is taking? The answer: The antipsychotic Seroquel, mood stabilizer Lithium, benzodiazepine Klonopin. He tried antidepressants, but they increased his rapid-cycling. In the past, he took the antipsychotic Zyprexa but his doctor was worried about his cholesterol so he switched to the antipsychotic Seroquel.
I currently take Lamictal and use Ativan as needed. I can't take the other mood stabilizers or antipsychotics due to side-effects and definitely can't take antidepressants at all due to rapid cycling. Another friend of mine takes Tegretol , Lamictal, Zyprexa, Klonopin and Prozac! And he stays pretty stable. It's important to note that we all work very closely with our medication HCPs and watch for mania.
Healthcare professionals often face a medication dilemma with Bipolar Depression as the symptoms can be so complicated. Doctors must consider:
- Does the person with Bipolar Depression have Bipolar I which means they have the risk of full blown mania?
- Does the person have a history of psychosis?
- Do they have Bipolar II with hypomania which means they don't necessarily need an anti-mania mood stabilizer, but they are at risk of an antidepressant sending them into full blown mania?
- Is there a history of rapid cycling?
- Is it depression with the common signs of anxiety or is it a mixed episode?
- Does the person hear voices?
This can be a lot, especially for a general practitioner, which is why information for the HCP on the two types of depression is essential.
Bipolar Depression Approved Medications
All four of the above medication categories used to treat mood disorders are either approved by the Food and Drug Administration (FDA) for mood disorder treatment or they are used in what's called off-label use. Off-label use is an ethical and legal use of medications that have not specifically been sanctioned for use of a specific condition by the FDA.
FDA Approved BIPOLAR Depression Medications: At this time, there are two medications specifically approved for BIPOLAR Depression treatment:
- Symbyax: a combination of the antidepressant Prozac and the antipsychotic Zyprexa. (Approved in 2004)
- Antipsychotic Seroquel. (Approved in 2007)
There are four medications approved for maintenance of general Bipolar disorder symptoms:
- Lithium (mood stabilizer, 1974)
- Lamictal (anti convulsant/mood stabilizer, 2003)
- Zyprexa (antipsychotic, 2004)
- Abilify (antipsychotic, 2005).
Maintenance means the drugs can manage both mania and depression, though Lamictal is mainly indicated for depression and rapid cycling.
This is a lot of medication information to take in at once, especially if you or someone you care about was just diagnosed. There is also a Medication Chart from Dr. John Preston at the end of this article from Dr. John Preston. This explains the four categories and the specific medications under each. There are also many articles on HealthyPlace.com with more in-depth information on the use of mood disorder medications.
Last Updated: 11 July 2017
Reviewed by Harry Croft, MD