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Medications for Bipolar Disorder

 

Aim of this leaflet

This leaflet is for anyone who wants to find out about the medications used to help stabilise unhelpful mood swings and to control mania in bipolar disorder. It discusses how they work, why they are prescribed,ABPI: new Code of Practice for the Pharmaceutical Industry their effects, side-effects and some alternatives. 

What is mania?

If you suffer from mania, you may find yourself feeling elated, over-confident and full of energy - 'on top of the world'. You may sleep very little, talk very fast, and do things impulsively that are out of character.

 

In bipolar disorder, you may have both manic and depressive mood swings at different times.

 

These mood swings can be very unpleasant and destructive.  It is important to start treatment early, before the condition becomes severe. For more information, see our leaflet on Bipolar Disorder.

 

Mania is a condition that can come back again and again. Many doctors will advise taking medication to prevent this happening. Medication can be used to treat mania once it has started, or to prevent it from starting.

 

To Treat Mania To Prevent Mania
Mood Stabilisers

Lithium

Valproate

Lithium

Valproate

Carbamazepine

Olanzapine

Antipsychotics  

Atypical: Olanzapine, Risperidone, Quetiapine
Asenapine

Typical: Chlorpromazine, Haloperidol

Usually used together with a mood stabiliser, not usually on their own

Benzodiazepines
Diazepam
Lorazepam
Clonazepam

Mood Stabilisers

Lithium

Lithium has for 40 years been the most commonly used drug to prevent relapse.

How does it work?

We don’t know, but we know that it works on chemical signals in the brain and that it makes brain cells more resilient to stress.

 

What effect does it have?

It ‘evens out’ mood swings in either direction.

 

How is it taken?

In tablet form, once or twice a day. It is important to continue with the Lithium when you are feeling better - suddenly stopping it may trigger depression or mania.

 

What are the side effects?

You may notice:

in the first few weeks

  • a slight shaking of the hands
  • dry mouth
  • a metallic taste in the mouth
  • tiredness

later

  • weight gain
  • thirst
  • urinating more often
  • under-active thyroid gland.

Not everybody will get these side-effects. If you do have any of these, it is worth bearing in mind that most will go away with time as your body gets used to the Lithium.

 

Is Lithium dangerous?

No - Lithium is a safe drug when taken at the correct dose. However, you don't have to go very far above the safe dose before it becomes unsafe. A test to measure the amount of Lithium in your blood is the best way of making sure you are getting the right dose.

The following signs suggest that your Lithium level is too high. Contact your doctor immediately if you notice:

  • you feel very thirsty
  • you have bad diarrhoea or vomiting
  • obvious shaking of your hands and legs
  • twitching of your muscles
  • you get muddled or confused.
Sensible precautions while taking Lithium

The body gets rid of Lithium in your urine, so the amount of Lithium in your blood is easily affected if you lose fluid. If you take in less, by drinking less, or lose more, through sweating or urinating, the higher your level of Lithium will be.

 

Your ability to get rid of Lithium in your urine is affected by the amount of salt in your blood – if you have less salt, you pass less Lithium in your urine, and so the level of Lithium in your blood may rise.

 

Some other drugs and medicines, whether prescribed by a doctor or available over‑the‑counter, may interfere with Lithium. Please check with your doctor or pharmacist before starting any new medication, wherever you have got it from.

 

So:

  • drink plenty of non-alcoholic fluids - diet drinks can help to prevent weight gain;
  • if you are on holiday in a hot climate, drink more fluids than usual and don't spend a long time out in the sun;
  • avoid low-salt diets;
  • be careful if you are exercising heavily - you may get too dry or lose too much salt in your sweat;
  • don't have a sauna.
Blood tests

These are needed to:

  • check the amount of Lithium in the body (see above);
  • check that your kidneys and thyroid gland are working properly.

The blood test is usually done 12 hours after the last dose of Lithium.

  • If you take it twice a day, and are having the test in the morning, remember to miss your morning dose on the day of the test.
  • At first these tests are done every week or fortnight. After the level of Lithium in your blood has become steady, they need only be done every three or four months.

Valproate

This medication is becoming more widely-used to treat mania. It is also used to prevent recurrence of extreme mood swings, and a recent study has found that the combination of valproate with lithum may be more effective than either of these medications on their own.

 

Like lithium, we don’t know exactly how valproate works.

 

What are the side effects?

Common:

  • sleepiness
  • dizziness
  • increased appetite and weight gain
  • feeling of sickness, nausea
  • skin rashes
  • changes in blood count
  • irregular periods.

Very rare:

  • pancreatitis or inflammation of the pancreas (less than 1 in 10,000 cases): abdominal pain, nausea and vomiting;
  • liver failure (less than 1 in 50,000 cases): weakness, loss of appetite, lethargy, drowsiness and sometimes repeated vomiting and abdominal pain. If you have any of these symptoms, get help immediately.

Your doctor will usually take blood before you start treatment, and then for the first six months of treatment to monitor your blood count and liver function.

 

Carbamazepine

This is usually given to people who don’t get on with Lithium. Some doctors believe that it may be better for people who have 'rapid-cycling' bipolar disorder (that is 4 or more episodes of depression and mania within a 12 month period).

 

What are the side effects?

It usually causes fewer side-effects than Lithium. The most common ones are:

  • feeling tired or dizzy;
  • blurred vision;
  • nausea;
  • stomach ache;
  • diarrhoea or constipation;
  • about 10% of people will develop a mild rash. About 1 in 200 people may develop a serious rash that requires urgent treatment;
  • 1 in 50 people can develop changes in the blood count, but these are rarely serious. These changes are more likely to occur at the start of treatment, so your doctor may take blood tests for a while. You should consult your doctor immediately if you get a fever, sore throat, ulcers in your mouth, easy bruising, or a rash - particularly if the rash is of small purple spots.

Antipsychotics

These may be used alone, or with Lithium or Valproate. They can help if you become too active, psychotic or aggressive when you are manic. 

 

There are two groups of antipsychotics; the older ‘typical’ group and the newer ‘atypical’ group. The older group are more likely to cause muscle stiffness or tremor. The most commonly used antipsychotics are now 'atypical'.

 

What are the side-effects?

All antipsychotics may cause sleepiness or dizziness. If you take them for a long time you may put on weight. Older drugs from the ‘typical’ group, such as haloperidol, may also cause tremor or muscle stiffness.

 

They can be used to prevent relapse, but are usually used with one of the mood-stabilisers described above, when treatment with one drug has not been effective.

 

Benzodiazepines

These drugs are usually given, just for a few days, along with the drugs mentioned above. They help treat the symptoms of irritability, over-activity and lack of sleep.

 

What are the side effects?
  • sedation - reduced excitability and feeling calm
  • unsteadiness.

If used for more than a couple of weeks, they can be addictive.

How effective are these medications...

...in treating mania?

Lithium, Valproate, Quetiapine, Risperidone, Olanzapine and Asenapine are all probably equally effective.  Carbamazepine has been used, but there is less evidence that it works. Lithium is used less as it has more side-effects and needs more careful monitoring.

 

Whichever drug is used, mania is not an easy condition to treat, and you may take several weeks to recover. It is important to stick with the treatment and take it regularly.

 

How do I choose between the different medications?
  • In the acute phase, you might not be well enough to be too involved in the decisions about which drug to use.
  • If you have been ill before, doctors will often try to treat you with what has worked for you in the past.
  • When you are well, it might be worth agreeing with your doctor which medication you would prefer if you become ill again.
What else can I do to get over the acute phase?
  • You may not believe that you are unwell when you are high.
  • It important that you have family or friends who you can trust to tell you how you are.
  • If you don’t trust the professionals treating you, tell them why.

...in preventing mania?

  • Lithium is probably the most effective. You have a 30–40% chance of not being unwell again.
  • Valproate is a little less effective on its own, but less so than Lithium. Valproate and Lithium together are probably better than either on its own.
  • Carbamazepine is less effective than Valproate.
  • Olanzapine is effective in preventing mania if you responded well to it during a manic episode, but probably less effective than lithium longer-term.
How do I choose between treatments?
  • Lithium will usually be recommended for long-term treatment.
  • Carbamazepine may be suggested if you tend to get ill again very rapidly.
  • Some people may need a combination of drugs.
  • Much depends on how well you get on with a particular medication. What suits one person may not suit another.

Breast feeding and pregnancy

Pregnancy
  • Some of these drugs can affect a baby, so it is very important to discuss the risks with your doctors who will help you weigh up the risks of stopping the treatment, and the risks of carrying on with it.
  • If you get pregnant accidentally, don't suddenly stop your tablets as this can make you very ill.
Breast-feeding
  • Most drugs taken by a mother will be present in their milk, but the concentration will vary. You should discuss this with your doctor.

What happens if I don’t take medication?

In the acute phase:

Mania can be very disruptive and serious. It can alarm your family, you may lose your job, get into debt, or even get into trouble with the police. Your mood may take weeks or months to correct itself, and a lot of damage can be done during that time.  On average, an untreated manic episode will last around 6 months.

 

In the prevention phase:

The most accurate predictor of having a manic episode is how often you have had them in the past. The more manic episodes you’ve had, the more likely you are to have another one.

 

For some people, episodes can tend to be more frequent as they get older.

 

If you have had a manic episode, it’s worth giving some thought to treatments that might stop it from happening again.

 

Life events and stress can precipitate relapse. If this seems to be the case in your life, then you might want to consider a course of counselling or psychotherapy. This may help you cope with stress better, and help you find more stability in life.

 

Other ways of controlling “highs”

  • Some medical treatments used to treat other conditions can cause mania, so it is important to discuss your medicines with your doctor.
  • If you feel you are going high, get advice early.  Adjusting your medication, resting and avoiding stress may be enough to prevent a full relapse.
  • Find out as much as you can about the illness and its treatments.
  • People often have warning signs that they are going high. Not sleeping is one of the most important. It has been shown that if you can sit down with a professional and a family member, and draw up a list of warning signs and possible triggers, this can help to prevent relapses.
  • If you are going through a stressful time, and have early warning signs of mania such as insomnia, you may be able to prevent a relapse by taking a short course of a sleeping tablet, or an antipsychotic such as olanzapine. 

Where can I find out more?

The information leaflet that comes with the tablets will describe the side-effects in more detail. If you have concerns, discuss them with your doctor.

 

What is a ‘licensed’ drug? Are unlicensed drugs dangerous?

  • In Britain, drugs are licensed by the European Agency for the Evaluation of Medicinal Products. A license is only granted if the medicine is safe and seems to help patients.  
  • A drug may be unlicensed because there hasn’t been enough research into its effect in treating a particular condition. This doesn’t necessarily mean it is dangerous.
  • Drugs are commonly used to treat conditions for which they don’t have a license. For example, it is common to use benzodiazepines in the acute phase of mania, but they are not officially licensed for this condition.

References

The British Association for Psychopharmacology guidelines for treatment of bipolar disorder: a summary. Goodwin GM, Young AH. J Psychopharmacol. 2003 Dec;17(4 Suppl):3-6.

 

Bipolar disorder. Geddes J. Evid Based Ment Health. 2003 Nov;6(4):101-2.

 

NICE: Final Appraisal Determination: Olanzapine and valproate semisodium in the treatment of acute mania associated with bipolar I disorder.

 

Helpful organisations

Bipolar UK

Tel: 020 7931 6480: email: info@bipolaruk.org.uk. Provides support, advice and information for people with bipolar disorder, their friends and carers.

Bipolar Scotland

Tel: 0141 560 2050; email: info@bipolarscotland.org.uk. Provides information, support and advice for people affected by bipolar disorder and all who care for them. Promotes self-help throughout Scotland, and informs and educates about the illness and the organisation.

 

Depression Alliance

Tel: 0845 123 23 20; email: information@depressionalliance.org. Information, support and understanding for people who suffer with depression, and for relatives who want to help. Self-help groups, information, and raising awareness for depression.

 

Depression UK (Previously the Fellowship of Depressives Anonymous) 

Email: info@depressionuk.org. Organisation run as a source of support for people with depression, or their carers. A national mutual support group for people suffering from depression

AWARE 
Helpline: 1890 303 303. An Irish organization that assists and supports those suffering from depression and their families. A helpline is available as well as support groups, lectures and current research on depression. 

Further reading

Official Patient information leaflets

Original Leaflet written by: Dr Martin Briscoe and Professor John Geddes.

Revised: Dr Daniel J. Smith

 © August 2013. Date for review: August 2015. Royal College of Psychiatrists. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from permissions@rcpsych.ac.uk. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly.

 

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Please note that we are unable to offer advice on individual cases. Please see our FAQ for advice on getting help.

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