Bipolar Disorder and Medication
Dr Jonathan Haverkampf
There are different types of bipolar disorder, but what they all have in common is that there are alterations in mood between above ‘normal’ (hypomania, mania) and normal or below normal (melancholia, depression). The other important mood disorders are the various types of depression, while mania without episodes of depressions is a rarity.
Bipolar disorder is a condition that can be treated with a combination of medication and psychotherapy/counselling. Especially the less severe forms often remain untreated, leading to unnecessary suffering, also in terms of failed relationships and absences at the workplace, and even suicide. Treatment should always include psychotherapy. Research shows that people who take medication for bipolar disorder tend to recover much faster and control their moods better if they also get therapy.
Medication with mood stabilizers can bring mania and depression under control and prevent relapses once the mood has stabilized. Medication should be regarded as long-term treatment. In many cases, medication is not used long enough, leading to a relapse that interferes significantly with the quality of life or even suicidal thoughts. Psychotherapy as a complement helps to get a better sense of oneself and build strategies to reduce stress and anxiety and increase one’s control over the depths and heights of the mood swings. Since mood depends on thoughts, activities and situations as well as sleep hygiene and caring for one’s physical health, there is a lot that can be done besides medication which nevertheless remains the most important piece of treatment for bipolar disorders that go beyond cyclothemia. Making healthy choices in one’s life can affect mental-wellbeing. Alcohol is a depressant and makes recovery even more difficult. It can also interfere with the way medication works.
Medication should be continued over a while, even if the bipolar symptoms disappear, because of the high rate of relapse after discontinuing medication. Therapy probably can reduce the risk somewhat, but it is important not to discontinue the medication too early.
It can take a while to find the right bipolar medication and dose. Everyone responds to medication differently, so it may be necessary to try some before settling on one that has the best trade-off between high effectiveness and low side-effects. Patients with bipolar disorder should be seen more often when medication with bipolar drugs is begun. There should be room for support and therapy to help with anxieties, doubts, social, work-related and partnership problems and questions in general. During acute mania or depression, most patients talk with their healthcare professional at least once a week, or even every day, to monitor symptoms, medication doses, and side effects. Once the symptoms have subsided, medical monitoring can gradually be done less frequently, although it is still good practice to see patients once per quarter as a minimum. They should also be told to make contact quickly if they have suicidal or violent feelings, changes in mood, sleep, or energy or changes in medication side effects.
Since medication used to treat bipolar disorder can have interactions with other drugs, whether over-the-counter or prescribed, patients should discuss this with their doctor. Possible interactions with other medication, side-effects that can affect one’s ability to drive or operate machinery and the risks for pregnancy should be discussed. Using a daily reminder/medication saver system can be helpful.
An accurate diagnosis is important, especially in distinguishing between monopolar depression and bipolar disorders. Antidepressants can trigger manic episodes especially if there already is an underlying bipolar disorder. If they are needed to treat the depressive episodes in a bipolar disorder, they should only be used in combination with a mood stabilizer to prevent the exacerbation of a manic episode.
In the following I will discuss some important mood stabilizers used in the treatment of bipolar disorders. Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They are the cornerstone of treatment, both for mania and depression. I also include other chemical groups that are sometimes considered when a patient suffer from bipolar disorder.
- Lithium
- Anticonvulsants
- Antipsychotics
- Benzodiazepines
- Calcium channel blockers
- Thyroid hormone
Lithium
Lithium was the first mood stabilizer for bipolar disorder Lithium is the oldest and most well-known mood stabilizer. It is highly effective for treating mania, but can also help in the treatment of bipolar depression. It is not as effective for mixed episodes or rapid cycling forms of bipolar disorder. Often patients notice greater stability in their mood swings early on, full effectiveness, however, can take up to a couple of months.
The following side effects are common on lithium. Some may go away as the body adapts to the medication.
- Weight gain
- Drowsiness
- Tremor
- Weakness or fatigue
- Excessive thirst; increased urination
- Stomach pain
- Thyroid problems
- Memory and concentration problems
- Nausea, vertigo
- Diarrhea
Regular blood tests are necessary to make sure the blood levels are within a narrow therapeutic window. A dose that is too high can be toxic, one that is too low ineffective. Ranges for blood levels can vary from lab to lab, hospital to hospital and country to country. The lowest seems to be 0.4 mmol/L and the upper limit 1.2 mmol/L. However, it is always important to remember that ultimately the patient’s symptoms are treated and not the blood lithium level. I have seen 0.5 a perfectly sufficient dose in some cases, while in others 1.1 was needed. The famous lithium tremor may be one of the earliest signs when one reaches toxic levels, but there is no guarantee it always will be. I would start out with weekly lithium blood levels, and after reaching a stable dose to biweekly tests. After about six weeks one can move to monthly tests. In most cases, if one stays within a therapeutic range with 1.2 mmol/L as the upper limit and conducts regular blood tests, lithium is relatively safe and effective.
After the first couple of months and if the medication works well and side-effects are either tolerable or absent, the frequency of blood tests may be reduced to every two to three months. But it should not be discontinued completely because various changes in eating habits, athletic activities and other medication can affect the lithium blood levels.
Other factors that can influence the lithium levels are:
- Weight loss or gain
- The amount of sodium in the diet
- Seasonal changes (lithium levels may be higher in the summer)
- Many prescription and over-the-counter drugs (e.g. ibuprofen, diuretics, and heart and blood pressure medication)
- Caffeine, tea, and coffee
- Dehydration
- Hormonal fluctuations during the menstrual cycle and pregnancy
- Changes in health (for example, heart disease and kidney disease increase the risk of lithium toxicity)
The amount of salt in the diet should not suddenly be changed; it is especially important not to suddenly reduce your salt intake. Patients should make sure that they drink enough fluids, especially if one exercises heavily or in hot weather when one will sweat more. Alcoholic drinks can lead to an overall water loss, which can become a problem especially in hot weather of when one tries to still one’s thirst by drinking alcoholic beverages.
Anticonvulsants
Anticonvulsants are used in the treatment of bipolar disorder as mood stabilizers. Originally developed for the treatment of epilepsy, they have been shown to relieve the symptoms of mania and reduce mood swings.
Valproic acid (Depakote®, Depakene®, Depakine®)
Valproic acid, also known as divalproex or valproate, is a highly effective mood stabilizer. Common brand names include Depakote® and Depakene®. Valproic acid is often the first choice for rapid cycling, mixed mania, or mania with hallucinations or delusions. It is a good bipolar medication option if lithium is not tolerated.
Common side effects include:
- Drowsiness
- Weight gain
- Dizziness
- Tremor
- Diarrhea
- Nausea
Other anticonvulsant medications for bipolar disorder
- Carbamazepine (Tegretol®)
- Lamotrigine (Lamictal®)
- Topiramate (Topamax®)
Antipsychotics
If you lose touch with reality during a manic or depressive episode, an antipsychotic drug may be prescribed. They have also been found to help with regular manic episodes. Antipsychotic medications may be helpful if you have tried mood stabilizers without success. Often, antipsychotic medications are combined with a mood stabilizer such as lithium or valproic acid.
Second-generation antipsychotic medications used for bipolar disorder include:
- Olanzapine (Zyprexa®)
- Quetiapine (Seroquel®)
- Risperidone (Risperdal®)
- Ariprazole (Abilify®)
Ziprasidone (Geodon®) is used more rarely.
Clozapine (Clozaril®) is used in cases where the other second-generation antipsychotic drugs do not work. However, because of a relatively rare but potentially lethal agranulocytosis, regular counts of white blood cells are required.
Common side effects of antipsychotic medications for bipolar disorder are
- Drowsiness
- Weight gain
- Sexual dysfunction
- Dry mouth
- Constipation
- Blurred vision
Sexual and erectile dysfunction is a common side effect of antipsychotic medications, one that often deters bipolar disorder patients from continuing medication. A recent study has shown that the medication Sildenafil citrate (Viagra®) is relatively effective in the treatment of antipsychotic-induced erectile dysfunction in men, but it may in many cases be better to switch the antipsychotic medication, which can make the problem disappear. Also, it needs to be remembered that it may sometimes be the underlying psychiatric condition that causes the sexual dysfunction.
All antipsychotics, with the apparent exception of Clozapine, can potentially cause late dyskinesia, which is in many cases untreatable. Some may also prolong the QT interval more than others, which makes an ECG part of good practice before administering a second-generation antipsychotic.
Benzodiazepines
Mood stabilizers can take up to several weeks to reach their full effect. In the meantime, benzodiazepines can bring some relief of anxiety, agitation, or insomnia. Benzodiazepines are fast-acting sedatives that work within 30 minutes to an hour. Because of their high addictive potential, however, benzodiazepines should only be used until the mood stabilizer or antidepressant begins to work. A history of substance abuse requires special caution.
Calcium channel blockers
Traditionally used to treat heart problems and high blood pressure, they also have a mood stabilizing effect. They have fewer side effects than traditional mood stabilizers, but they are also less effective. However, they may be an option for people who cannot tolerate lithium or anticonvulsants.
Thyroid hormone
People with bipolar disorder often have abnormal levels of thyroid hormone. Thyroid dysfunction is particularly prevalent in rapid cyclers. Lithium treatment can also cause low thyroid levels. In these cases, thyroid medication is added to the drug treatment regimen. While research is still ongoing, thyroid medication also shows promise as a treatment for bipolar depression with minimal side effects.
Antidepressants
Mounting evidence suggests that antidepressants are not effective in the treatment of bipolar depression. A major study funded by the National Institute of Mental Health showed that adding an antidepressant to a mood stabilizer was no more effective in treating bipolar depression than using a mood stabilizer alone. Another NIHM study found that antidepressants work no better than placebo. Antidepressants can trigger mania in people with bipolar disorder. If antidepressants are used at all, they should be combined with a mood stabilizer such as lithium or valproic acid. Taking an antidepressant without a mood stabilizer is likely to trigger a manic episode.
If antidepressants are discontinued, the tapering process may have to be done slowly to reduce adverse withdrawal effects. Venlafaxine (Effexor®) is an example. However, antidepressants may have to be stopped immediately if any symptoms of mania or hypomania develop.
In any case, it should be kept in mind that patients on medication for bipolar disorder tend to recover much faster and control their moods much better if they also get psychotherapy.
There are many approaches that support the pharmacological therapy, for example
- Exercise
Getting regular exercise can reduce bipolar disorder symptoms and help stabilize mood swings. Exercise is also a safe and effective way to release the pent-up energy associated with the manic episodes of bipolar disorder.
- Sleep hygiene
Studies have found that insufficient sleep can precipitate manic episodes in bipolar patients. To keep symptoms and mood episodes to a minimum a stable sleep schedule should be maintained. It is also important to regulate darkness and light exposure as these throw off sleep-wake cycles and upset the sensitive biological clock in people with bipolar disorder.
- Healthy diet
Weight gain is a common side effect of many bipolar medications, so it is important to adopt healthy eating habits. Caffeine, alcohol, and drugs should be avoided as they can adversely interact with bipolar medications. Omega-3 fatty acids may lessen the symptoms of bipolar disorder.
- Social support network
Living with bipolar disorder can be challenging, and having a solid support system in place can make all the difference in one’s outlook and motivation. Participating in a bipolar disorder support group allows the sharing of experiences and learning from others. Support from loved ones also makes a huge difference.
© Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling, Communication, Medicine (Psychiatry); Dublin, Ireland
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