Tell me about benzodiazepines.

These include Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam). Their main purpose is to relieve anxiety and promote sleep, but they can be very effective in quickly bringing down a person from a manic state or as an additional med in the cocktail. Their main drawback is they can be habit forming, with severe withdrawal symptoms, as well as having a depressive effect, so they are typically prescribed short-term or on an as-needed basis.

What about pregnancy and breastfeeding?

Please check with your doctor or psychiatrist. In general, antidepressants are considered safe through all phases of pregnancy and breastfeeding. As for the mood stabilizers, lithium runs an outside risk of heart defect in the first trimester, while the risk of spina bifida is too great to be taking Depakote or Tegretol (and possibly the other mood stabilizers) during the first trimester. Of the antipsychotics, Haldol, the most studied, can be used safely during pregnancy. Frederick Goodwin MD, author of the definitive book on bipolar, at a 2001 conference stated that because of the risk of postpartum mania, it is critical for expectant mothers to get back on meds well before giving birth. Alternatives to meds include omega-3 and light therapy, and, as a last option, ECT. Drugs to avoid while breastfeeding Lithium, Lamictal, antipsychotics.

Can I drink alcohol?

Not if you are expecting your meds to work. Those who find it hard to quit should bring this up with their psychiatrist. Caffeine and nicotine are other drugs you should seriously consider eliminating or cutting back on.

How do I know which meds I should be on?

The short answer is you don’t. The APA and other groups have come up with treatment guidelines and treatment algorithms, based on expert consensus, to guide clinicians through a range of options. The state of Texas, in its pioneering bipolar algorithm, for example, recommends either lithium or Depakote or Zyprexa for treating mania, and various two-med combinations if the result is less than satisfactory until we graduate to three-med combinations in stage five. The reason lithium, Depakote, and Zyprexa are mentioned as first choices is because they are the most studied. They are also the only three that are FDA-approved for treating mania (a number of companies have applications pending).

But because every individual is unique and no two cases of bipolar are the same, you are basically a guinea pig. Very rarely do one’s first meds work like a charm, and the process of finding the combination that works best can involve months and even years of heartbreak and frustration.

This sounds very discouraging.

Only if you believe you should sit back and let your meds do all the work. Smart lifestyle choices and various coping techniques can make a world of difference. Meds treatment can also be combined with talking therapy to great effect.

What is cognitive therapy?

Cognitive therapy - also called cognitive behavioral therapy - works to change erroneous thoughts (such as "It’s the end of the world.") into more positive ones (such as, "Let’s find a solution.") Once one is thinking and behaving in a positive way - such as working toward a solution than bewailing the end of the world - one actually begins feeling better. The therapy applies equally well to depression and mania. The therapy typically lasts 10 to 20 sessions, and involves active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone.

What about other types of talking therapy?

Before you engage in therapy that involves working on painful issues or suppressed memories, it is very important that your mood be stabilized, as otherwise these therapies can cause your condition to deteriorate. Some talking therapists take a dim view of medications, and their opinions on the subject are the last thing you need to be exposed to while you are still recovering and vulnerable. Having said that, if your boss is making you unhappy and your family is causing you stress, simply taking meds or doing cognitive therapy is not going to change these situations. These represent very dangerous triggers that need to be addressed. Talking therapy that can help you resolve these issues may literally save your life.

What about ECT?

Electro-convulsive therapy, also known as shock treatment, has been used successfully to treat both depression and mania, but because of risk of short-term memory loss - and in rare cases long-term memory loss - is regarded as a treatment of last resort, except if the patient’s condition puts him or her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on.

The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than candid over the memory loss element, and neglects to mention that relapses are common, which necessitates additional periodic "booster" treatments.

Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their bipolar in remission should do their research now and make their decision accordingly, while they have their wits about them. You can state your wishes in the form of a psychiatric advance directive, which you can find more about at www.bazelon.org/advdr.html.

NOTE Next months Bipolar "Alternative Treatments" part 4