Antipsychotics for the treatment of bipolar disorder

Examples

First-generation, or typical, antipsychotic medicine

Second-generation, or atypical, antipsychotic medicines

These medicines are available in liquid, tablet, or injectable form.

How It Works

These medicines balance certain chemicals in the brain (neurotransmitters). It is not clear exactly how these medicines work for the treatment of bipolar disorder. But they quickly improve manic episodes.

Why It Is Used

Each of these medicines has been approved by the U.S. Food and Drug Administration (FDA) to treat bipolar disorder. Some medicines work better for different people than others. Second-generation antipsychotic medicines may have fewer side effects than first-generation antipsychotic medicines. Be sure to talk with your doctor about how the medicine is working for you. Sometimes you might need to try more than one type of medicine before you find one that works best for you.

These medicines have all been found to be an effective treatment of manic episodes. Quetiapine has been approved by the FDA to treat both mania and depression. Other antipsychotic medicines, such as olanzapine, are also being studied for the treatment of depression in bipolar disorder. The single medicine combining olanzapine and fluoxetine (Symbyax) is also used to treat depressive episodes associated with bipolar disorder. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), which is used to balance certain brain chemicals (neurotransmitters) that are thought to cause depression.

How Well It Works

Drugs in this classification work quickly in the treatment of bipolar disorder, especially in older adults. These medicines have all been found to be an effective treatment of manic episodes. Some studies show the combination of an antipsychotic and a mood stabilizer may be more effective than a mood stabilizer alone.¹

Side Effects

The most common side effects of olanzapine include dry mouth, constipation, weight gain, drowsiness, and increased appetite.² Other common side effects are shakiness or tremors, slurred speech, and low blood pressure that makes you feel dizzy when you stand up. In addition, olanzapine raises the risk of diabetes and/or abnormalities in cholesterol levels. Abnormalities in blood glucose levels have been reported less for people who use risperidone or quetiapine.

Risperidone may cause sleepiness, weight gain, abnormal cholesterol levels, and breast tenderness. Side effects include a rash, headaches, constipation, decreased sexual desire and function, or increased heart palpitations. Risperidone may also be linked to an increased risk of stroke in older adults.

Ziprasidone may make you sleepy or cause nausea, dizziness, restlessness, diarrhea, coughing, or a rash. Ziprasidone may also cause abnormal muscle movements such as tremors or shuffling.

Quetiapine can cause side effects such as sleepiness, headaches, dizziness, rash, fever, weight gain, abnormal cholesterol levels, dry mouth, and other flu-like symptoms.

The use of antipsychotics has also been linked to the risk of movement disorders. The risk of developing a movement disorder is less for newer antipsychotics such as aripiprazole, olanzapine, risperidone, and quetiapine. But it is important to tell your doctor about any abnormal muscle movements.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Before taking olanzapine, risperidone, ziprasidone, or quetiapine, be sure to tell your doctor if you have:

• A heart condition.
• A seizure disorder.
• Problems with liver function.
• Problems with blood pressure.
• Diabetes or high blood sugar.
• Constipation.
• A history of breast cancer.
• Problems with swallowing.
• Problems with fainting.

You should not take ziprasidone if you have long QT syndrome (a specific heart-rhythm problem) or severe heart failure or you have had a recent heart attack. Ziprasidone should not be taken with certain medicines used to treat abnormal heartbeats.

Aripiprazole has been linked to a rare risk for neuroleptic syndrome. Neuroleptic syndrome is a life-threatening reaction that begins with a high fever along with changes in heart rate and breathing patterns.

These medicines should be started in low doses, especially in the elderly. Talk with your doctor about any other medicines you may be taking to make sure there are no negative drug interactions.

You may need regular blood tests and blood pressure monitoring while taking these medicines.

Avoid herbal stimulants (such as ma huang, ginseng, or kola), which may increase your chances of having serious side effects.

Talk to your doctor or pharmacist about drinking grapefruit juice while you are taking an antipsychotic medicine. Grapefruit juice can increase the level of these medicines in your blood. Having too much medicine in your blood increases your chances of having serious side effects.

Taking medicines during pregnancy for bipolar disorder may increase the risk of birth defects. If you are pregnant, or thinking of becoming pregnant, talk to your doctor. Medicines may need to be continued if your bipolar disorder is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.

Complete the new medication information form (PDF) (What is a PDF document?) to help you understand this medication.

References

Citations

1. Scherk H, et al. (2007). Second-generation antipsychotic agents in the treatment of acute mania: A systematic review and meta-analysis of randomized controlled trials. Archives of General Psychiatry, 64(4): 442-455.

2. Tohen M, et al. (2002). Efficacy of olanzapine in combination with valproate or lithium in the treatment of mania in patients partially nonresponsive to valproate or lithium monotherapy. Archives of General Psychiatry, 59(1): 62-69.

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