context: Bipolar disorder is a mental illness that can include mood swings from extreme highs to the depths of depression. Most people have more than one of these âepisodesâ of dramatic mood shifts. There can be a long period of time without problems in between those mood swings. Doctors don't completely understand what causes the condition. But they do understand it much better than they did in the past. With that understanding has come targeted treatment. Although there is no cure, there are treatments that can manage the symptoms. If you have mania, you'll probably need to take medicine to bring it quickly under control. Your doctor will also likely prescribe a mood stabilizer, also called an âantimanicâ medication. These help control mood swings and prevent them, and may help to make someone less likely to attempt suicide. You may need to take medicine for a long time, sometimes indefinitely. Your doctor may prescribe lithium and certain anti-seizure drugs like carbamazepine ( Tegretol), lamotrigine ( Lamictal), or valproate ( Depakote). You may need very close medical supervision and blood tests while you take these. If your mania is severe, you may need to stay in a hospital until your symptoms are under control. Electroconvulsive therapy ( ECT) may also be something your doctor considers. Your doctor may change your medicine dose, or add or subtract medicine. For instance, she may stop antidepressants, or add an antipsychotic or another drug to lessen your symptoms. You may also find that psychological therapy and a well-ordered daily routine help, along with your medicine. Lithium ( Eskalith, Lithobid) is the drug used and studied longest for treating bipolar disorder. It helps make mania less severe and more rare. And it may also help relieve or prevent bipolar depression in some people. Studies show that lithium can lower the risk of suicide among people with bipolar disorder. It also helps prevent future manic episodes. Doctors may prescribe it for long periods of time as maintenance therapy. What It Is: Lithium is a drug that acts on the brain and spinal cord. It helps people with bipolar disorder have more control over their emotions, sleep, energy, and extremes in behavior. What to Expect: It usually takes several weeks for lithium to work. Your doctor will give you blood tests during your treatment because lithium can affect how well your kidney s or thyroid work. Lithium works best if the amount of the drug in your body stays at a constant level. The level shouldn't be too low or too high. Your doctor will also probably suggest you drink eight to 12 glasses of water a day during treatment and use a normal amount of salt in your food. This helps to keep your lithium level steady. Different people need different doses. Your dose may also change over time. You may need to take other medicines, too. But sometimes, lithium alone is enough. Risks and Side Effects: Most people who take lithium -- about 75% -- have some side effects, although they may be minor. They may become less troublesome after a few weeks as your body adjusts to the drug. Sometimes, your doctor can change your dose to stop side effects. Never change your dose or drug schedule on your own. Don't change brands of this medication before you check with your doctor or pharmacist first. If you have any problems, talk to your doctor about your options. Common side effects include: Weight gain Trouble remembering Poor concentration Mental slowness Hand tremor Drowsiness or tiredness Hair loss Acne Being very thirsty Peeing more than usual Your thyroid doesn't work as well Problems with how your kidney s work Tell your doctor if you have lasting symptoms from lithium or if you have diarrhea, vomiting, a fever, unsteady walking, tremors, fainting, confusion, slurred speech, or a rapid heart rate. Be sure to tell your doctor about if you've ever had cancer, heart disease, kidney disease, epilepsy, or allergies. And make sure your doctor knows about all other drugs you take. If you take lithium, don't avoid foods that contain sodium. Too little sodium in your body can make your blood's lithium level too high. While taking lithium, be careful when driving or using machinery, and avoid alcohol. Ask your doctor what to do if you miss a dose, or if you have an illness that makes you vomit or gives you diarrhea (losing fluids can affect your lithium levels). If you miss a dose, doctors and pharmacists usually recommend taking it as soon as you remember it -- unless the next scheduled dose is within 2 hours (or 6 hours for slow-release forms). If so, they usually recommend skipping the missed dose and resuming the usual dosing schedule. Don't "double-up" the dose to catch up. There are a few serious risks to consider. It's rare, but lithium may cause weak bones in children. Lithium also can rarely (1 in 1,000 to 1 in 2,000 cases) cause a particular type of heart valve birth defect. So your doctor may not want you to take it if you're pregnant. Don't breastfeed if you take lithium. People on high blood pressure drugs called diuretics, especially thiazide diuretics, need to be extra careful because dangerous levels of lithium can build up in the blood. Also, in a few people, long-term lithium treatment can interfere with how well your kidneys work. Your doctor may consider whether you need carbamazepine ( Tegretol), lamotrigine ( Lamictal), or valproate ( Depakote) to treat or prevent the mood symptoms of bipolar disorder. These are drugs that help prevent seizures. Your doctor may call them âanticonvulsants.â He may prescribe them alone, with lithium, or with an antipsychotic drug to control mania and depression or prevent another episode. Some other anticonvulsant drugs -- such as gapabentin ( Neurontin), oxcarbazenpine ( Trileptal), and topiramate ( Topamax) -- aren't proven treatments for mood symptoms in bipolar disorder. But doctors sometimes prescribe them either experimentally or for symptoms other than mood (such as anxiety or pain). What It Is: These medicines calm hyperactivity in the brain in various ways. For this reason, some of these drugs are used to treat epilepsy, prevent migraines, and treat other problems. Doctors sometimes favor them over lithium or use them with lithium or antipsychotic drugs for people who have ârapid cycling,â which is four or more episodes of mania and depression in a year. What to Expect: Each anticonvulsant acts on the brain in a slightly different way. So your experience may differ depending on the medicine you take. In general, it takes at least several weeks or longer to judge their effect. You may need to take blood tests now and then while you take these medicines. Some can affect your liver or lower the amount of platelets in your blood. Risks and side effects: Each medicine may have slightly different side effects. Common ones include: Dizziness Drowsiness Fatigue Nausea Tremor Rash Weight gain Most of these side effects get better with time. Serious risks include: Birth defects: Pregnant women shouldn't take certain anticonvulsants (like Depakote and Tegretol) because they may cause birth defects. So tell your doctor if you're planning a pregnancy or if you find out that you're pregnant. Liver problems: If you take certain anticonvulsants for the long term, your doctor may require blood tests to check your liver. Drug interactions : Some anticonvulsants can interact dangerously with other drugs -- even aspirin or birth control pills -- or make those other drugs work less well. Be sure to tell your doctor about any medicines, herbs, or supplements you take. Don't take anything else during treatment without talking with your doctor. Stevens- Johnson syndrome: This is a potentially life-threatening skin rash that Tegretol or Lamictal may cause. Doctors used to prescribe these medicines as a short-term treatment to control agitation or psychotic symptoms such as hallucinations or delusions that can happen during mania or severe depression. Today, they are increasingly being used for other symptoms (such as agitation or insomnia) along with mood stabilizers to bring about faster improvements, and to help prevent relapses. Doctors also use some antipsychotic drugs as antidepressants for bipolar depression. Some of the newer antipsychotics seem to help stabilize moods on their own. As a result, doctors may use them as long-term treatment for people who can't take or don't respond to lithium and anticonvulsants. What It Is: Antipsychotic drugs affect chemicals in the brain called neurotransmitters. It is not clear exactly how these drugs work, but they usually improve manic episodes quickly. What to Expect: The newer antipsychotics can help you avoid the reckless and impulsive behaviors associated with mania. People often start to get back to normal thinking within a week. But the full effects may take several weeks. Antipsychotics used to treat bipolar disorder include: Aripiprazole ( Abilify) Asenapine ( Saphris) Cariprazine ( Vraylar) Clozapine ( Clozaril) Lurasidone ( Latuda) (for bipolar depression) Quetiapine ( Seroquel) (for mania or bipolar depression) Olanzapine ( Zyprexa) Risperidone ( Risperdal) Ziprasidone ( Geodon) Risks and Side Effects: Certain antipsychotics cause rapid weight gain and high cholesterol levels. They may also raise the chance of high blood sugar levels or eventual diabetes. Your doctor should first check on your risk for heart disease, stroke, and diabetes. Common side effects of antipsychotic drugs include: Blurry vision Dry mouth Drowsiness Muscle spasms or tremor Involuntary facial tics Weight gain Also, ziprasidone ( Geodon) has been linked to a rare but potentially fatal skin reaction called "drug reaction with eosinophilia and systemic symptoms" ( DRESS syndrome). Doctors usually don't use older antipsychotics to treat bipolar disorder. But these medicines may help if a person has troublesome side effects or doesn't respond to the newer drugs. Older antipsychotics include: Chlorpromazine ( Thorazine) Haloperidol ( Haldol), loxapine ( Loxitane) Perphenazine ( Trilafon) These drugs appear more likely than the newer antipsychotics to cause a serious, long-term side effect called tardive dyskinesia, an involuntary movement disorder. What They Are: These medicines are sedatives. They slow the brain and nerves. In doing so, they can help treat mania, anxiety, panic disorder, insomnia, and seizures. They may also help restore normal sleep patterns and calm agitation in people with bipolar disorder. Benzodiazepines prescribed for bipolar disorder include (among others): Alprazolam ( Xanax) Clonazepam ( Klonopin) Diazepam ( Valium) Lorazepam ( Ativan) What to Expect: You'll probably take these for a brief time, up to 2 weeks or so, with other mood-stabilizing drugs. These medicines act quickly and bring on a sense of calmness. They can sometimes cause lightheadedness, slurred speech, or unsteadiness. Risks and Side Effects: Benzodiazepines can be habit-forming. You can become dependent on them. They are also dangerous (or possibly even fatal) if combined with alcohol. So you shouldn't drink any alcohol if you take this type of medicine. Other side effects include: Drowsiness or dizziness Lightheadedness Fatigue Blurry vision Slurred speech Memory loss Muscle weakness If you have been taking the drugs for a long time, you may have withdrawal symptoms if you stop them suddenly. Talk with your doctor about how to taper off the drug, and ask if you still need them. What It Is: Doctors use electroconvulsive therapy ( ECT), also known as electroshock therapy, to treat hospitalized people who are severely depressed or manic, suicidal, psychotic, or persistently agitated and unable to take basic care of themselves. It works for nearly 75% of people. ECT is one of the fastest ways to relieve symptoms in people who have mania or severe depression. It's not a "last resort" only when the illness does not respond to medicine or psychotherapy. Instead, doctors should consider it sooner rather than later when medicines aren't effective or when there it's urgent to ease severe symptoms, such as when depression causes severe suicidal thoughts or psychosis that needs care very quickly. What to Expect: You'll get general anesthesia so that you aren't awake during the procedure. You'll also get a muscle-relaxing drug. Your doctor will put electrodes on your scalp. He'll use a finely controlled electric current to cause a brief seizure in the brain. Because your muscles are relaxed, the seizure will probably only slightly move your hands and feet. Your doctor will watch you carefully during the treatment. When you wake up a few minutes later, you won't remember the treatment and you may be confused at first. This confusion typically lasts for only a short period of time. ECT is given up to three times a week usually for 2 to 4 weeks or sometimes longer. Risks and Side Effects: Safety risks from ECT are related mainly to the risks of general anesthesia. Some people with certain heart problems shouldn't get ECT or may need especially close monitoring. Headache and short-term memory loss are the most common side effects of the procedure. But these usually don't last long. ECT is often considered a treatment of choice during pregnancy. But late in the pregnancy there is a chance you could go into early labor, so the anesthesiologist must keep a close watch on you during the procedure. Other side effects include: Confusion Nausea Muscle aches Jaw pain These effects may last from several hours to several days. A third of people who have ECT report some long-term memory loss. These problems may be related to other things such as a history of drug or alcohol abuse or other things that have hurt the brain. The technique used to deliver the treatment, such as where the electrodes go on your scalp, may help avoid those problems.