Bipolar Disorder Medications

Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability
by Julie A. Fast, John Preston, Psy.D.

(Page 3 of 7)

The following section will help you as well as your family members and friends understand the different types of medications used to treat bipolar disorder. Please note that this chapter includes only a general outline of current bipolar disorder medications. It's suggested that you always research any medication that your doctor suggests at your local library and online. You need to know the dosage guidelines, potential drug interactions, and any other information that's important to you personally. Taking a drug blindly can lead to problems.

Being an Informed Consumer

Do you know:

• What drugs you're taking?
• The specific symptoms they're treating?
• The recommended dosage?
• Any potential interactions?
• Their side effects?

Talk with your doctor, research the drugs in books and on the Internet, and talk with your pharmacist so that you can ask intelligent and informed questions when you go to your appointments.

It's a good idea for you to ask your doctor any questions you may have about your medications, and the more information you already have, the easier it will be to talk with your doctor. You want to be an informed patient. It helps if family members are also well informed.

There are six categories of psychiatric medications that have been found to be effective in treating bipolar disorder:

1. Lithium.
2. Anticonvulsants.
3. Antipsychotics.
4. Antidepressants (including Symbyax, which is a combination of an antidepressant and an antipsychotic - Prozac and Zyprexa).
5. Calcium channel blockers.
6. Benzodiazepines (tranquilizers).

The following table gives you some examples from the preceding categories. Notice that the drugs are known by a generic name and one or more brand names, and that dosages differ greatly depending on the drug. It's always suggested that you research every drug you are taking or might take, so that you are aware of the generally agreed-upon dosage ranges, the potential side effects, and what food and drugs you need to avoid while taking the drug.

There is a chart in appendix C you can use to track your medications.

Be Careful!

Some anticonvulsant mood stabilizers and lithium have been associated with causing birth defects. Talk with your doctor if you're pregnant or planning to get pregnant and are taking these drugs.

Tegretol, Trileptal, Topamax, and the herb St.-John's-wort can interfere with the actions of birth control pills.

All benzodiazepines are potentially habit forming and can be addicting if taken by people who have a history of drug addictions or alcoholism.

Neurontin (generic name gabapentin) is a non-habit-forming alternative to benzodiazepines that can reduce anxiety but without risk of addiction. Recent studies have shown Neurontin to be ineffective in treating mania, but it's often added to other mood stabilizers because of its ability to reduce anxiety.

More Information on Antidepressant Medications

There is currently some controversy regarding the use of antidepressants in the treatment of bipolardisorder depression. Antidepressants were first developed in the 1950s and have a solid track record of success in the treatment of unipolar depression. (Unipolar is the more common variety of depression, which affects up to 17 percent of people in the United States.3) But their use in bipolar disorder has some limitations:

Large-scale studies looking at treatment outcomes for hundreds of patients appear to indicate that antidepressants alone (as monotherapy) are not significantly more effective than placebos in treating bipolar depression. However, as important as group studies are, they fail to highlight that some individuals do, in fact, appear to respond to antidepressants. The point is, the research suggests that, in general, the effectiveness of antidepressants alone is not robust.

Antidepressants can, at times, cause what is known as a switch. When this occurs, it's typically seen during the first two to three weeks of treatment with antidepressants. The person rather rapidly comes out of the depression and goes into a state of mania or hypomania. This is a serious treatment complication.

Some evidence indicates that the use of antidepressants (especially over a prolonged period of time) may cause a condition referred to as cycle acceleration. This is an overall worsening of the illness in which major mood episodes become more frequent and more severe. This is also a serious treatment complication.

All antidepressants studied have shown that between 3 and 4 percent of people starting treatment experience increased thoughts about suicide. This generally occurs either in the first two weeks of treatment (before the medication effects kick in) or after discontinuing the medication. Many of the antidepressants can cause some initial "activation," or restlessness, as a side effect, and this can be experienced a few hours after the first dose. In seriously depressed people, this restlessness can add to the sense of discomfort and may be why some people experience the increase in suicidal thoughts. This is a real issue, although it affects a small percentage of patients. If this happens to you, contact your doctor as soon as possible. Often other medications such as tranquilizers can be prescribed to reduce the restlessness until the antidepressant begins to take effect. Also, always report any suicidal feeling to your doctor. These thoughts should be taken seriously.

There is general agreement that these potential problems with antidepressants do exist, but the fact remains that some individual patients do have a positive response to antidepressants. Recent studies reveal that despite these risks, 19 percent of people experiencing bipolar depression must have antidepressants added to mood stabilizers in order to achieve successful resolution of their depressions. We must be very clear that antidepressants are not recommended as a monotherapy - in other words, they should never be taken alone - and must be taken along with a mood stabilizer. It's important that you talk with your doctor about these issues.

Over-The-Counter Supplements

Billions of dollars each year are spent on over-the-counter dietary supplements and herbal products. Obviously, many people seek out this kind of treatment, and studies have shown that 70 percent of people taking these supplements never mention them to their doctors. Some of the top sellers are products that claim to have an impact on emotions and brain functioning, including St.-John's-wort and SAM-e. These two over-the-counter drugs do, in fact, have a significant amount of research documenting their effectiveness in treating some forms of depression. To date, however, they have not been adequately studied in the treatment of bipolar disorder. What is clear is that any drug - prescription or over-the-counter - that reduces depression can actually trigger mania in someone with bipolar disorder. This fact has been well documented in the cases of St.-John's-wort and SAM-e, and thus neither should ever be taken except under careful monitoring by a psychiatrist. In addition, St.-John's-wort has been shown to have very significant drug interactions when taken by people also taking other prescription medications. Such interactions can be potentially dangerous. Never take either of these over-the-counter products without consulting your physician.

Omega-3 Fatty Acids

One exception to the research on over-the-counter supplements and bipolar disorder is the use of omega-3 fatty acids. Omega-3 fatty acids are an essential ingredient in brain structure and functioning: 30 to 35 percent of the brain mass is made up of these fatty acids. Several research studies have shown omega-3 fatty acid supplements to be a helpful adjunct in stabilizing mood in bipolar disorder4 and, more recently, in the treatment of unipolar depression.5 Initially, large doses were tried (9 grams per day), but more recent studies suggest that 1 to 2 grams (1000 to 2000 mg) a day may be as effective with fewer side effects. Omega-3 fatty acids generally are available in 0.5-gram (500 mg) or 1-gram (1000 mg) capsules. It is definitely beneficial for you to talk with your health care professional about omega-3 fatty acids.

Problems and Solutions for Over-the-Counter Supplements

There are three potentially very serious problems when it comes to the use of over-the-counter products:

The Food and Drug Administration doesn't regulate the production of such dietary supplements. In other words, you can never be sure if the product contains the ingredients listed on the label. Some over-the-counter products have been found to have inadequate amounts of the mood-altering ingredient or to contain contaminants.

As noted above, some of these over-the-counter products can cause very significant drug interactions. Most notably, a large number of people have experienced serious drug interactions while taking St.-John's-wort with other medications. Keep in mind that "natural" does not necessarily mean "safe." At times, drug interactions can actually kill you.

Anything that reduces depression can potentially provoke a manic episode in people with bipolar disorder. SAM-e and St.-John's-wort have both done this.

Despite the aforementioned cautions, some people do, in fact, benefit from some over-the-counter supplements for treating mood symptoms or for reducing side effects. Here are some guidelines for exploring your options safely.

Always talk with your doctor before introducing supplements.

See a qualified naturopathic doctor who has experience treating bipolar disorder to talk about your supplemental options.

Talk with a pharmacist about potential interactions between bipolar disorder medications and over-the-counter products.

Look for a label that says USP (US Pharmacopoeia) or NDF (National Sanitation Foundation). These labels let you know that the product has been independently tested to verify that it contains the ingredients listed and is free from contaminants. This doesn't necessarily mean that the product is effective, but it does let you know the bottle contains what it says it does.

Copyright © 2006 by Julie A. Fast and John Preston, PsyD.

About the Author

Julie A. Fast is the founder of Bipolar Happens, a popular online resource, and lives in Portland, Oregon.

John Preston, Psy.D., is a board certified neuropsychologist and lives in Shingle Springs, California.