Key Takeaways Key Takeaways

  • Regulating sleep patterns is crucial before initiating bipolar-specific medications, significantly reducing the risk of manic episodes.

  • Lithium is the gold standard for bipolar disorder, known for effectively reducing episodes of mania and depression, lowering suicide risk, and potentially protecting against dementia.

  • Combining Lithium and Lamotrigine creates a more powerful, more comprehensive approach—known as the “belt and suspenders” method—to stabilize mood across bipolar subtypes.

Why Lithium Remains the First-Line Medication for Bipolar Disorder

Effective management of bipolar disorder involves a balanced understanding of biological and psychological elements, focusing not only on symptom relief but also on maintaining overall lifestyle stability.

Dr. Robert Herman, MD, FAPA, and Dr. Joe Fondriest, MD, two LifeStance psychiatrists specializing in bipolar disorder treatment, share their insights on the best medication options for bipolar disorder (including Lithium, Lamotrigine (Lamictal), Olanzapine, and Depakote) and highlight the essential role of sleep in effectively managing bipolar disorder.

Why Bipolar Disorder Management Starts with Sleep Stabilization

Both doctors agree that sleep is one of the most crucial parts of bipolar disorder management, and the first step is to regulate sleep patterns. So before addressing medications for bipolar disorder, it’s essential to get sleep under control.

According to Dr. Fondriest, “Sleep is king”. When sleep is disrupted, it significantly increases the risk of manic episodes. Common disruptions like significant life changes, night shifts, or medications such as corticosteroids can trigger these episodes. Once sleep starts slipping below six hours, a person with bipolar disorder can quickly move toward a manic state within days, highlighting the urgency of addressing sleep issues promptly.

Sleep is king. Once sleep starts slipping below six hours, a person with bipolar disorder can quickly move toward a manic state within days, highlighting the urgency of addressing sleep issues promptly.

To quickly reestablish stable sleep patterns, Dr. Fondriest often begins treatment by choosing a strongly sedating mood stabilizer or antipsychotic medication, such as Olanzapine, Lithium, or Depakote. “Once you have sleep regulated, managing the rest becomes significantly easier. If patients consistently achieve six to eight hours of sleep at roughly the same time each night, the stability greatly improves.”

Dr. Herman agrees strongly, noting that disrupted sleep patterns serve as an unmistakable sign of bipolar disorder. He compares the brain’s rhythm to musical harmony: if one beat is missed, the entire performance is affected. This analogy emphasizes the importance of maintaining consistent circadian rhythms—daily sleep and wake cycles—to manage bipolar disorder effectively. Both psychiatrists stress that stabilizing sleep is foundational in preventing and managing bipolar episodes.

Why Lithium Remains the First-Line Medication for Bipolar Disorder

Lithium remains one of the best and most widely recommended medications for bipolar disorder. Dr. Herman emphasizes, “Many experts believe everyone with bipolar disorder deserves a trial of lithium due to its common effectiveness.” He highlights lithium’s significant role in preventing both manic and depressive episodes, and notably, its reputation for reducing suicide risk.

Dr. Fondriest also acknowledges lithium’s efficacy, stating, “Lithium has unparalleled power in stabilizing bipolar disorder,” but he remains cautious about potential long-term kidney and thyroid risks, especially in younger patients. Regular monitoring is essential to mitigate these and other potential side effects.

Additionally, emerging research indicates that low doses of Lithium may help prevent dementia, and low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with limited adverse effects.

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Lamotrigine and Lithium: A "Belt and Suspenders" Approach to Bipolar Disorder

Lamotrigine, marketed as Lamictal, holds a distinctive role in bipolar disorder management, particularly praised for its common effectiveness in addressing depressive aspects of the condition. Dr. Herman highlights that lamotrigine is often especially beneficial in preventing depressive episodes, making it particularly suitable for bipolar II disorder or milder forms of bipolar disorder predominantly characterized by depressive episodes. He explains, “Lamotrigine does not reliably prevent mania but is generally very effective at keeping depressive episodes at bay.”

A clinical study comparing Lithium, Lamotrigine, and a placebo found Lamotrigine significantly effective in reducing depressive relapses over extended periods. Lamotrigine often complements Lithium well in treatment regimens, combining their respective strengths in managing both mania and depression. This approach, often referred to by professionals as “belt and suspenders,” leverages the strengths of both medications in an effort to achieve more robust mood stabilization.

Complementary Approaches

Beyond medications, the importance of maintaining regular rhythms and structured routines through therapies like interpersonal and social rhythm therapy (IPSRT) is paramount. This approach educates patients about managing their daily routines to support stable moods.

Resources for Support

Dr. Herman suggests several valuable resources for patients:

References

  1. Bowden CL, Calabrese JR, Sachs G, Yatham LN, Asghar SA, Hompland M, Montgomery P, Earl N, Smoot TM, DeVeaugh-Geiss J; Lamictal 606 Study Group. A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder. Arch Gen Psychiatry. 2003 Apr;60(4):392-400. doi: 10.1001/archpsyc.60.4.392. Erratum in: Arch Gen Psychiatry. 2004 Jul;61(7):680. PMID: 12695317.

  2. Ishii N, Terao T, Hirakawa H. The Present State of Lithium for the Prevention of Dementia Related to Alzheimer’s Dementia in Clinical and Epidemiological Studies: A Critical Review. Int J Environ Res Public Health. 2021 Jul 22;18(15):7756. doi: 10.3390/ijerph18157756. PMID: 34360049; PMCID: PMC8345730.

  3. Sarai SK, Mekala HM, Lippmann S. Lithium Suicide Prevention: A Brief Review and Reminder. Innov Clin Neurosci. 2018 Nov 1;15(11-12):30-32. PMID: 30834169; PMCID: PMC6380616.

Authored By 

LifeStance Health

LifeStance is a mental healthcare company focused on providing evidence-based, medically driven treatment services for children, adolescents, and adults.

Contributed By

Robert Herman, MD

Robert A. Herman, M.D., FAPA, received his medical degree from the State University of New York at Buffalo in 1983. He completed his residency in Psychiatry at New York University-Bellevue Hospital Center in 1987 and completed psychoanalytic training at the Columbia University College of Physicians and Surgeons in 1992. He was certified in Psychiatry by the American Board of Psychiatry and Neurology, and is a Distinguished Life Fellow in the American Psychiatric Association. Dr. Herman has taught at New York University, Columbia University, the Mount Sinai School of Medicine and the University of Maryland School of Medicine. He is on the consulting medical staff of Anne Arundel Medical Center in Annapolis. Dr. Herman has worked in a variety of treatment settings including psychiatric hospitals, general hospitals, substance abuse treatment programs, University mental health services, and private psychiatric practice. He has experience in treating patients with individual psychotherapy including psychoanalysis, group and family therapy, as well as employing medical treatments including medications and transcranial magnetic stimulation.

He has experience diagnosing and treating a wide variety of psychiatric disorders, including depression, bipolar disorders, anxiety disorders, ADHD, PTSD, Dissociative Disorders, and Substance Use Disorders. He treats children, adolescents, and adults. He no longer performs psychotherapy, but works collaboratively with patient’s therapists at LifeStance other locations to provide high-quality psychiatric care. On a personal note, Dr. Herman hails from Long Island, NY. He sings bass in the ‘Bach in Baltimore’ Concert Series, lauded for over thirty years for high-quality Baroque community performances and engaging music education. He has three grown daughters and several grandchildren.

Joseph Fondriest, MD

Dr. Joseph Fondriest completed his psychiatry residency at Cleveland Clinic Akron General / Summa Health where he served as chief resident and psychiatry representative for resident staff council. He received his medical degree from Northeast Ohio Medical University, and his bachelor’s degree and computer science minor from Miami University. He specializes in treating mood disorders, anxiety disorders, PTSD, OCD, and personality disorders. He places a heavy emphasis on listening closely to patients. He utilizes a team-based approach to mental healthcare, working alongside patients and their therapists. He treats adults of age 18-64.