Bipolar disease (also known as bipolar disorder, formerly manic depressive illness) is a mood disturbance. A person with bipolar disorder experiences distinct mood episodes. These are periods of normal mood, periods of depression, periods of mania/hypomania, and finally, mixed episodes, in which the patient has all the symptoms of depression and all the symptoms of mania all at the same time. Everyone with bipolar disorder has depressed, manic, and normal moods, but not all have mixed episodes.

If the depressive periods are prominent, these are very uncomfortable. Both patients and family members say that the depression of bipolar disorder is much harder to handle than the manic periods of the illness. Depression is miserable and leads to loss of effective participation in life, work, home duties, and relationships. Worse, the existence of continuing depression often means that the bipolar illness itself may be growing more unstable. This indicates more frequent and intense periods of depression “and”mania to come.

For all these reasons, it is important to treat depressive symptoms effectively as part of an overall bipolar disease treatment plan, but for reasons to be discussed below, it is best to do so without the use of antidepressants if possible.

Depression is an extended period of low mood. Mania refers to a period of elevated mood, which can be either euphoria and intense social activity or intense irritability not accompanied by depression. The key symptom in mania is a markedly reduced need for sleep occurring at the same time as the manic mood change. Additional symptoms may include inability to self-regulate impulses, leading to spending sprees, hypersexual behaviors, substance use or unregulated eating (note to editor binge eating is a very different condition so phrase not appropriate here) . Mania may or may not be accompanied by hallucinations, delusions, or other significant symptoms of emotional dysregulation. Mania that is mild and lasts between four and seven days is termed “hypomania” (little mania). More severe mania, or mania that lasts longer than seven days, is simply called mania.

The different types of bipolar disease are characterized by how long the mania lasts 

Bipolar Disease Type I: This type consists of periods of mania lasting longer than seven days, periods of depression of any length  or if there are any periods of psychosis coinciding with mania.  

Bipolar Disease Type II: This type consists of periods of mania lasting between four and seven days and periods of depression of any length, with no psychotic experiences. 

Bipolar Disease Type III: This term refers to a condition in which mania occurs only while the patient is taking an antidepressant medication. In some cases, this may only be a medication side effect. In others, such mania is the first sign that a patient previously diagnosed with major depression on its own is beginning to develop Bipolar I or II.  Developing Bipolar III is extremely serious, which is why using antidepressants to treat bipolar disorder is a risky and weighty decision. 

Mood stabilizing medications are the mainstay of bipolar disorder treatment. These include lithium and the anti-seizure medications Depakote®, Lamictal®, Trileptal®, and Tegretol®. Atypical antipsychotic medications can also be used for mood stabilizing, including Abilify®, Latuda®, Rexulti®, Risperdal® Seroquel® and others. Fortunately for many patients, such mood stabilizing medications not only reduce or eliminate mania, they can often do the same for depression. The problem comes when depression persists so that some form of treatment of the depression is needed. 

The use of antidepressants is to be avoided in treating bipolar disorder if at all possible. Antidepressants can trigger mania (classified as Bipolar III), or make existing mania more intense. Even if antidepressants do not cause changes to mania, and even if it helps reduce depression,there is good evidence that the use of antidepressants over time can make bipolar disorder more unstable, with more frequent, longer lasting, and deeper mood episodes of all types. This risk increases with the number of months that antidepressants are used, even if mood stabilizers are also used. 

Despite this risk, persistent depression is such a frequent problem that about 80% of patients with bipolar disorder have been treated with antidepressants at some point. 

As observed in many published studies, TMS can effectively treat the depressive episodes of bipolar disease. 

Although research is ongoing, available data indicates that TMS, unfortunately, does not reduce existing mania. However, there are only a handful of reports of TMS possibly triggering mania — a very low incidence rate compared with antidepressant treatment. This means that patients with bipolar disorder should continue taking mood stabilizers to control mania, but may be able to  use TMS instead of antidepressants. New TMS procedures are also constantly being evaluated, so it may yet be possible at some point in the future to use TMS to treat the whole condition, including both manic and depressive aspects.

There is no current evidence that TMS treatment of depressive episodes can worsen the long-term course of bipolar disease. TMS use can definitely reduce exposure to antidepressant medications, however, which are known to pose a risk of long-term harm to patients with bipolar disease. 

Modern medical literature makes it clear that TMS can be a safe and effective treatment for bipolar illness. Indeed, there are strong arguments for why TMS might be the safest as well as most effective treatment for depression associated with bipolar disease. Unfortunately, TMS treatment of bipolar disorder cases is still considered “off-label” in the US. Most insurance companies will only pay for TMS treatment of major depression and exclude the treatment of bipolar disease, although some companies are beginning to show some flexibility.

TMS is approved to treat depression associated with bipolar disorder in the European Union, and hopefully, the US FDA may  approve its use here within the next year or so.

Increasingly, we are seeing some insurance companies approve requests for TMS coverage for patients with bipolar disorder. For patients whose coverage providers will not approve this “off label” use, but who wish to pursue this treatment for bipolar disorder out of pocket, we do offer special reduced rates. Contact us and let us work with you to see what might be possible.