Helping Patients Understand Changes in Treatment for Bipolar Manic Episodes

Helping Patients Understand Changes in Treatment for Bipolar Manic Episodes

Changes in Treatment for Bipolar Manic EpisodesThe looming threat of a manic episode is frequently familiar to patients with bipolar disorder. For some, these episodes are characterized by feelings of extreme euphoria, which can lead to spontaneous decisions they later regret. Others experience manic episodes as periods of intense irritability that can escalate into violent outbursts.1

When a bipolar patient experiences a manic episode, doctors will typically alter the patient’s pharmacologic treatment strategy to encourage mood stabilization. But as a pharmacist, it is essential that you can offer patients education on the specific drug and prescribed changes to their treatment plan. Ensuring that patients know as much as possible about their treatment regimen can help them feel more confident when managing manic episodes.

Understanding Changes to Prescription Medication During a Bipolar Manic Episode

Bipolar patients who have experienced episodes of acute mania or depression in the past may already be taking a mood-stabilizing drug such as lamotrigine, carbamazepine, or risperidone, possibly in conjunction with lithium or valproate.2 In order to reduce symptoms during a manic episode, however, the patient’s physician may increase the dosage of the current medication or add an additional mood stabilizer.3 You can explain to patients that this adjustment helps relieve short-term symptoms, minimizing the disruptive effects of the manic episode. At the same time, there is a chance that a higher dosage will trigger side effects, so it is important to caution patients that they may be more likely to experience drowsiness, dizziness, and stomach upset than when taking their usual medication.

For patients experiencing the manic symptoms of bipolar disorder for the first time, doctors may also prescribe a benzodiazepine alongside a maintenance mood stabilizer. Since regular mood stabilizers don’t begin working immediately, benzodiazepine can be used to temporarily reduce symptoms for up to two weeks. When patients are prescribed short-term benzodiazepines, it is your responsibility as a pharmacist to make sure they are aware of the potential for dependence if the drug is taken longer than the prescribed period. Too often, patients who extend their treatment beyond two weeks find themselves physically dependent, which may lead them to struggle with physical addiction and withdrawal symptoms for months or even years.4 It is also important to warn patients of possible side effects, including drowsiness, dizziness, slurred speech, and muscle weakness, which can interfere with daily activities until the patient stops taking the benzodiazepine.5

Some bipolar patients also take antidepressants—usually selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors (SNRIs). These can sometimes enhance the symptoms of mania and even increase the patient’s risk for suicide. However, these medications should never be discontinued immediately. In the event of a manic episode, it is critical that these medications be slowly titrated down to avoid discontinuation syndrome.

In addition to established treatment methods, some doctors are prescribing certain medications for off-label use in the treatment of manic episodes. One new treatment option showing some promise is tamoxifen, an estrogen receptor modulator typically used for breast cancer treatment and prevention.6 It is best to tell your patients that the FDA has not yet approved these drugs for bipolar mania but that doctors are seeing more and more evidence that they effectively reduce symptoms, particularly when given with lithium. You should also advise patients that these medications are only for reducing acute manic symptoms—there is no evidence that they are an effective long-term method for managing bipolar disorder. Like benzodiazepines, these therapeutics should be discontinued when the manic episode is over.

The Benefits and Limits of Dietary Recommendations and Behavioral Therapies

While there is no miracle dietary solution for manic episodes, there is some evidence that certain foods and nutritional supplements can help (or hinder) patients’ efforts to combat their symptoms, including:

  • Increasing intake of omega-3 fatty acids may help with the movement of neurotransmitters in the brain, which can help improve depression.7 Most pharmacies offer omega-3 supplements, so you can direct patients to these. You can also recommend that they eat more natural sources of omega-3, such as salmon, trout, tuna, and walnuts.
  • Reducing intake of omega-6 fatty acids like those commonly found in vegetable oil.8 If your pharmacy stocks combination supplements that include both omega-3 and omega-6, advise bipolar patients to steer clear of these.
  • Avoiding alcohol is essential, as it can interfere with many medications, especially lithium.
  • Limiting caffeine intake can help keep bipolar mania symptoms at bay as well since it can act as a stimulant and may reduce the effects of benzodiazepines.

It can take several weeks for dietary changes to take place at the cellular level, so they cannot be used to manage immediate manic episodes. Instead, they can help lay the groundwork for future management if they’re implemented and maintained long before the manic episode.

The same is true for some of the behavioral changes recommended for patients experiencing manic episodes. Here are a few common strategies to suggest:

  • Cognitive behavioral therapy techniques
  • Talking to a therapist
  • Meditation
  • Aerobic exercise9

These lifestyle changes may help boost the effectiveness of pharmacologic treatments, and if the patient makes a habit of them even after the episode is over, they may be better equipped to stave off symptoms of bipolar mania in the future. By offering patients this advice, you can help increase the likelihood that they will be able to mitigate their symptoms. Pharmaceutical intervention remains essential to controlling bipolar disorder, but dietary and lifestyle changes have shown a great deal of promise in helping patients further manage their symptoms.

Pharmaceutica North America provides high-quality bulk active pharmaceutical ingredients, including some of the mood stabilizers, antidepressants, and calcium channel blockers prescribed for the treatment of bipolar manic episodes. Contact us today to find out how we can support your patients with bipolar disorder and fulfill your other pharmaceutical needs.

Show 9 footnotes

  1. “Manic Episode Symptoms,” September 2, 2016,
  2. “Maintenance Treatment for Bipolar Disorder,” 2016,
  3. “Bipolar Disorder Treatment Overview,” 2016,
  4. “Benzodiazepines revisited–will we ever learn?” December 2011,
  5. “Benzodiazepines for Bipolar Disorder,” 2016,
  6. “Tamoxifen Shows Promise as Antimania Agent in Bipolar Disorder,” April 2, 2008,
  7. “9 Natural Therapies for Bipolar Depression,” January 15, 2016,
  8. “5 Foods to Avoid If You Have Bipolar Disorder,” November 4, 2015,
  9. “Exercise Can Help Bipolar Disorder,” April 5, 2010,

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