Understanding Your Bipolar Medication Options
Every day we take bipolar medication (or medications) several times a day as directed by our doctor, hoping for the best result. In a perfect world, the expected results would quickly manifest, alleviating us from our symptoms and allowing us to go on with our lives. But the real world is not perfect, and doctors can spend months, even years, finding the right combination of drugs for each patient.
The process can be long and drawn out in some part because the process is not an exact science. Simply put, even the best doctor cannot predict how a patient will react to a medication.
As more drugs are added to the cocktail, the process gets more complicated and even less predictable. So most of us will experience ongoing changes in our medications.
If you have bipolar, your cocktail generally consists of three types of drugs: mood stabilizers, antidepressants, and antipsychotics. Let’s take a look at the options for each.
Mood Stabilizers
Mood stabilizers are drugs that help keep you steady, avoiding both the highs and lows of the illness. The primary mood stabilizers are:
Lithium
Unlike other psychotropic drugs, lithium is derived from nature and is not created in a laboratory. It is a widely used drug, but because it is technically a salt, you must drink plenty of water and stay hydrated. While my doctors did not encourage a low-salt diet, they did state that I should not dramatically increase or decrease my salt intake while on lithium.
When taking lithium, it is important to have your lithium level checked via a blood test. If your lithium level is too low, you will not get the full benefit of the drug. If your lithium level is too high, it can be toxic.
Common side effects of lithium may include dry mouth, mild tremors (shakiness), weakness and diarrhea. Lithium consumption has also been associated with an underactive thyroid, so it is important also to monitor your thyroid function. If your tremors become severe or if you have other side effects, contact your physician.
Depakote (valporic acid)
Depakote was as originally patented as an anticonvulsant medication for seizures. It has been widely used for bipolar disorder since the early 1980s and surpassed lithium as the most used mood stabilizer in the 1990s.
Taking Depakote can damage your kidneys, so it is important to monitor your blood creatinine levels on a regular basis.
Common side effects for Depakote may include:
- Gastrointestinal issues like upset stomach, diarrhea, and constipation.
- Mild tremors (shakiness)
- Weakness
- Drowsiness
- Hair loss.
If these side effects become severe or if you experience other side effects, contact your physician.
Lamictal (lamotrigine)
Like Depakote, Lamictal was also used as an anticonvulsant medication for seizures. It was introduced for use in bipolar patients around 2003.
Lamictal has been demonstrated to be especially useful when given to patients experiencing bipolar depression. Common side effects may include:
- Mild tremors (shakiness)
- Blurred vision
- Dry mouth
- Upset stomach
- Changes in menstrual periods
- Back pain
The most important thing to remember when taking Lamictal is that it can induce the Steven-Johnsons syndrome, an adverse reaction that causes a dangerous rash. If you experience any type of rash when using Lamictal, see a physician immediately.
Equetro, Tegretol (carbamazepine)
Carbamazepine also originated as an anticonvulsant but was approved for use in bipolar patients in 2005.
Antidepressants
Antidepressants are one of the most prescribed drug classes in all of the medicine, so there are many choices. However, researchers have noted differences in the treatment of bipolar depression versus unipolar depression.
Generally speaking, some medications are not as effective in bipolar patients, giving them fewer choices. Many antidepressants are indicated for OCD (obsessive-compulsive disorder), eating disorders and other conditions. The following is a review of the different sub-classes of antidepressants.
Common side effects of antidepressants include:
- Drowsiness
- Nausea
- Dry mouth
- Insomnia
- Anxiety
- Diarrhea
- Dizziness
- Sexual problems including reduced sexual desire and erectile dysfunction.
If these side effects escalate or if you experience different side effects, see a physician immediately.
One important note of caution, you should never abruptly stop taking an antidepressant unless under direct order from a physician. Even then, ask your doctor about tapering you off of the medication instead of suddenly stopping your medication. In some cases stopping your medication, “cold turkey" can lead to extreme mood swings and in some instances, it leads to suicidal thoughts and behaviors.
Tricyclic Antidepressants
TCAs were developed and marketed in the 1950s. The goal of the TCA is to increase the amount of neurotransmitters like serotonin and noradrenaline.
However, TCAs work differently than SSRIs and SSNIs. These drugs prevent the neurotransmitters from binding to specific receptors on the nerves where they build up in between the nerve cells. This allows the neurotransmitter levels to increase.
Common TCAs include:
- Amitriptyline
- Amoxapine
- Desipramine (Norpramin)
- Doxepin
- Imipramine (Tofranil)
- Nortriptyline (Pamelor)
- Protriptyline (Vivactil)
- Trimipramine (Surmontil)
Monoamine Oxidase Inhibitors
MAOIs were introduced in the late 1950s and used up into the 1970s. These drugs inhibit the activity of the monoamine oxidase enzyme family. Because of potentially lethal dietary and medication interactions, MAOIs are now reserved as a last line of treatment, used only when other classes of antidepressant drugs have failed.
MAOIs include:
- Isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
Tetracyclic Antidepressants
TeCAs came on the market in the 1970s. They are similar to TCAs in that they increase the neurotransmitter levels; however, unlike TCAs, which have three rings on the atomic level, tetracyclic antidepressants have four rings.
- Amoxapine (Asendin)
- Maprotiline (Ludiomil)
- Mianserin (Bolvidon, Norval, Tolvon)
- Mirtazapine (Remeron)
- Setiptiline (Tecipul)
Selective Serotonin Reuptake Inhibitors (SSRI)
SSRIs are designed to increase the level of the neurotransmitter serotonin. This is done by limiting its reabsorption into a specific type of cell, which then increases the level of serotonin in other cells so it can bind to the desired receptors.
SSRIs became available in the 1980s and are the most widely used antidepressants. However, for some bipolar patients SSRI drugs can induce manic symptoms, so you if you take these drugs you need to be aware of this tendency. Common SSRIs include:
- Celexa (Citalopram)
- Lexapro, Cipralex (Escitalopram)
- Paxil, Seroxat (Paroxetine)
- Prozac (Fluoxetine)
- Luvox (Fluvoxamine)
- Zoloft, Lustral (Sertraline)
Antidepressants
Serotonin and Noradrenaline Reuptake Inhibitors (SNRI)
SNRIs are similar to SSRIs, but also limit the reabsorption of noradrenaline in addition to that of serotonin. SNRIs became available in the 1990s, and are not as widely used as SSRIs. Common SSRIs include:
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Levomilnacipran (Fetzima)
- Milnacipran (Ixel, Savella)
- Tofenacin (Elamol, Tofacine)
- Venlafaxine (Effexor)
Noradrenaline Reuptake Inhibitors
NRIs work by blocking the action of the norepinephrine transporter (NET). Norepinephrine is also a neurotransmitter, like serotonin. This blockage allows for increased concentrations of norepinephrine outside of the cells.
- Reboxetine (Edronax)
- Viloxazine (Vivalan)
Melatonergic Antidepressants
These are a new class of antidepressants that came in the last ten years. The drugs are the result of an accidental discovery of a synthetic melatonin and its effect on serotonergic receptors. This led to a more thorough investigation where the serotonin benefits were documented. Options include:
- Agomelatine (Valdoxan, Melitor, Thymanax)
Atypical Antipsychotic Drugs
Although these drugs are primarily used to control mania, they have demonstrated effectiveness in managing depression:
- Latuda (Lurasidone)
- Seroquel (Quetiapine)
- Abilify (Aripiprazole)
Antipsychotic Drugs
Antipsychotics are used to inhibit bipolar mania. Those diagnosed with schizophrenia also uses many of these drugs.
In the past 30 years a new class of antipsychotic medications was developed; because they were different from the original drugs, they became known as atypical antipsychotics.
Atypical antipsychotics are so named because they treat the symptoms in a manner that is not like its predecessors. The chemistry of these drugs involves neurotransmitters but is more complicated as the drug attacks specific sites of the cell, relying upon particular receptors.
Just like anti-depressants, anti-psychotics work on the brain chemistry. Also affecting the serotonin and noradrenaline, these drugs also affect the dopamine levels. If your doctor has prescribed an antipsychotic it is likely one of these medicines:
- Aripiprazole (Abilify)
- Asenapine (Saphris)
- Clozapine (Clozaril)
- Olanzapine (Zyprexa)
- Quetiapine (Seroquel)
- Lurasidone (Latuda)
- Risperidone (Risperdal)
- Ziprasidone (Geodon)
Commonly prescribed typical antipsychotics are listed below:
- Chlorpromazine (Thorazine)
- Haloperidol (Haldol)
Thorazine was introduced in the 1950s, and Halodol came in the 1970s. While it is possible for your doctor to prescribe one of these medications temporarily, it is unlikely you will be on any of these drugs for the long term.
The newer atypical antipsychotic drugs represent significant advancement, leaving little need for the original antipsychotics.
Side Effects of Antipsychotic drugs
Common side effects of antipsychotic medications may include:
- Blurred vision
- Dry mouth
- Drowsiness
- Muscle spasms or tremors
- Weight gain
If these side effects escalate or if you experience different side effects, see a physician immediately.
It is important to note that several atypical antipsychotic drugs have been linked to increases in blood sugar and diabetes. When taking these medications be sure to watch your intake of carbohydrates and have your blood sugar levels checked regularly.
Finding the Right Bipolar Medication for You
As you start your journey with bipolar medication, remember that most people try many different drug combinations before they find one that is effective.
Even after an effective bipolar medication regimen is achieved, it will often need occasional, “tweaking." Again, keep a brief journal of your mood and your side effects to assist your doctor in making the best choices for you. Don’t be afraid to do your own research to understand how the medications work.
Also, if you have a first-degree relative (e.g., parent or sibling) who has bipolar disorder and has found success with a specific drug, there is a chance that this drug will work well for you. I discovered this because my mother also has bipolar disorder and on several occasions, my doctors successfully put me on a medication that she was using.
In Conclusion...
On a final note always remember that bipolar medication represents only a part of your treatment journey. Proper nutrition, exercise, and self-care will make any medication regimen much more effective!