The crux of treatment for bipolar disorder may involve a mood stabilizer such as Lithobid (lithium), Lamictal (lamotrigine), Depakote (valproic acid), or Tegretol (carbamazepine).

The two short paragraphs below require some knowledge of psychobiology to understand.

Generally speaking, mood stabilizers work on ionotropic receptors. That is to say, they largely work with GABA, which we recall is the main inhibitory neurotransmitter in the nervous system. In short, GABA stops neurons that make us excited from firing as much.

Mood stabilizers also usually act on sodium ion channels. Opening sodium channels creates excitatory impulses. Mood stabilizers tend to work largely by closing sodium channels to prevent as much stimulation as would normally occur. By the same token, more postassium and chlorine ion action decreases membrane potential, which makes it harder for a neuron to fire, creating a sense of calm in the patient.

The below figure can be somewhat more clear after reading through the sections on how the brain works; I must admit that I don’t recognize many articles in this ven diagram. The three things that these three mood stabilizers have in common is (lamictal was left out)…

  1. Up-regulation (more) or GABA-B receptors
  2. Decreasing the amount of GABA (the main inhibitory neurotransmitter, or, psychoactive chemical, in the central nervous system) being metabolized and recycled
  3. Decreasing the amount of dopamine ( the neurotransimtter associated with novelty) being metabolized and recycled)

A lot of the other actions have to do with intracellular mechanisms dervied from “second mesenger” systems, and alteration of fequency of various ion channels opening and closing. But we also see more basic actions happeining.

For instance…

  • Valproate increases the release of GABA
  • Carbamazepine antagonizes the adenosine (involved in sleep) receptor
  • Lithium reduces activity at one of the adrenergic receptors

  • Lithium
    • Tends to be a bit more effective for mania than depression
      • Has significant antidepressant qualities too.also
      • The so-called “gold standard” of mood stabilizers
    • The template by which other mood stabilizers are judged
    • Has use in cluster headaches, too
    • After about a weak, treatment begins to kick in
    • A month into treatment, maximum efficacy is usually experienced
    • Lithium is effective about 80%-90% of the time
    • It’s extremely useful in dealing with suicidality.

The following three mood stabilizers also have utility in treating epilepsy

  • Lamotrigine
    • Known for being more useful for depression than for mania
    • Touted as having very few, if any, side effects.
    • Unique in how it works
  • Valproic acid
    • particularly effective for mania
    • About 50%-90% effective for acute mania and maintenance.
  • Carbamazepine
    • Effective in the maintenance and acute manifestations of bipolar disorder
    • Both carbamazepine and valproic acid can begin working in the first several days of treatment, but bloodwork determines the therapeutic dose
    • For acute mania, it’s about 60% effective
    • For maintenance, 60%-75%

Antipsychotics are oftentimes very useful in treating bipolar disorder, too. The following medications are approved to treat bipolar disorder in the acute phase, and where noted, as maintenance therapy.

  • Abilify (aripiprazole)
    • Also approved for bipolar maintenance
  • Risperdal (Risperidone)
    • Including the injection
      • Also approved for bipolar maintenance
  • Saphris (asenapine)
  • Seroquel (quetiapine)
    • Licensed to treat bipolar without a mood stabilizer
    • Also approved to treat bipolar maintenance
  • Zyprexa (olanzapine)
    • also indicated for depression
    • Also approved to treat bipolar maintenance

When it comes to acute mania, antipyschotics are more effective than conventional mood stabilizers.

Klonopin (clonazepam) is, rarely, used to combat mania. It carries the risk of addiction, which, given that many people with bipolar disorder also tend to abuse substances, could prove disastrous. That’s why it’s prescribed very judiciously

If mania is controlled, it’s not unheard of for an antidepressant to be started. Mood stabilizers generally work much better at controlling mania, than depression.

  • Ketamine
    • Recently, and progressively, used to combat symptoms of depression, and for bipolar disorder overall
    • Works extremely fast
    • One study relates how one ketamine dosage led to a “rapid and robust antidepressant response“, and significantly reduced suicidal ideation
    • Will probably become a mainstream treatment within two years
    • Is not going to be administered in high enough doses to promote hallucinations and euphoria

Above we have the late Carrie Fisher, who related her struggles with bipolar disorder and addiction to the world. We owe great thanks to celebrities with mental illness coming out to talk to the public about it. Because of Ms. Fisher’s words, society stigmatizes bipolar disorder, and mental illness overall, less so.

Sources: Dr. John Bezirganina, Condensed Psychopharmacology 2013: A Pocket Reference for Psychiatry and Psychotropic Medications, Abnormal Psychology