When people are diagnosed with bipolar disorder, one of the first issues involves the question of taking medications. It’s important to remember that bipolar disorder is a genetically based condition that affects the brain’s development and ability to regulate emotion. This results in excessive changes in brain chemistry. Bipolar medications are designed to moderate brain activity and allow the individual better opportunities to improve everyday life through therapy.
Indications of Bipolar Medication
What to look for with bipolar medications can be broken down to their indicated effects and side effects. The indicated effects of a medication are the FDA-approved results leading to the treatment indication. For bipolar specifically, medications can be more anti-manic or anti-depressive, or used for long-term maintenance.
Depending on several factors, certain medications can be fairly balanced between causing anti-manic and anti-depressive effects. Bipolar patients with a recent or current manic episode often start with medications that are anti-manic, which calm symptoms down toward the baseline.
If the current or more recent mood episode is depression, then beginning bipolar medications known to have an anti-depressive effect are preferred. These medications tend to be less calming and can lift up a mood toward the baseline with less chance of triggering a manic response.
How Prescribing Bipolar Medication Works
Most prescribing doctors start a medication at the lowest dose appropriate for the patient and the severity of the presenting symptoms. A standard treatment philosophy is to increase medication dosages until patients reach the maximum level of benefit while maintaining the minimal level of side effects. Adding one or more medications to the overall treatment plan is also typical. In addition, certain medications can be replaced or eliminated when it’s apparent they’re no longer necessary.
There are frequently multiple medication choices for a single diagnosis, so if one medication has not worked well, another option is likely available. And if medications can be held off for a time through therapy, then perhaps that can be a useful trial period to reassess the need for medications later. Also, it’s typically a good idea to ask prescribers what their procedures are in following the course of medication, and what to expect if it doesn’t work. Medication needs can change as patients move through treatment.
Common Types of Bipolar Medications
Although several types of medications are used to treat bipolar disorder, the most common ones are addressed here in four groups:
- Mood stabilizers
- Antipsychotics
- Antidepressants
- Antianxiety / Anxiolytics
Mood Stabilizers
Mood stabilizers include a mineral, anticonvulsants (medications designed for the treatment of seizures) and antipsychotics. They’re known as either anticonvulsant or antiseizure medications.These medications can help the brain regulate mood states without the risk of becoming manic catalysts or creating undue sedation that can worsen depression. Mood stabilizers can also be given with other psychiatric medications to enhance the stabilization process by targeting specific symptoms, including psychotic ones.
Commonly prescribed mood stabilizers include:
- lithium (Eskalith, Lithobid, Lithonate)
- divalproex (Depakoate)
- carbamazepine (Tegretol)
- lamotrigine (Lamictal)
- topiramate (Topamax)
- oxcarbazepine (Trileptal)
- gabapentin (Neurontin)
How lithium works in the brain isn’t fully understood, but this mineral is believed to act similarly to other chemicals involved in brain-cell conduction.1 Such elements as potassium and sodium permit electrical signals to pass along each nerve cell and communicate with every subsequent nerve cell along a given pathway in the brain. Due to its steady properties, lithium stabilizes this conduction process in a wide-ranging manner while ensuring the pathways work consistently and without the neurological changes that could produce mood swings.
Anticonvulsants work in a similar way. They essentially calm brain activity, especially in brain areas that can overreact, such as in epileptic seizures. Certain anticonvulsants such as divalproex or carbamazepine can be more anti-manic than anti-depressive while others, such as lamotrigine, can be more anti-depressive.2 They’re prescribed singularly or with another med in this or another class.
Lithium by itself is balanced enough to be both an anti-manic and a maintenance drug, and it has been shown to significantly decrease the risk of suicide during long-term use.3 When switching from initial doses to maintenance doses, lithium is usually decreased and kept at a lower level for the long term. The body processes lithium by way of the kidney instead of the liver, making it a potentially good choice for those who have a history of liver disease.
With lithium being the gold standard bipolar med with all these good properties, why would people with bipolar need anything else? As is true for any bipolar medication, not all patients respond to lithium the same way. In fact, there’s no way to predict how someone will react without trying it first. And that applies to any medication. So understanding the range of options available along with a measure of patience is needed to fully assess progress.
With lithium, there’s a “targeted therapeutic window” for the stabilizing effects to occur. If the lithium level in the blood is too low, below the therapeutic window, it can’t do its job. If the level is too high, above the therapeutic window, moderate to severe side effects can occur. When patients begin lithium treatments, they should have blood-serum samples drawn according to their doctors’ requirements to verify good lithium levels. People should also talk to their doctor or pharmacist about the potential side effects to see if the drug is right for them.
Antipsychotics
First made available in the 1950s, antipsychotic medications were found to be effective in treating schizophrenia. The first generation “major tranquilizers” also reduced mania, but they had strong side effects, especially when used long-term. Today, a second generation of these medications known as atypical antipsychotics is often prescribed. They have fewer side effects than the earlier generation in treating bipolar disorder.4 This is particularly good for patients whose mood events include psychotic features, seen in the most severe forms of mania and depression.
Commonly prescribed antipsychotics:
- aripiprazole (Abilify)
- asenapine (Saphris)
- clozapine (Clozaril)
- olanzapine (Zyprexa)
- paliperidone (Invega)
- risperidone (Risperdal)
- quetiapine (Seroquel)
- ziprasodone (Geodon)
- lurasidone (Latuda)
Antipsychotics can be quite effective as anti-manic agents, and they can be used with other bipolar medications depending on the individual’s need. Antipsychotics can also be prescribed for bipolar depression. At times, certain ones are paired with an antidepressant to avoid becoming a catalyst for mania. Physicians sometimes turn to antipsychotics to even out mixed episodes of mania and depression, at least until a more identifiable mood pattern takes form.5 Although they may be used for bipolar without psychotic symptoms, these medications help reduce agitation, delusional or paranoid thoughts, and hallucinations that accompany psychotic mania or psychotic depression.
Sometimes, physicians turn to antipsychotics when they are not sure about a bipolar diagnosis in a given patient. When uncertain about bipolar, they may feel more comfortable treating patients with these medications, since some symptoms cross over with other disorders that are treatable with antipsychotics. This may be particularly true for severe depression when bipolar is suspected because they won’t induce mania.
People should also talk to their doctor or pharmacist about the potential side effects to see if the drug is right for them.
Antidepressants
Antidepressant medications come in several subtypes, including:
- SSRIs
- SNRIs
- Atypicals
- Tricyclics
- MAO Inhibitors
Neurotransmitters thought to be associated with depression, namely serotonin, norepinephrine, and dopamine, are increased,or made more available in the nervous system, with the use of antidepressant medications.1 These medications are believed to work over time as a way to improve moods in many who suffer from depression.
Commonly prescribed antidepressants used for bipolar disorder include:
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- sertraline (Zoloft)
- vilazodone (Viibryd)
- desvenlafaxine (Pristiq)
- duloxetine (Cymbalta)
- levomilnacipran (Fetzima)
- venlafaxine (Effexor)
- bupropion (Wellbutrin)
- mirtazapine (Remeron)
- vortioxetine (Trintellix)
Most antidepressants do well in the treatment of non-bipolar major depression and dysthymia, but they can act as manic catalysts in people predisposed to bipolar disorder. As a result, antidepressants alone are not recommended as a treatment for bipolar depression.4
Although antidepressants certainly have anti-depressive effects in most people, for people with bipolar in particular, they may have an excessive effect. Antidepressants given by themselves have been shown to increase the risk of mania, while antidepressants provided with a mood stabilizer did not increase that risk.6 In fact, if an antidepressant medication alone results in the first manic or hypomanic episode of the person’s life, the diagnosis is likely bipolar disorder.7
This can account for situations when misdiagnosed people with bipolar—especially young people—start an antidepressant and become more agitated, more hyperactive, or more suicidal than before within the first few days of taking the drug. Some people react poorly to drugs of all types, but these peculiar reactions to antidepressants can act as a diagnostic for bipolar.
Although antidepressants can create problems for bipolar patients, they can be useful by maintaining an anti-depressive effect in some bipolar patients. This is usually in conjunction with an anti-manic agent that keeps a lid on mania. But because there are anti-depressive alternatives for bipolar patients that won’t induce mania by themselves, having an antidepressant such as an SSRI or SNRI paired with an anti-manic would usually occur after other options were attempted.
Antidepressant medications also carry a black box warning, the most serious warning given by the FDA, for increased risk of suicide in children and adolecents. People should talk to their doctor or pharmacist about the warnings and potential side effects to see if the drug is right for them.
Antianxiety/Anxiolytics
Typically, these medications are effective in relieving mild to severe anxiety in many circumstances. Other medications may take anywhere from a few days to a few weeks to achieve full effect, but anti anxiety medications work within minutes to calm nervous system functioning. Their immediate benefit can help reduce irritability and excitability, especially in dysphoric mania. They can also aid sleep. While they are not intended to replace other bipolar medications, doctors often use anti anxiety medications in conjunction with anti-manic ones.8
Some of the antianxiety medications include:
- alprazolam (Xanax)
- chlordiazepoxide (Librium)
- clonazepam (Klonopin)
- clorazepate (Tranxene)
- diazepam (Valium)
- flurazepam (Dalmane)
- lorazepam (Ativan)
- buspirone (BuSpar)
The antianxiety agents known as benzodiazepines, which include drugs such as alprazolam, clonazepam, diazepam, flurazepam, and lorazepam are the only bipolar medications known to be habit forming. Patients who use these medications over an extended time run the risk of dependency.1
For bipolar treatment in general, taking an antianxiety medication can help control some manic symptoms along with reducing early signs of anxiety—that is, until the full effect of mood-stabilizing medications take hold.4 Doctors often prescribe these medications for a brief period but don’t necessarily continue their use for long-term maintenance. If used long term, they’re often provided on an “as needed” basis to reduce occasional bouts of anxiety. People should also talk to their doctor or pharmacist about the potential side effects to see if the drug is right for them.
Common Bipolar Medication Side Effects
Among the various kinds of side effects, there are a particular few that many people find hard to live with, sometimes to the point of discontinuing medications on their own.
Side effects of bipolar medication can include:
- Intestinal distress (nausea, constipation, diarrhea)
- Dizziness
- Tremors (especially in the hands)
- Weight gain
- Sexual dysfunction
*This is not a comprehensive list of side effects for medications used in bipolar treatment. Individuals should talk with their doctor or pharmacist about all potential side effects.
Mild intestinal distress, mild dizziness and mild tremors usually resolve within the first few days of medication use. If they stay mild but don’t resolve, the prescribing physician might want to change medications for something more easily tolerated. If they get worse, especially with lithium or anticonvulsants, the physician should be contacted immediately, as these can be signs of toxicity (above the therapeutic window).
But even as these side effects are typically well managed, anyone’s sensitivity to medications in general and the preconceived stigma about bipolar medications in particular, can result in someone ending their treatment without really giving the time and opportunity to work through these problems. It seems these immediate signs of discomfort can offer confirmation to patients that medications are basically bad or simply not worth the trouble.
Weight Gain Caused By Bipolar Medication
One side effect that is often distressing for some patients is weight gain. For some of the above medications, it can be a real deal breaker. Because weight gain is not experienced immediately, patients are already into their treatment before it becomes an issue. But once the pounds start adding on, patients become quite concerned.
Not all medications produce weight gain, thus a physician can try switching. Yet, it is a common side effect among lithium and a few of the anticonvulsants, antidepressants and antipsychotics. Obviously this is a problem for most patients, especially if they’ve had a history of obesity before bipolar disorder became life’s number one problem. The effect on self-image and overall health can threaten any early enthusiasm to get on medications for life-long treatment.
Rather than abandoning medications, it’s important to discuss concerns with the prescribing physician to ensure that all options are explored. Also, it’s good to complete an overall health assessment when medications are initiated. This can give us a preview of how they will adjust to medications in general, but particularly if positive changes should be made with diet and exercise. So a physician’s referral to a clinical dietician could be a useful way to properly manage this issue.
Sexual Side Effects of Bipolar Medication
Similarly, people don’t always like to discuss sexual problems, although some medications may have a suppressing effect. This can occur in sexual desire and/or performance, both in men and women. Again, this problem can be resolved by switching to other medications known to have fewer sexual side effects.
Sometimes, without a thorough discussion about the issue, patients may stop medications or try certain adjustments that may complicate their overall care. For example, some patients may intend to stop medications when they want to have sex. But switching back and forth, for any reason, can seriously impair medication effectiveness, especially for the long-term. Discussing sexual related concerns through treatment is often one of the more important considerations in maintaining life-long collaboration.
For any side effect, the number one thing to remember is discussing concerns with the physician and treatment team. Communication and collaboration are keys to overall success in bipolar disorder treatment.
Overcoming Stigma of Medication For Bipolar Disorder
Many people are afraid of taking medications. There certainly are well-founded concerns about medications, but these are typically handled within the context of collaborative treatment discussions.
A combination of therapy and medication may be the most effective approach for many people suffering from mental health conditions, not just bipolar disorder. However, researchers in 2017 found that people seeking mental health treatment consistently preferred psychotherapy over medication, with stigma and negative attitudes towards people with mental illness reducing the chance of reaching out to prescribing psychiatrists.9 However, therapy and medication are meant to work together.
Many people are afraid to start taking medication because of the stigma surrounding it. Open communication about stigma can explore the possible feelings of shame in individuals and among their family members, especially when cultural biases may be present. If these are concerns for you, it’s important to share them with the treatment team.
Alongside shame and stigma is the question many people ask, “Will medications change who I am?” Identity issues very often are revealed through this process, which can be explored to increase overall therapy results.10 Again, sound information and sensitivity to your fears and concerns can set a productive framework for medication collaboration, as well as advancing treatment for all involved.
Another important question is, “How long do I have to take medications?” or “Do I have to take medications forever?” The important thing here is to ask these questions out loud to the treatment team, and openly discuss the future of medications and all aspects of psychological treatment. Working together through these concerns improves all outcomes while minimizing the possibility of treatment failures and symptom relapse.3
