Medicines for bipolar disorder

Medicine is a key part of treatment for bipolar disorder. It helps calm a high (mania), lift a low (depression), and, most important, keep new mood episodes from coming back. Bipolar disorder usually needs treatment for life, and the right medicine can make that life steady and full.¹

Each of the main medicines has its own benefits, side effects and checkups. This page explains what each one does, which tests to expect, and what to watch for at home. It does not give doses. Your doctor chooses those for you.

How bipolar medicines work together

Doctors often think of treatment in two parts. The first part treats the episode happening now. The second part, called maintenance, keeps new episodes from starting.¹ Some medicines help with both. Others help mostly with one.

It is common to try more than one medicine before finding the best fit. Some people take two medicines together.¹ Sleep or anxiety medicine may be added for a short time.¹

A word about antidepressants. In bipolar disorder, antidepressants are not used alone. On their own, they can set off mania or fast mood swings, called rapid cycling. If a doctor adds one during depression, it is usually alongside a mood stabilizer or an antipsychotic.¹ Learn more about antidepressant medicines and how bipolar disorder can be mistaken for depression.

The table below shows what a recent guideline from the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) found each medicine helps with.⁸

Source for the table: VA/DoD guideline summary.⁸ Many other antipsychotics also treat mania.⁸

Lithium

Lithium has been used for bipolar disorder for decades. It treats mania and helps prevent both highs and lows.⁸ Strong evidence It may also lower the risk of suicide.^1,8 It can take one to three weeks or longer to feel the full effect. Keep taking it even when you feel well.³

Why blood tests matter

With lithium, the amount that helps is not far from the amount that harms. That is why the FDA puts its strongest warning, a boxed warning, on lithium about toxicity (poisoning from too much in the blood).²

Your care team will order a lithium level, a blood test that shows how much is in your blood. It is checked often at first and after any dose change. After that it is checked on a regular schedule.² The test is usually timed about 12 hours after the last dose, so ask the clinic exactly when to go.² Levels are also rechecked when you get sick or start a new medicine.²

Kidney, thyroid and calcium checks

Lithium leaves the body through the kidneys. Over many years, it can affect them. The FDA label calls for:²

• Kidney tests before starting and regularly during treatment. Changes matter even if results stay in the normal range.
• Thyroid tests before starting, at about 3 months, and then every 6 to 12 months. Lithium can make the thyroid slow (hypothyroidism), which can cause tiredness, weight gain and low mood. Thyroid pills can treat it.
• Calcium tests on a regular basis. Long-term lithium can make the parathyroid glands (small glands in the neck that control calcium) overactive.

Some people notice much more thirst and urination. This can be a kidney effect called nephrogenic diabetes insipidus. Tell your doctor if it happens.²

Medicines and situations that raise lithium levels

Many common things can push the lithium level up. Tell every doctor, dentist and pharmacist that you take lithium.

• Pain relievers called NSAIDs, such as ibuprofen (Advil, Motrin) and naproxen (Aleve). Do not start these without asking your doctor first.^2,3
• Water pills (diuretics), such as hydrochlorothiazide or furosemide.²
• Some blood pressure medicines, called ACE inhibitors (such as lisinopril) and ARBs (such as losartan or valsartan).^2,4
• The antibiotic metronidazole.²
• Changes in caffeine. Cutting back on coffee suddenly may raise lithium levels. Check before making a big change.⁴

Fluid and salt matter too. Low-salt diets and dehydration raise the risk of toxicity.⁴ Heavy sweating, diarrhea, vomiting or a fever can all cause trouble.² Hot weather, hard exercise and stomach bugs are common examples. Follow your doctor's advice about fluids and salt, and call if you get sick.^2,3

Lithium in later life

As people age, the kidneys clear lithium more slowly. Older adults can get toxic at blood levels a younger person would handle well. Doctors usually start low and check kidney function closely.² Older adults also take more medicines that interact with lithium, such as water pills and blood pressure pills. See bipolar disorder in later life for more.

Valproate (divalproex)

Valproate is also called valproic acid or divalproex (Depakote). It is used to treat mania.^5,8 Strong evidence

It carries boxed warnings for three serious risks:⁵

• Liver damage, most often in the first 6 months. Your doctor will order blood tests.
• Pancreatitis (swelling of the pancreas). Call right away about stomach pain that may spread to the back, with nausea, vomiting or loss of appetite.
• Harm to an unborn baby. It can cause serious birth defects and lower intelligence and learning problems in the child. Women who could become pregnant need reliable birth control and a careful talk with their doctor.

Common side effects include weight gain, a shaky hand, hair loss, upset stomach and sleepiness.⁵ Sleepiness can be strong in older adults and may lead them to eat and drink less.⁵ Valproate can also affect blood clotting.⁸ Tell the lab you take it before any blood or urine test.⁵

Lamotrigine

Lamotrigine (Lamictal) helps people with bipolar I disorder go longer between episodes. Its main strength is preventing depression.^6,8 Moderate evidence It does not treat an episode that is already happening, so other medicines are used for that.⁶

The rash warning

Lamotrigine can cause a serious, even life-threatening rash. This is rare, but it is the main reason for its boxed warning.⁶ Serious rashes usually appear in the first 2 to 8 weeks, but can happen later.⁶

The risk is higher when:⁶

• The dose goes up faster than prescribed
• A person also takes valproate
• A person had a rash before with lamotrigine or a seizure medicine

This is why doctors start low and go slow with lamotrigine. Never raise the dose on your own.⁶ If you miss several days in a row, call your doctor before starting again.

Lamotrigine can make hormonal birth control work less well.⁶ Stopping it suddenly can cause seizures, so do not stop without your doctor's plan.⁶

Atypical antipsychotics

Atypical antipsychotics are among the most common medicines for bipolar disorder.¹ The word "antipsychotic" can sound alarming. In bipolar disorder, these medicines are used to calm mania, lift depression and prevent new episodes, whether or not a person has psychosis.

Quetiapine (Seroquel) and olanzapine (Zyprexa) can help with mania, depression and prevention.⁸ Strong evidence Lurasidone (Latuda) and lumateperone (Caplyta) help with bipolar depression.⁸ Aripiprazole, risperidone, ziprasidone and others treat mania.⁸ Olanzapine can also be added to lithium or valproate.⁷

Metabolic checks

Many of these medicines can cause weight gain, high blood sugar and high cholesterol. Rarely, blood sugar gets dangerously high.⁷ Your doctor should check these before you start and again during treatment:⁷

• Weight, on a regular basis
• Fasting blood sugar (a blood test after not eating)
• Fasting cholesterol and other blood fats

Tell your doctor if you notice strong thirst, urinating a lot, or feeling very hungry and weak. These can be signs of high blood sugar.⁷ Walking, healthy meals and good sleep can help. If weight or blood sugar becomes a problem, ask whether another option might fit better.

Other side effects to know

• Dizziness on standing. This can lead to fainting or falls, especially when the medicine is new. Stand up slowly.⁷
• Tardive dyskinesia. These are movements of the body or face that a person cannot control. They can become permanent. Report any new movements early.⁷
• Neuroleptic malignant syndrome. This is rare but serious: high fever, stiff muscles and confusion. Call 911 if this happens.⁷

Why staying on treatment matters

Bipolar disorder rarely goes away on its own. Long-term treatment helps keep symptoms under control.¹ Missing doses can raise the risk of a new episode.⁴

People stop their medicine for many reasons. They feel well and think they no longer need it. They miss the energy of a high. Or the side effects bother them. These are real concerns, and your doctor wants to hear them.

A few habits make treatment safer:

• Keep every lab and doctor appointment.^3,5
• Keep one up-to-date list of all your medicines, vitamins and supplements. Bring it to every visit and pharmacy.
• Use a weekly pill box or phone alarm. A family member can help.
• Track your mood and sleep. Our page on living well with bipolar disorder shows how.
• Pair medicine with therapy. Adding therapy helps many people once the worst of an episode has passed.⁸

Family members can help a lot. See supporting someone with bipolar disorder.

Questions to ask the doctor

When to get help

• Call the doctor soon if mood starts to rise or fall, sleep changes, or side effects appear.
• Call the doctor the same day for signs of lithium toxicity, a new rash on lamotrigine, or severe stomach pain on valproate.
• Call or text 988 any time you or someone you love has thoughts of suicide. It is free and open 24 hours a day.
• Call 911 for a seizure, fainting, trouble breathing, a person who cannot be woken, or immediate danger.

You can also make a safety plan ahead of time, or visit our help page.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.