Key Takeaways
- Bipolar disorder is treated with a few medication families: mood stabilizers (such as lithium, valproate and lamotrigine) and second-generation antipsychotics, with antidepressants used only as an add-on.
- Which medicine fits depends on the phase being treated: an acute manic episode, an acute depressive episode, or long-term prevention (maintenance).
- CANMAT/ISBD 2018 and NICE CG185 both give lithium a central place in long-term treatment, but no medication is the right choice for everyone.
- Several of these drugs carry FDA boxed warnings and need regular blood tests, so the monitoring plan is part of the treatment.
- Stopping a mood stabilizer suddenly raises the risk of relapse; changes should be planned with the prescriber.
Bipolar disorder medications fall into a small number of families. Mood stabilizers (lithium, valproate, lamotrigine and carbamazepine) and second-generation antipsychotics do most of the work, and antidepressants are used only alongside one of them, never alone. Which medicine makes sense depends on what is being treated: mania, depression, or keeping new episodes from starting. This page maps the options the major guidelines name for each phase, the lab monitoring they involve, the FDA boxed warnings, and why stopping on your own is risky. It lists names only. Doses belong in a conversation with your prescriber.
The main medication families
Most people with bipolar disorder take one or two medicines from these groups. Each one has its own page in this guide, so this section is just the map.
| Family | Examples (generic, with a brand in parentheses) | Where it fits |
|---|---|---|
| Lithium | Lithium carbonate | Mania and long-term prevention; the reference long-term treatment in NICE CG185 |
| Anticonvulsant mood stabilizers | Divalproex/valproate (Depakote), lamotrigine (Lamictal), carbamazepine (Equetro) | Valproate and carbamazepine for mania; lamotrigine for preventing depressive episodes |
| Second-generation antipsychotics | Quetiapine (Seroquel), aripiprazole (Abilify), lurasidone (Latuda), cariprazine (Vraylar), lumateperone (Caplyta), asenapine, risperidone, olanzapine | Mania, bipolar depression (specific drugs only) and maintenance |
| Antidepressants | For example, SSRIs or bupropion | Only as an add-on to a mood stabilizer or antipsychotic, never alone |
The mood-stabilizer group is explained as a class in mood stabilizers explained. The antipsychotics have their own page, antipsychotics for bipolar disorder, and the antidepressant question is covered in antidepressants and bipolar disorder. NIMH explains why antidepressants are not used alone: on their own they can trigger mania or rapid cycling.
Treating a manic episode
The CANMAT/ISBD 2018 guidelines, still the current CANMAT reference, list these as first-line single-drug options for acute mania: lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone and cariprazine. They also list combinations in which quetiapine, aripiprazole, risperidone or asenapine is added to lithium or divalproex.
NICE CG185 takes a similar line. If someone develops mania while taking an antidepressant on its own, NICE advises considering stopping it and offering an antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone. NICE also says plainly: do not offer lamotrigine to treat mania. The VA/DoD 2023 guideline suggests lithium or quetiapine first.
Severe mania, especially with psychosis, often needs a higher level of care than an outpatient office. Symptoms are described in signs of a manic episode.
Treating a depressive episode
Bipolar depression is treated differently from ordinary depression, and only a few medicines have good evidence. For bipolar I depression, CANMAT/ISBD 2018 lists quetiapine, lithium, lamotrigine and lurasidone as first-line, plus lurasidone or lamotrigine added to another treatment. A 2023 evidence update by the same group moved cariprazine up to first-line for bipolar I depression and added lumateperone as a second-line option for bipolar I and II depression.
Bipolar II depression has a shorter list: in CANMAT/ISBD 2018, quetiapine is the only first-line option. NICE CG185 suggests quetiapine alone or fluoxetine combined with olanzapine, with olanzapine alone or lamotrigine alone as options if the person prefers them. The VA/DoD guideline gives its strongest recommendation to quetiapine.
For a fuller walk-through, including why antidepressants are handled cautiously, see treatment for bipolar depression.
Mixed features and long-term prevention
When mania and depression overlap
Episodes with mixed features are harder to treat. The 2021 CANMAT/ISBD mixed-features update found that no medicine met the bar for first-line treatment. For mania with mixed features it named asenapine, cariprazine, divalproex and aripiprazole as second-line options; for depression with mixed features, cariprazine and lurasidone.
Maintenance: keeping episodes from coming back
Most people with bipolar disorder need treatment that continues after an episode ends. NIMH notes the illness usually needs lifelong treatment. For bipolar I maintenance, CANMAT/ISBD 2018 lists lithium, quetiapine, divalproex, lamotrigine, asenapine and aripiprazole (oral or monthly injection) as first-line, plus quetiapine or aripiprazole combined with lithium or divalproex. For bipolar II maintenance the first-line list is quetiapine, lithium and lamotrigine.
NICE CG185 is more direct: it says to offer lithium as a first-line long-term treatment, and to consider an antipsychotic such as aripiprazole, asenapine, olanzapine, quetiapine or risperidone if lithium does not work, is not tolerated or is unsuitable. Lithium and lamotrigine each have a dedicated page: lithium for bipolar disorder and lamotrigine for bipolar disorder.
What monitoring looks like
Several bipolar medicines need blood tests or body measurements on a schedule. The table summarizes what labels and NICE CG185 ask for; the general picture across psychiatric medicines is in our lab monitoring guide, and the bipolar-specific panel is in lab tests for bipolar disorder.
| Medicine | Typical checks | What they protect against |
|---|---|---|
| Lithium | Blood lithium level, kidney function, thyroid, calcium, weight | Toxicity, kidney and thyroid effects, high calcium |
| Valproate | Liver tests, platelets, pregnancy status | Liver injury, low platelets, harm to a developing baby |
| Carbamazepine | Blood counts, liver tests, sodium; HLA-B*1502 gene test for some ancestries | Rare blood disorders, severe skin reactions, low sodium |
| Lamotrigine | No routine level; close watch for rash, especially early | Serious skin reactions |
| Antipsychotics | Weight or BMI, blood pressure, glucose or HbA1c, lipids | Weight gain, diabetes, cholesterol changes |
NICE also recommends a yearly physical health check for everyone with bipolar disorder, adding kidney, thyroid and calcium tests for people on long-term lithium. Exact timing is set by the prescriber; how lithium blood levels work is covered in lithium levels explained.
FDA boxed warnings to know about
A boxed warning is the strongest safety statement the FDA puts on a label. It does not mean a drug is off-limits; it flags a serious risk that shapes how the drug is started and watched.
- Lithium: toxicity is closely tied to the blood level and can happen at doses close to the helpful range, so levels must be measurable before treatment starts.
- Valproate (Depakote): life-threatening liver injury, pancreatitis, and fetal harm, including neural tube defects and lower IQ after exposure in the womb.
- Carbamazepine: serious skin reactions (Stevens-Johnson syndrome and toxic epidermal necrolysis) linked to the HLA-B*1502 gene variant, plus aplastic anemia and agranulocytosis.
- Lamotrigine (Lamictal): serious skin rashes; since October 2025 the warning also names HLA-B*1502 as a risk factor. See lamotrigine rash warning signs.
- Antipsychotics: all carry a warning about increased death in older adults with dementia-related psychosis. Those with a depression indication, such as quetiapine, aripiprazole and lurasidone, also carry the antidepressant warning about suicidal thoughts in children and young adults.
Why stopping suddenly is risky
Feeling well is often a sign the medicine is working, not a sign it is no longer needed. NIMH warns that steady treatment works better than starting and stopping, and that stopping medication suddenly can be dangerous.
- For lithium, NICE advises reducing the dose gradually over at least four weeks, preferably up to three months, and watching closely for relapse during that time and for three months afterward.
- The lamotrigine Medication Guide says not to stop without talking to a healthcare provider, because stopping suddenly can cause serious problems.
- Restarting can also carry risk. Lamotrigine, for example, may need to be rebuilt slowly after a break.
If side effects or cost are the reason you want to stop, say so. There is usually another option. Our general guide on stopping psychiatric medication safely covers how those conversations go.
Side effects, weight, genes and life stages
Side effects differ a lot between medicines, and they are one of the main reasons people stop treatment. Weight and metabolic changes with some antipsychotics and valproate are covered in bipolar medication and weight gain. For a medicine you already take, the general side effects guide explains what to report.
Genetic testing has a narrow, real role: the FDA labels for carbamazepine and lamotrigine mention HLA-B*1502, but no test picks "the right" bipolar medicine. See genetic testing and bipolar medication. Teens have a different set of FDA approvals (bipolar medication for teens), and pregnancy planning changes the picture again (bipolar disorder and pregnancy).
At Willow & Stone
Dr. Stacey Forbes, a board-certified psychiatric-mental health nurse practitioner, evaluates and treats bipolar disorder at the Arlington, Texas office and by telehealth in Texas, New Mexico, Florida, Alaska, Arizona, Colorado and Washington. Medication options are discussed at your evaluation, labs are ordered as needed, and the practice pairs medication with therapy, sleep and lab work as described in our integrative approach to bipolar medication. Willow & Stone provides outpatient, scheduled care and is not an emergency service. To get started, see bipolar disorder treatment at Willow & Stone or the complete bipolar disorder guide.
Common Questions
What is the best medication for bipolar disorder?
There is no single best medication. Guidelines list several first-line options for each phase. NICE CG185 calls lithium the most effective long-term treatment, while CANMAT/ISBD 2018 lists quetiapine as the only first-line option for bipolar II depression. The right choice depends on your episode pattern, health, other medicines, pregnancy plans and side-effect priorities.
What medications are used for bipolar disorder?
The main ones are lithium; the anticonvulsants divalproex (valproate), lamotrigine and carbamazepine; and second-generation antipsychotics such as quetiapine, aripiprazole, lurasidone, cariprazine, lumateperone, asenapine, risperidone and olanzapine. Antidepressants are sometimes added to one of these, but not used alone.
Can bipolar disorder be treated without medication?
Therapy, sleep regularity and routine help a lot, and NIMH and NICE recommend them alongside medication. But NIMH says bipolar disorder usually needs lifelong treatment, and the FDA has not approved any complementary approach for it. Most people do best with medication plus therapy.
What happens if you stop taking bipolar medication?
The risk of a new manic or depressive episode goes up, especially if a mood stabilizer is stopped suddenly. NIMH warns that stopping suddenly can be dangerous, and NICE advises tapering lithium over at least four weeks with close follow-up. Talk to your prescriber first.
Can a psychiatric nurse practitioner prescribe bipolar medication?
Yes. A board-certified psychiatric-mental health nurse practitioner (PMHNP) can evaluate, diagnose and treat bipolar disorder, including prescribing mood stabilizers and antipsychotics. None of the core bipolar medicines are controlled substances.
Is there a bipolar medication without weight gain?
Weight effects vary widely. Some antipsychotics and valproate are more often linked to weight gain, while others carry less risk. Whether a lower-risk option suits you depends on your symptoms and history, so raise weight as a priority at your visit.
Part of our bipolar disorder guide
Sources & Further Reading
- Yatham LN et al. CANMAT and ISBD 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 2018 (PMID 29536616)
- Keramatian K, Chithra NK, Yatham LN. The CANMAT and ISBD guidelines for bipolar disorder: an update of evidence. Focus 2023
- Yatham LN et al. CANMAT/ISBD 2021 update on the management of mixed presentations. Bipolar Disord 2021 (PMID 34599629)
- NICE CG185: Bipolar disorder: assessment and management (last updated 2 September 2025)
- NIMH: Bipolar Disorder (NIH Pub. No. 25-MH-8088, revised 2025)
- VA/DoD Clinical Practice Guideline for the Management of Bipolar Disorder (Version 2.0, 2023)
- DailyMed: Lithium carbonate prescribing information and Medication Guide (2026)
- DailyMed: DEPAKOTE (divalproex sodium) prescribing information (2026)
This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.
If you need help right now
Willow & Stone is an outpatient practice and is not an emergency service. If you or someone you care about is in immediate danger, call 911.
For urgent mental health support at any hour, call or text 988 to reach the Suicide & Crisis Lifeline, or text HOME to 741741 for the Crisis Text Line. Both are free, confidential, and available 24/7 nationwide.
Dr. Stacey Forbes, DNP, APRN, PMHNP-BC
Board-certified Psychiatric-Mental Health Nurse Practitioner and founder of Willow & Stone Integrative Mental Health. Nearly two decades of clinical experience; integrative, root-cause psychiatry in person in Arlington and by telehealth. Licensed in Texas, New Mexico, Florida, Alaska, Arizona, Colorado & Washington.
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