Medications for Bipolar Disorder: Mood Stabilizers, Antipsychotics, Antidepressants, and Novel Agents

1. Mood Stabilizers (Foundation)

• Lithium: Gold standard; anti-manic, anti-depressive, anti-suicide. Requires level monitoring (0.6–1.0 mmol/L), renal/thyroid/parathyroid surveillance.
• Valproate: Broad efficacy; rapid loading possible. Teratogenic; weight gain, tremor, hepatotoxicity.
• Carbamazepine/Oxcarbazepine: Alternatives; CYP3A4 auto-induction; hyponatremia risk.
• Lamotrigine: Best for bipolar depression/maintenance; slow titration (SJS risk); no antimanic effect.

2. Atypical Antipsychotics (FDA-approved for BD)

• Quetiapine (bipolar depression, mania, maintenance)
• Lurasidone (bipolar depression)
• Cariprazine (mania, depression)
• Olanzapine, Risperidone, Aripiprazole, Asenapine, Ziprasidone (mania/mixed)
• Monitor: metabolic (weight, glucose, lipids), EPS, prolactin.

3. Antidepressants (Cautious Use)

• Only with mood stabilizer/antipsychotic to prevent switch.
• SSRIs/SNRIs preferred; avoid TCAs/MAOIs (higher switch risk).
• Discontinue once depression remits (continuation controversial).

4. Novel/Adjunctive

• Brexpiprazole: Adjunct for MDD; studied in BD.
• Ketamine/Esketamine: Rapid anti-suicidal/antidepressive; off-label in BD.
• Modafinil/Armodafinil: Residual fatigue/hypersomnia.
• Omega-3, N-acetylcysteine: Adjunctive evidence modest.

Principles

• Monotherapy → combination if needed.
• Measurement-based care (YMRS, MADRS, CGI).
• Long-term maintenance essential (relapse rate >90% off meds).
• Shared decision-making re: side effects, pregnancy, comorbidities.