Medications for Bipolar
Under Review April
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,
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
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.
Olanzapine, Risperidone, Quetiapine
Typical: Chlorpromazine, Haloperidol
Usually used together with a mood stabiliser, not usually on
Lithium has for 40 years been the most commonly used drug to
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
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
- weight gain
- 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
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
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.
- 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
- 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.
These are needed to:
- check the amount of Lithium in the body (see
- check that your kidneys and thyroid gland are
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.
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
What are the side effects?
- increased appetite and weight gain
- feeling of sickness, nausea
- skin rashes
- changes in blood count
- irregular periods.
- pancreatitis or inflammation of the
pancreas (less than 1 in 10,000 cases): abdominal pain, nausea
- 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.
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;
- 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
- 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
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.
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
If used for more than a couple of weeks, they can be
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
- 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
- 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
...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
How do I choose between treatments?
- Lithium will usually be recommended for long-term
- Carbamazepine may be suggested if you tend to get ill again
- 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
- 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
- If you get pregnant accidentally, don't suddenly stop your
tablets as this can make you very ill.
- Most drugs taken by a mother will be present in their milk, but
the concentration will vary. You should discuss this with your
What happens if I don’t take
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
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
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
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
- 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
- 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.
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
Tel: 020 7931 6480: email: email@example.com. Provides
support, advice and information for people with bipolar disorder,
their friends and carers.
Tel: 0141 560 2050; email: firstname.lastname@example.org.
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
Tel: 0845 123 23 20; email: email@example.com.
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.
(Previously the Fellowship of Depressives
Organisation run as a source of support for people with depression,
or their carers. A national mutual support group for people
suffering from depression
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
Official Patient information leaflets
Original Leaflet written by: Dr Martin
Briscoe and Professor John Geddes.
Revised: Dr Daniel J. Smith
Under Review April 2018
Royal College of Psychiatrists. This leaflet may
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