Monday, October 22, 2007

And Now a Word or Two about Mood Stabilizers

I came to talk about mood stabilizers and figured I'd start by summarizing our sidebar poll "What is Your Favorite Mood Stabilizer?" Only every time I come on, the poll has gotten more votes, so I guess I'm waiting for the mood stabilizer poll to stabilize.

Here's where we're at so far:

What's Your Favorite Mood Stabilizer?

32 (22%)
Depakote (Valproate)
27 (19%)
Zyprexa (Olanzapine)/ other atypical anti-psychotics
29 (20%)
Carbamazepine (Tegretol)
1 (0%)
Gabapentin (Neurontin)
9 (6%)
Lamotrigine (Lamictal)
44 (30%)

143 votes, Lamictal has been consistently in the lead since the beginning. Both surprising and not surprising.

I talked about How A Shrink Chooses an Antidepressant. I have less to say about how a Shrink Chooses a Mood Stabilizer. In fact, I'm not really sure. I'll tell you how This shrink chooses a mood stabilizer. It's not that much different, so click on the that post for more details.

  • History of Past Response.
  • Family History of Response
  • Patient Preference. This is a big one with mood stabilizers. The gold standard is Lithium and some patients just won't hear of it. They think taking lithium means they're really far gone, that it's heavy duty stuff, that it means they're crazy.
  • Medical issues: lots of them with mood stabilizers.... lithium can effect the thyroid and kidneys, it interacts with lots of other meds, depakote can effect the liver, so can tegretol, lots to think about, lots to monitor.
  • How strongly I'm convinced that the patient has had a full blown manic episode. Plenty of people say "I'm Bipolar" but the history doesn't reveal a story for episodic, syndromic co-occurance of the hallmark symptoms of mania: elevation in mood or irritability, increased energy/ decreased need for sleep, quickening of thoughts or speech, impulsivity with regard to spending, sexuality, religion, hallucinations, grandiose delusions, inflated sense of worth or well-being. None of these symptoms alone are enough to diagnose mania, ya gotta have a few and they have to occur at the same time as the other symptoms. Lots of people shop impulsively to cheer themselves up, lots of people have periods where they feel more energetic and productive, lots of people get happy when they win the lottery. It's sometimes hard to get a history for a syndromic diversion from a baseline (or pre-morbid) personality.
  • If I think someone definitely has bipolar disorder, and there isn't a reason not to use it, I start with Lithium. It's a good mood stabilizer. It's cheap. I'm familiar with how to use it. It's also a good anti-depressant augmenter. Despite all the hype about the awful side effects (weight gain, nausea, tremor, cognitive slowing, renal and thyroid impairment), I've seen lots of people have good responses and not have any side effects, so I start with that assumption and I use low doses. If the patient gets better, I don't push the level, even if it's really low. If the patient has intolerable side effects, I try another preparation of lithium (eskalith, lithobid), and if that doesn't work, I stop it and try another med. Why do I like lithium? I think because I've heard enough people put up resistance, then try it and come in saying "I feel normal for the first time." The down side is that you have to do bloodwork every 3-4 months even if the patient is well and has no symptoms.
  • If I'm not so sure about the manic component as a real, syndromic entity, and the primary complaint is depression, I start with Lamictal. The upside-- it's well tolerated, people like it, there's no routine labwork and there's no stigma. The down side-- slow going to build up from a dose of 25mg to the therapeutic range of around 400mg. Another down side-- that fatal rash risk. And the final down side-- I've heard a couple of anecdotes of patients who have ended up in the ICU with rashes, liver zorkout, life-threatening problems. Not a lot, but it only takes one such story to make you hold your breath when you write a prescription and I have a friend who says "I'll never be able to prescribe Lamictal again." It's not science. I actually tell patients this story-from-hell when I prescribe it, and they'll still take it over lithium. Mostly, it's a good medication, it's well tolerated, and it helps.
  • If a patient doesn't want Lithium, I prescribe depakote. It's associates with it's own issues, including weight gain, needs lab monitoring, and if the patient doesn't have insurance, it's expensive and hard to get samples of.
  • I haven't prescribed tegretol in ages and I wondered if the reason it's so unpopular on our sidebar is because it isn't used so much.
  • I prescribe anti-psychotic medications to people who are agitated, acutely suffering, not sleeping, in need of something quicker than lithium/depakote/ or lamictal. These medications work, they're well-tolerated, patients like them. And I worry about the metabolic effects and wish there was some free ride.
  • Sometimes I use one of the older anti-psychotic-- navane may be my favorite
  • If there is no history of substance abuse (---hmmm, that's rare in people with bipolar disorder), I may prescribe some ativan or klonopin for the short term.
  • I haven't used Trileptal, I don't know why. I have a patient or two on Neurontin, I stopped prescribing it when studies showed it didn't help with mood stabilization. Perhaps I was wrong. And I haven't seen very many people tolerate Topamax, though I have seen it work wonders for migraines.
  • Lithium is my favorite.
Okay-- I know there are lots of people out there who've had bad experiences with lithium. I'm not advocating that anyone re-try a medication they didn't tolerate. I'm just suggesting that everyone responds differently and before the medication is prescribed, your doc doesn't have any way of knowing if you will have problems or be one of those people who has a wonderful response and no side effects.

And to one of our anonymous commenters who wrote in:
Anonymous said...

I hope you have a really great reason for purposely for gathering useless data.

Yes, anonymous, I had a really great reason: I was curious, wondered if I'd learn something (and I did) and I thought I'd use the information for a blog post. Rest assured, I have indeed gathered completely useless and out of context data. It still makes me happy when my useless information is quoted by the Wall Street Journal.


NeoNurseChic said...

Um...I like your "useless information" polls...! I always learn something from your posts, and also from the discussions started by them! And while I have tons of experience with these "mood stabilizers" as they are used for headache, I don't really have experience with how they are used for moods, and when I took them, I never even thought to wonder what effect they might have for me. So it's interesting to read the subsequent discussion on experiences. While not a mood stabilizer, until the other day I didn't know that verapamil helped some people as an adjunct to antidepressant therapy! And how would I have learned that without a "useless info" poll?? hehe

Take care!
Carrie :)

Sarebear said...

Yup. I like the questions too. That's one of the funnest and most defintely bloggy things to do.

I saw a green (why green?) brain mouse for the computer the other day. It's between usual mouse-shaped and brain-shaped. What a thoughtful present that'd make, lol!

Rach said...

hmmmm Dinah. Interesting, interesting. You don't presribe topomax so much? That surprises me. When I was on Lithium way back in the day (to use my own words from another comment - I was far gone... excuse that comment by the way... it wasn't a good week last week)), my psychiatrist prescribe Topomax to counteract the weight-gain effects - which had great effects (despite side effects).

Maybe you should do a poll on what side effects people will put up with (ie: I'll put up with sleep disruption, pain, hair loss, change in taste profile but I WON'T under any circumstances put up with WEIGHT GAIN or start with any med that has WEIGHT GAIN as part of the side effect profile). I think this goes back to your prescribing preferences, but nonetheless, I think it it's interesting...

Anonymous said...


True as everyone puts up with something different... I can't tolerate meds that have large side effect instances of nausea/vomiting/reflux and subsequent weight loss. While I don't want to take a med that might cause weight gain, I am willing to put up with a SMALL degree of weight gain (talking 5-10 lbs, 15 at max) for a benefit.

The biggest thing to me is how bad is the need? For relief of my headaches, I'd be willing to take quite a few more side effects if it brought significant or near relief than I would for something that doesn't plague me as badly.

It's a balancing act, and would make for an interesting poll!

Take care,
Carrie :)

Midwife with a Knife said...

I picked lamotrigine because I feel less concerned about fetal effects with lamotrigine than with the others.

NeoNurseChic said...

I always thought Lamictal was category X for pregnancy/lactation. But then, I had a patient who was taking it - although I don't know if she took it her entire pregnancy - only thing that worked for seizures for her. At the time, I was also on it, and I was relieved to hear that it was something that wouldn't cause severe fetal anomalies because everything I'd read stated otherwise.

Good to hear it from you, too, MWWAK, even though I'm not on it right now.

Take care,
Carrie :)

Anonymous said...

I don't have blood tests for valproate and hadn't realised I was supposed to. So I've learnt something from coming here. Next time I have my annual review with my GP, I shall ask him to do whatever these tests are.

Anonymous said...

I just read something about Lamictal and pregnancy. And they said that people with "severe" illnesses like bipolar should not breast feed


(wood verification)

NeoNurseChic said...


I used to think I wouldn't be able to breastfeed when I have a baby. The rationale for me was that I would come off all my meds long enough during pregnancy (I dont' want to be on any meds except those I absolutely cannot live without when pregnant), but then as soon as I had the baby, I'd have to go right back on them. Then I learned of a book that lists all the meds you can take while breastfeeding - turns out quite a lot are okay!

I wouldn't go just based on "people with severe bipolar" unless there is a little better reason than that! Is that comment based on medication? On issues related to disease? I'd definitely want more info!

Take care,
Carrie :)

word verif: weekcpvc Not really relevant, just a more interesting-appearing one than usual!

Anonymous said...

Sarebear: maybe I'll get green mouse brains as gifts for my co-bloggers. Oops, now it's not a surprise.

Rach: no poll on what side effects people will put up with-- I'm not sure I'd get much out of that and I try to get people on a regimen with maximum efficacy and minimum (or ideally no) side effects. And side effects are relative-- If you gain 50 pounds and have No positive response, well that totally bites. But if you've been miserable for years, a medicine works miracles, but your baseline weight goes up 5 pounds, maybe it's a fair trade. One patient I had was thrilled to gain 20 pains (we stopped the med because of amenorrhea).
I think I hate the side effect issue because people worry about what MIGHT be and resist trying something that might help because they MIGHT get X effect.
Once a patient Does have a side effect, I'm mostly left to say that it's their decision if they want to stop or change the med-- I'm not the one who's felt the benefit of the med, I'm not the one suffering from the side effect. If they went from horribly sick to wonderfully well, I might encourage them to put up with it, but ultimately...

I may do some more med polls and then switch to another topic. Anything to keep me off the streets and out of trouble.

Nutty: Liver function is generally monitored on valproate. These are often done with any routine blood draw. Sometimes levels are monitored, but not always as they are mostly standardized for seizure control-- if the patient is well and not having side effects, the "level" whatever it is, is right.

LadyAK47: you have such a sweet voice!

Anonymous said...

i've been on trileptal for several years and it's been one of the only mood stabilizers that has helped keep me from hypomania.

Anonymous said...

Here's my experience with mood stabilizers... and this is coming from someone who was misdiagnosed with bipolar (turns out ptsd fits much, much better and the standard treatment protocols much more effective).
Started on depakote... felt so very, very ill... lost my job, couldn't pay rent, nearly homeless on the street. Didn't stop taking it until my hair started falling out in clumps.
Moved to tegretol... increased libido somehow... and wacky out of control crying, hysterical moments... stopped that because I kept showing up in my shrinks office sobbing and unable to come up with any reason why.
Tried Lamictal (which was brand spanking new at that point... only available to me because my shrink was the head of the psych department at a major university)... actually felt ok with Lamictal... but this is all relative of course. Not terribly ill, not crying uncontrollably, didn't feel awful... not sure that it helped anything but didn't seem to hurt as much as the first two.
About 6 weeks after I started taking it I left the state and quit cold turkey. I'm way smarter now and wouldn't ever quit cold turkey... luckily enough no bad withdrawal.
I still feel a little burned by the whole experience, it wasn't the first diagnosis that had me caught in a cycle of one bad med after another.

NeoNurseChic said...


I totally agree with you on the side effect stuff!! I was trying to say that in terms of how much benefit one gets from the med determining how many side effects they are willing to put up with. On some of the headache support sites, someone goes to try a med and the copy and paste the side effect profile. One should note that half the meds used preventatively for headaches have a potential side effect of headache. People freak about side effects that very often have less than 1% of even occurring. Or the fact that not every person gets every side effect.

Personally, I know that if a med has nausea/vomiting/reflux/GI issues as a side effect, then I am very likely to get that as I have a lot of trouble with those issues. But even that didn't keep me off some meds - as some people know, I put up with quite a lot of vomiting last fall due to benefit I finally got from a med. (And then fortunately domperidone came into my life, and while my periods have completely stopped and have to be restarted every 3 months due to elevated prolactin levels, at least I'm not puking my brains out every day... I don't know if there are any long term detrimental consequences to not ovulating, but I cannot come off the domperidone at this point in time.)

Side effects are a very touchy issue. Everyone's tolerance of them varies, and I agree that benefit of the drug has a HUGE role. I would've even put up with the brain-fog stupidity that topamax gave me if it had actually helped! My psychiatrist explained to me last week that the reason he had been such an advocate of getting off meds before was because I was on a lot of meds, experiencing a lot of side effects, but the meds weren't having the desired beneficial effect that I was taking them for. I had thought he was antimedication - turns out he was antimedication when meds equal only side effects with no clear benefit. NOW I get it!

Anyway - I'm rambling....brain tired, stress overload this week...

Take care,
carrie :)

Rach said...

Dinah, your patient was thrilled to gain 20 pains or 20 pounds?

hmmmm... what drug was that, you say?

(jokes, jokes)... But yes, I see your point regarding the polls...

In med school, is there a "class" on side effects, or is it trial and error? Also... and maybe this is something all 3 of you can comment on... what kind of interactions do you have with pharmacists? I know that in my situation, my pdoc hates my pharmacist because the pharmacist is thorough and calls with clarifications, and the pharmacist hates the pdoc because the pdocs scrawl is nearly illegible. I find it difficult when my pdoc says "ask the pharmacist" and the pharmacist says "ask the pdoc"... round in circles, is what ends up being.

Midwife with a Knife said...

carrie: It's not class X (I think it's actually class D), but the FDA class ratings are kind of useless anyway. It's all about risk: benefit ratio. If someone needs drug Xyz to keep them safe/alive during pregnancy, we give it. That includes the nasty ones. We find the safest alternative. My philosophy is that even a perfectly healthy fetus does very poorly in a dead or dying mother. Certainly bipolar disorder can be a deadly illness. We recently had a woman brought into the trauma bay after she shot herself in the head. Both she and her fetus died. I don't know that she had bipolar disorder, but certainly any mood stabilizer (or any medication in general) would have been safer for that fetus than what happened. Women with untreated bipolar disorder are also at higher risk for postpartum psychosis which is also potentially deadly to mom and baby.

I had a friend who has a seizure disorder due to an aneurysm who did well on lamcital during her pregnancy.

There are some concerns about facial clefts from one of the lamictal registries and from some studies in experimental rodents, but it's not like valproate, carbamezepine, etc. don't have the concern of congenital anomalies. The risk with lithium is also real (although perhaps overplayed). I don't know that we have enough experience with Zyprexa and friends to exclude the possibility they could also be associated with anomalies. If a patient needs meds, as their obstetrician, I'd much rather have them on meds than have them be unsafe. In fact, I think that limiting their suffering is also a perfectly reasonable reason to treat with meds during pregnancy.

It is best if women plan their pregnancies and are on the lowest possible dose of the safest possible medication for the fetus. Also, if you find out you're pregnant at... say... 15 weeks, the critical period for major malformations for almost all meds is past, anyway, so there's really no benefit in d/c'ing meds at that point (with a few exceptions that are kind of beyond the scope of this discussion).

I'm certainly long-winded at 1am. I blame the prednisone. ;)

Midwife with a Knife said...

Oops! It's actually Class C. I looked it up. Like I said, the FDA class system is next to useless anyway. Class C basically means "we think it's safe".

Another note about anticonvulsants (whether they're used for mood stabilizers or anti-epileptic drugs) is that all woman on an anti-convulsant who are or might become pregnant should take folate. It's my folate-plug-of-the-day.

Now I'm going to try to go back to bed!

Midwife with a Knife said...

One more thing... Reprotox is actually my preferred pregnancy-drug reference of choice. Much more helpful than the class system.

Now.. .really... back to bed!

NeoNurseChic said...

Ah I stand corrected. I'm thinking of something else that is category X then, because something I took was... I agree with you that it's healthier to mom and baby to be treated - I've always felt that way. I know I'm going to have to be on some medications when pregnant (though the methotrexate DEFINITELY has to go! haha), but I hope to limit them as much as possible. I know that I always have to plan - no surprises for me!

Working in the NICU, we see all the effects of treatment with various things - both good and bad outcomes. As I said above, one mom had to take lamictal - only thing that would work for her, and she had perfectly normal kids. Always nice to see such things. :)

Take care,
Carrie :)

Anonymous said...

To all the people who are concerned about meds and pregnancy and/or breastfeeding, consider the side effects of having children. If you think you have troubles now....and I had to laugh when I read the aside about someone having perfectly normal children. That is an oxymoron. It is perfectly normal for kids to be so many things, but perfectly normal is not one of those things.
Anyway, among the many side effects that you may experience: weight gain, skin changes, nausea, oh yeah the nausea, insomnia, travelling aches and pains, fatigue, memory loss, transient hair loss, mood swings and so many more. Those are just the ones before the birth. After the kids are a little older, watch what you eat--finishing their macaroni and cheese is a bad idea. You will lose sleep for the rest of your life--sick kids, bad dreams, theirs and yours, a spider in the bathroom sink, broken curfew. Oh, you will also suffer from periodic disorders of the vocal chords. ;)

Parent Not Otherwise Specified

Anonymous said...

I think a lot of side effects are placebo effects, honestly. A lot of people don't like to take meds (esp. psych meds) and then they come up with these stories about how they have teeerrriblle side effects to everything. Paradoxical, extreme side effects. Seems unlikely that so many people have extreme, undocumented side effects.

As was said, it's a pro/con thing, and if a medication really helps you, who cares about side effects? I take lithium and have only minor side effects, but if they were worse, who cares? Would I rather be thirsty/shaky/nauseous or crazy and destroying my life? I'll take thirsty/shaky/nauseous, thanks.

NeoNurseChic said...


Lucky for you then that you haven't had bad side effects! You touch on an important point that the benefits must be weighed against the side effects, but I disagree that side effects are placebo. Maybe some people connect unrelated things with side effects from a drug or overmagnify the side effects - I've seen that before. But the extrapyramidal and other extreme side effects of many psychotropic drugs DO in fact, exist. And while a bit of nausea may be tolerable to you - imagine waking every morning and throwing up, losing 15 lbs in a couple weeks time (when you're already thin), and being malnourished, exhausted, dehydrated, and looking anorexic. Nausea in small volumes is not such a bad thing - especially if it wears off after one has been on the med for a bit, or if it can be treated with antinausea meds like compazine or reglan or zofran. However, I personally experienced nausea like what I just described, and while it has finally been controlled by motilium, I was completely wiped out before we found something to stop it. So for some, it can definitely reach levels of intolerable. Now, the benefit of the med I was taking was such that I was more interested in finding something to keep the side effect at bay than stopping the med altogether. However, even my doctor was saying that if I didn't stop losing weight, I'd have to come off the med, like it or not.

It's all about degree of severity plus weight of side effects versus benefit of the drug. I wouldn't have been any good if the pain in my head had been controlled if I was unable to hold any food down...

Take care,
Carrie :)

NeoNurseChic said...


I made the comment about perfectly normal children. And I stand by that. They are infants - and I saw them when they were babies, in the hospital. At that point, they were perfectly normal. I'm not referring to all the things a person can become, and the fact that there really are no "normals" when it comes to human beings. But as infants who had just popped out, her children were perfectly normal.

I'm someone who believes the benefits of parenthood far outweigh the risks... :)

Take care,
Carrie :)

Gerbil said...

When I was still on psychiatric meds, I used to worry that I'd have to go to the hospital for 9 months if I got pregnant--as nothing I was taking was particularly safe during pregnancy.

Now, I'm on a slew of things for allergies and asthma. Before I got pregnant, I discussed the risks and benefits of my various medications (now all for allergies and/or asthma) with my allergist. She decided that the lack of data on Allegra outweighed the fact that it works much better for me than Zyrtec, which is safe in pregnancy.

Zyrtec doesn't do a whole lot for my allergies, but at least (a) it's better than nothing and (b) the baby is happily squirming around quite well in there!

Anonymous said...
This comment has been removed by a blog administrator.
NeoNurseChic said...

Ooooh Gerbil!! Congrats!!! :)

Gerbil said...

Thanks! :D

Anonymous said...

Hey Carrie -
Absolutely, extreme side effects do exist, I didn't mean that they never do. But the 2 scenarios you mentioned -- people connecting unrelated things to the drug, and people magnifying minor effects -- are rampant. And when those things happen with someone who has negative feelings about taking the drug in the first place, you get a lot of situations where people say they are "severely allergic" to drug x (then describe something totally un-allergy-like) or "absolutely can't take it" or got extremely sick from it (then describe what sounds like the flu), etc. Overall it's a quality of life issue, and if someone feels that their quality of life is worse ON the drug then OFF (for whatever reason) then they shouldn't take it. Situations like you describe, which sounds like a life-threatening side effect, are a whole different category.

NeoNurseChic said...


Thanks for the response - I see what you are saying. It's a big pet peeve of mine when people say they are "allergic" to a med, but what they really mean is that the med gave them side effects they couldn't tolerate. I truly am anaphylactically allergic to 3 different meds, but I have another short list of 1 med and 1 category of drugs that give me very severe side effects that would qualify as adverse reactions. I'm not allergic to my short list there - but I cannot receive them. There is a CLEAR difference. Allergy means anaphylaxis. And it drives me nuts when people say they are allergic when they really aren't. I carry an Epi pen because my internal medicine doctor feels my allergies are to such random things (one of the drugs I'm allergic to is benadryl - truly allergic, not just bizarre side effects!) and sometimes I'm fine and then the next second my throat closes and I can't breathe or talk - so she wanted me to carry the pen with me. That's an allergy.

So I do hear ya. I also can't stand when people print off lists of side effects and then refuse to take a med because of all the potential (even rare) side effects. My personal advice is what's the harm in trying? If you get a side effect you can't tolerate, you can always come off. I've always carried that philosophy, although I've had a few "side effects" cause some permanent damage, such as the avascular necrosis I got from steroids and the triggering of my ADD from topamax. But I still personally feel that when I'm faced with a new med, even one with a really long list of side effects (hell I'm on methotrexate - the list of side effects doesn't get much worse than this), it's still worth it to me to try it out - then come off if the side effects are intolerable.

So I guess we're pretty much on the same page afterall! Thanks again for the response. I'm glad you don't get side effects from lithium!

Take care,
Carrie :)

NeoNurseChic said...

I should correct what I wrote. Allergy doesn't necessarily mean anaphylaxis - but it still has to do with an inflammatory response..... It doesn't necessarily go all the way to anaphylaxis every time, but it includes things like hives, tongue swelling, difficulty breathing, and so on.

Don't rake me over the coals for that one, anybody! :)

Anonymous said...


It was a joke--about the children. Mine are wonderful (when they are not having teen moments); they were worth all the side effects but parenthood changes your life. Also, the state of not being perfectly is perfectly normal.


jcat said...

I'm with Carrie on this one...if the way you are feeling is bad enough to justify almost any of the psych drugs, you'll try them. And if the actual side-effects are bad - but stop me from being a suicidal, tearful, demotivated, anti-social, total waste of space - heck. I'd take them. If only...

Aqua said...

I'm with Jcat on this one..."If only"...if only SOMETHING, anything, would work.

Anonymous said...

The benefits need to out-weigh the side effects, potential or otherwise. For me, you need to start with the least potentially damaging stuff first, then work your way up. I will definitely refuse something that has liver damage and significant weight gain as side effects if I think there might be other equally effective options out there with fewer side effects that we can try first. If we try those and they fail, then we'll have to try the ones with more side effects I guess. That's just the way it is. But the goal is to do as little harm as possible while getting the maximum benefit. Sometimes it just doesn't make sense to get out the butcher knife when a scalpel will do.

Dr. Pink Freud said...

Tegretol is a nasty, cannabalistic drug. It chews up other nice drugs that happen to use the CYP450 pathway. Inevitably, the dose of the nice drugs, as well as the nasty Tegretol has to be increased. Bad, bad Tegretol!

Anonymous said...

Thoughts About Bipolar Disorder

Bipolar Disorder (manic-depressive illness), if a disorder at all, has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and inflated elation- with the depressive episodes occurring more frequently. The disorder affects one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar disorder, yet the etiology remains entirely unknown. It is also believed that bipolar disorder presents itself when the affected one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980. Also, bipolar disorder is thought to be correlated with creativity and accelerated growth of neurons if one is affected by it.
Research has determined that as many as 15 to over 30 percent of bipolar disorder patients commit suicide if they are untreated. Also, as many as half of those affected with bipolar disorder also have at times severe substance abuse issues along with this disorder as well. Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as such. The disorder varies as far as severity goes- with some bipolar disorder patients being more affected than others. In fact, there are at least 6 classifications of bipolar disorder, according to the DSM. Bipolar patients are thought to be symptomatic half of their lives- with depressive episodes occurring more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some. As many as half of those suspected as having a bipolar disorder are thought to have at least one parent with some sort of mood disorder, which suggests a genetic predisposition to the disorder.
The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar disorder rose from being about 25 per 100 thousand people to being 1000 per 100,000 people. Most diagnosed with bipolar disorder are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which includes as many as 12 million people in the United States. A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar disorder. Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar disorder.
While not recommended, one half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years. Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar disorder- with a greater amount of research behind this class of drugs. Yet, entirely recognized treatments for bipolar disorder long term are lithium or lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
Atypical anti-psychotics have been prescribed for bipolar disorder, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well. As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar disorder who are pregnant, however.
Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago. Lithium is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar disorder,

Dan Abshear

Anonymous said...

As a person with bipolar, I was put on valproic acid and (at first) risperdal for the psychosis during mania. (I should say that the choice of meds was probably influenced by that available and commonly used in Canada at the time).The risperdal did not work (even at high doses it only reduced not elimated the voices), so I was put on olanzapine which did eliminate the voices. Unfortunately, it also increased my appetite and I gained 40 pounds in a month. Since then I was weaned off the olanzapine, with no recurrence of psychosis and slowly got my weight under control--although not back to my prior weight, I don't look bloated or eat abnormally now. I continue to have issues with anxiety and low mood sometimes. My mood is much better since I started on Effexor though. I continue to lead a largely solitary life and I don't work--my insurance company is helping me to retrain and I hope to start back at college in September. My brother and mother say I have less "spark" since I was hospitalized, I would say my personality has changed with having to deal with this and learning more about it, grieving the losses of having this diagnosis, and having my impulsiveness controlled more (I never was very impulsive--I would mainly blurt out stuff, now that I don't do that anymore my speech is more thoughtful, controlled and perhaps boring.) I hope this helps someone out there.

NotNormal said...

Old post, I know. I am a bipolar person who is, like many other bipolar folks, an OCD person as well. I prefer lamictal because I believe that it is not doing me harm whether this is indeed true or not.

I do worry about having to take some other mood stabilizer at some point. Really worry. Like really, really worry. You might call it an obsession. Even though I know that it's kinda silly, it's not really silly at all.

Not how a normal person would look at it of course but......

BG said...

I love Lamictal, and I'm not averse to taking lithium. In fact, I asked a doctor who kept upping my anti-depressant to prescribe some kind of mood stabilizer, and she went with lithium. First 300mg, then 600, but when I didn't have health insurance I was scared of needing blood tests.

(Blah, blah, I don't have strong bipolar 2 symptoms but I do get very restless and energetic in an unpleasant way in the spring, but I knew that there was something other than depression going on.

I'd ask my doctor to discuss whether I should take it if I ever want to get pregnant. Lamictal has been great for me, because I think my thinking is clearer, and I have less mood lability, but my mom has a psychotic spectrum illness with a mood component and weird sleep problems, so I may be a messy case.

[For my anxiety issues, propranalol has been the best drug I've ever taken.]

Hotbrain said...

Old post, but I see it is still getting comments, so I'll contribute.

I have Bipolar Disorder NOS (probably type II) and lithium is the best drug I've found for it. It makes me feel normal much of the time. I was taking lithium carbonate but now I'm on lithium orotate. I wish there was more research on lithium orotate, because I've found it to be just as effective as the carbonate, except that I don't get the tremor side effect that I had on the carbonate.

It's too bad that there is so much stigma about lithium.

LC said...

I am thinking of switching from lithium to lamictan. My shrink says its up to me. I've been on lithium for 8 years, mostly stable but feel if there is another drug that can give me the same or better cover with less side effects then maybe it will be worth it. Also I hear its better for depression, not as good for mania.

Anonymous said...


I just started Lithium for the second time in 2 years. The unfortunate thing is this. It works well in removing my obssesion to kill myself and it helps quiet my normally frenetic mind but at higher doses it seems to make me really agitated and restless. I also think I'm having an allergic reaction to it as after I take it my face and eyelids get swollen and my throat constricts a little bit. Now I know it's rare for people to have allergic reactions to lithium but I am one of those people. The thing I'm struggling to decide is if I continue it at the dose I'm on or discontinue it and try to live with my bipolar without meds. I say without meds as I have tried everything there is to try and my body can't tolerate anything. My liver processes things very slowly which leads to a build up of whatever I ingest. Whether it's a medicine, sugar, or caffeine I will suffer the side effects.
I'm very scared that I'm going to live a life of continual ups and downs that come with my manic episodes. I don't mean to sound like I'm whining but I'm very scared. My illness, when not treated, has led me to do things that have destroyed my life completely and thoroughly. Finally I find a medicine that brings my mind peace but yet again my body can't tolerate it. I'm on 60mg's twice a day. That just shows you how intolerant my body is to medicine. Most people can take 900 mg with only mild lithium side effects. When I was taking 120 mg's twice a day I could only sleep for four hours a day, would be very angry and couldn't stop myself from being tempted to hang myself in the garage.
I guess my hopes in posting this is not so much looking for advice on which med to take but if anyone with bipolar can relate to this feeling of absolute hopelessness that their illness will ever be stabilized when faced with the fact that your body can't tolerate any medicine. I feel like a diabetic who is resistant to insulin.
Thank you all