The first-line treatment for bipolar disorder is lithium, which is another mood stabilizer without any anticonvulsant effect. However, three anticonvulsants – carbamazepine, divalproex and lamotrigine – have also been shown to be effective in treating bipolar disorder.

Divalproex is considered a first-choice anticonvulsant treatment for mania and for rapid cycling (four or more manic episodes per year) bipolar disorder. Divalproex is also considered one of the first-choice anticonvulsant treatments  for mixed episodes (episodes with features of both mania and depression) of bipolar disorder.

Lamotrigine is approved for long-term treatment of adults with bipolar disorder, and is considered a first-choice anticonvulsant treatment for patients with predominantly depressed episodes of bipolar disorder, and a second-choice anticonvulsant treatment for rapid cycling.

Many experts consider carbamazepine to be a first- or second-choice anticonvulsant treatment for mixed episodes and a second-choice anticonvulsant treatment for mania.  However, unlike divalproex and lamotrigine, carbamazepine has not yet received approval from the U.S. Food and Drug Administration (FDA) for treatment of bipolar disorder.  Physicians frequently prescribe it “off label,” a common practice in which FDA-approved medications are prescribed in a manner other than which they were originally intended.

Other newer anticonvulsants may be used to treat bipolar disorder, but usually in addition to first-line anticonvulsant treatments or when such treatments do not work. These include oxcarbazepine, topiramate, tiagabine and gabapentin.