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Bipolar Disorder Information > Bipolar Disorder FAQ

BIPOLAR DISORDER FAQ 1.1 - FILE 3 OF 4
Continued from Part 2...
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4.4 What medications are commonly used in treatment?
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First, we'll lead off this section with an excellent introduction, written
by Joy Ikelman with additions by Dr. Ivan Goldberg.

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Ten Little Things I Have Learned About Drug Therapy

(1) We believe what we want to believe (about this topic or any topic).

(2) We bipolars know how it feels to be on these drugs--despite what the docs
might say about how we "should" feel. Side effects are often more complex and
difficult than the drug companies/PDR say they are.

(3) We bipolars know that the cycles sometimes break through despite the best
of drug therapies--even though docs say we "should" be completely stable on
this stuff. A lot of the time we just keep quiet when these breakthrough
episodes happen or else the doc might raise our dose or hospitalize us. (See
Item 2.)

(4) We all hope to be the lucky ones in this crap shoot of drug therapy.
Initially, we are optimistic. Maybe if we get just the right combination of
drugs, just the right dosage, just the right psychopharmacologist, just the
right attitude....something, something might just work....

(5) There are some combinations which work better than others. These should be
tried first.

(6) However, there is no magic formula which works perfectly for everyone.
It's mostly hit and miss. So, if something works, stick with it.

(7) And, after we find the right combo it may work wonderfully well for 30+
years, or sometimes after a few years it doesn't work any more and the search
resumes for another combo that will work. We hope that by then something new
and very effective will be available.

(8) Manic depression does not have a "cure." The mood stabilizing drugs are a
way to cope with the illness. Take the accustomed drugs away and for most
folks, the cycles come back full force, sometimes worse.

(9) We all have different ideas of what we will settle for, as a result of
drug therapy. Some will settle for nothing less than the elimination of all
cycling. Some will settle for a little cycling and learn to cope with it in
different ways. Some will settle for quite a bit of cycling, as long as the
manias aren't too high or the depressions too low.

(10) Drug therapy is a choice. The most important thing is stay alive and
possibly make some contribution to the few people you interact with in your
lifetime. Whatever it takes to stay alive (drugs or not), do it.


******************************************************************************


Now, on to a more general discussion of the meds.
Thanks to Millie Nissfor researching and writing the following
information:

There are three types of medications commonly used in treating Bipolar
Disorder:

-- mood stabilizers

-- antidepressants, and

-- antipsychotics.

Other medications may be given to help you sleep or to treat anxiety
and/or panic attacks if you have them.

Because many people need a combination of two or three drugs to get
stable, it can take quite some time to find the right medications
(and the right dosages of each.) This is usually on the order of magnitude of
weeks or months... but it's been known to take *years* to find the exact
combination and dosages that work.

If the first medication you get does not help, it *does not mean* you
are untreatable! Work with your doctor and make sure that he or she
is listening to you, and don't give up!

Some drugs can potentially cause relatively severe side-effects.
Don't hesitate to complain to your doctor and insist on lowering dosages
or trying a new drug if the side-effects are intolerable.

In particular, mood stabilizers and antipsychotics in high doses can make
you very tired and slowed down and "zombie-like."

Don't accept this as a "necessary" condition of getting well!

Sometimes, as with any drug, you will have to choose between total
elimination of symptoms and a tolerable level of side-effects; the
key thing is to *communicate* with your doctor about what you're
experiencing, and make sure that you know all your options.

(That being said, many people do quite well on lithium, or lithium plus
an antidepressant.)

We're listing potential side-effects below, as we discuss each drug.
Our objective here is not to frighten, but to inform and share experiences.
Everyone is different; some people will take these meds and experience
no side effects; some people will experience side effects that aren't
listed here.

*Communicate* with your doctor, your pharmacist, and the other members
of your health-care team about what's going on with you and your meds.


Mood Stabilizers
----------------

Mood stabilizers are the primary treatment for most people. They are
supposed to level your moods, so that you neither get too low
(depressed) or too high (manic). In practice, they work much better
at treating mania than depression, and may have a mood-dampening
effect, so that you get more depressed on a mood stabilizer than you
were before. For this reason, some people are now calling these drugs
"antimanics."

Mood stabilizers take a week or two to get a therapeutic blood level
and then it may take a few more weeks to get the full effect of the
drug. In acute situations, another drug may be needed while you wait
for the mood stabilizer to take effect.

The most common mood stabilizers are:

Lithium (Eskalith, Lithane, Lithobid, Lithonate, Lithotabs)
-----------------------------------------------------------

This is the oldest and most common mood
stabilizer and is usually the first drug you will get
when diagnosed with bipolar disorder. It tends to be
fairly easy to tolerate for most people, and stabilizes
50-60% of patients all by itself.

Common side-effects are: lethargy, diarrhea, nausea,
frequent urination, tremor, weight gain.

Symptoms of lithium toxicity are: intense versions of
the above, twitching, shaking, dizziness, loss of balance,
thirstiness, blurred vision, confusion, convulsions.

Note: if you cannot tolerate the side-effects of regular
lithium, you may want to try a time-released form of it,
such as Lithobid.

It is very important to get frequent blood tests when
first starting lithium because the therapeutic blood
level is quite close to the toxic level. After dosage
is established, blood tests can be every six months.
It is also a good idea to check liver and thyroid function
because these can be damaged by long-term lithium use.

The other mood stabilizers are anticonvulsants, used primarily to
treat epilepsy but also effective in the treatment of Bipolar Disorder:

Valproic Acid (Depakote, Depakene, Epival)
------------------------------------------

Side effects are similar to lithium, long term toxicity may
be less severe. Some people find that Depakote gives them
depression, or intensifies existent depression. It can also
cause sexual dysfunctions (anorgasmia, premature ejaculation,
retrograde ejaculation, reduction of libido) in both men
and women.

Carbamazepine (Tegretol)
------------------------

Tegretol is another anti-convulsant.

Side effects of Tegretol are generally more severe than for
lithium or Depakote, but some patients who cannot tolerate
lithium do fine on Tegretol. Tegretol is also especially
effective for rapid cyclers.

Side effects: nausea, dizziness, confusion, cognitive slowing,
loss of coordination, tremor, sores in mouth & gums,
*reduction in effectiveness of birth control pills.*

Other anticonvulsants are now being used as mood stabilizers
experimentally. Also, Klonopin (an anti-anxiety drug which is also an
anti-convulsant) may be used as a mood stabilizer.

Some people with mood swings who don't actually get fully manic may
get stabilized on an antidepressant alone. (See WARNING below,
however.)


Antidepressants
---------------

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WARNING: USING ANTIDEPRESSANTS ALONE TO TREAT BIPOLAR DISORDER CAN INVOLVE
SUBSTANTIAL RISK OF INDUCING HYPOMANIA OR MANIA.
--------------------------------------------------------------------------

Antidepressants (ADs) are part of most people's treatment if their
disease includes severe depression. However, they must be used cautiously by
bipolars. Although ADs normally do not cause folks to get high even when
taken in larger doses than needed, for a significant number of bipolars ADs
can cause mania or hypomania and/or may trigger rapid cycling. This is most
frequently reported with the older tricyclic ADs (like nortriptylene) and
apparently least likely to occur with the AD Wellbutrin. Usually these
undesirable effects can be avoided by using an "AD + mood stabilizer" combo,
but even this does not eliminate the risk entirely. Any bipolar starting on
an antidepressant should monitor their moods carefully and stay in close
contact with their physician until it is clear that these effects do not
appear or appear only to a degree that is acceptable.

Antidepressants can take a really long time to work--six weeks or more--
and then it may take a while to find the AD which works for you, so
the hardest part about ADs is often the waiting!

Antidepressants come in several flavors:

SSRIs
-----

"SSRI" means Selective Serotonin Reuptake Inhibitor.

These are the newest class of ADs and tend to be the first
drugs used these days, although there is no evidence that they
work better than tricyclics or MAOIs.

The SSRIs are: Prozac, Paxil, Zoloft, Luvox, Effexor (partly)

Side effects are: dry mouth, tremor, nausea, insomnia,
drowsiness, anxiety, hypomania, sexual dysfunction.

The SSRIs can cause rather extreme side-effects if they make
you manic (or induce rapid cycling), but they are not very
toxic so they are safest to use with a suicidal patient.

Tricyclics
----------

Common tricyclics include: Norpramin (desipramine),
amitriptylene, nortriptylene, Sinequan, Elavil, Anafranil,
Doxepin.

The side-effects are the same as for SSRIs--supposedly more
severe, but your mileage may vary.

The tricyclics are generally more sedating than the SSRIs,
and are often used as sleeping pills. They also tend to
cause weight gain.

Tricyclics are quite toxic in overdose, and there is a danger
of accidental overdose, especially when used as a sleeping
pill "as needed."

MAOIs
-----

"MAOI" = "Monoamine Oxidase Inhibitor."

Common MAOIs are: Nardil (phenelezine) and Parnate.

Side effects: Same as above, weight gain.

MAOIs are safer for your heart than tricyclics, so they are
safer to use with elderly patients or patients with heart problems.

MAOIs may be effective in patients who don't respond to SSRIs
or tricyclics. They are thought to be especially helpful
for people who are very tired and numb when depressed and
who can be cheered up/made more active by outside stimulation.

They may also be more effective with "atypical
depression," (more depressed late in the day rather than early,
weight gain rather than weight loss, too much sleep rather than too
little, etc.).

The main problem with MAOIs is that they interact dangerously
with foods containing tyramine (an amino acid). The
combination can lead to acute hypertension (high blood
pressure). This can be very dangerous and cause stroke,
heart attack, or death, though such a severe reaction is rare.
Symptoms of a hypertensive attack are severe headache in the back
of the head, nausea, weakness, sudden collapse.

A partial list of foods to be avoided is: cheese, yogurt, soy
sauce, avocado, ripe bananas or figs, smoked salmon, cured
ham, salami, pickled herring, broad beans.

Caffeine and chocolate should be used with caution.

There are also interactions with many drugs, and you should
not take any medication (including over-the-counter drugs)
without asking your doctor or pharmacist. Drugs to avoid
include: antihistamines, decongestants, any cold remedy,
codeine, amphetamines, Demerol and other narcotic pain
relievers, some forms of general anesthesia.

Because of these interactions with food and drugs, you should
get a Medic Alert bracelet if you are on an MAOI.

Other ADs
---------

Some other antidepressants include:

Wellbutrin
----------

Thought not to cause mania as much, but can make
people quite hyper and nervous. Side effects are as for the
others, with the addition of a significant risk of seizures
in extreme doses.

Serzone
-------

Desyrel (trazodone): used mainly as a sleeping pill as it is
not a very effective AD.

Antipsychotics
--------------

Also called "neuroleptics" or "major tranquilizers," these drugs have
several uses in bipolar patients. One main use is to calm people down
in acute mania, while waiting for a mood stabilizer to work. These
drugs are also used (in low doses) as sleeping pills or to combat
anxiety, and in higher doses for psychotic symptoms such as
hallucinations, delusions, etc. They are also used in combination
with a mood stabilizer as part of the maintenance medications used to
prevent further episodes.

The major antipsychotics are: Thorazine (chlorpromazine) , Mellaril
(thioridazine), Stelazine, Haldol (haloperidol), Risperdal
(risperidone), Clozaril (clopazine), Trilafon (perphenezine)

Side effects are similar for all of these although some drugs
(Mellaril, Thorazine) are relatively mild in their side-effects while
others (Haldol) have severe side-effects for many people.

The main side effects are: sleepiness, slowed speech and thinking,
difficulty walking or with balance, restlessness, twitching,
involuntary movements, confusion, stiffness

If the twitching/involuntary movement/stiffness becomes severe, this
can sometimes be relieved with an antiparkinsonian drug such as Cogentin.

The major risk with these drugs is a condition called tardive
dyskinesia--where the twitching or stiffness remains after the
drug is discontinued. It is quite rare at low doses and when the
drugs are not used for very long.


Other medications
-----------------

1) benzodiazepines or "minor tranquilizers"

These drugs are used to treat anxiety and panic attacks,
or as sleeping pills.

Common benzos are: Valium (diazepam), Ativan (lorazepam),
ProSom (estazolam), Restoril (temazepam), Klonopin (clonazepam).

Side-effects are drowsiness and nausea (rare)

The main problem with these drugs is that they can be
habit-forming, and people develop rapid tolerance (meaning
they need higher and higher doses to get the same effect).
It can also be difficult to get off a benzodiazepine because
of withdrawal effects. Some doctors won't use these drugs
for this reason, but most people will have no problem if
the use is short-term.

Benzos are much more gentle as sleeping pills than the major
tranquilizers.


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4.10 Resource Organizations
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The Depressive and Related Affective Disorders Association; Johns Hopkins
Hospital, 600 North Wolfe Street, Baltimore, MD, 21205.

National Alliance for the Mentally Ill: 200 N. Glebe Road; Suite 1015;
Arlington, VA 2203-3754. Phone: 703-524-7600.

National Depressive and Manic Depressive Association: 730 N. Franklin,
Chicago, IL 60610. Phone: 1-800-82N-DMDA.

National Institute of Mental Health: has free brochures and information.
Call 1-800-647-2642. Their Panic Disorder Education Program is
at: Room 7C-02, 5600 Fishers Lane, Rockville, MD 20857.


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5.0 How do I help a friend or loved one?
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Bipolar Disorder doesn't just affect the person who's diagnosed with it,
unfortunately. In this section, we talk about some things that friends,
family members, and loved ones can do to cope and help when someone they care
about is diagnosed.


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5.1 What to do (and what not to do) when someone you care
about is diagnosed
----------------------------------------------------------


Twelve things to do if your loved one has depression, manic-depression,
or some other mood disorder:

1. Don't regard this as a family disgrace or a subject of shame.
Mood disorders are biochemical in nature, just like diabetes, and
are just as treatable.

2. Don't nag, preach or lecture to the person. Chances are
he/she has already told him or herself everything you can
tell them. He/she will take just so much and shut out the rest.
You may only increase their feeling of isolation or force one
to make promises that cannot possibly be kept. (I promise I'll
feel better tomorrow honey; I'll do it then, okay?)

3. Guard against the "holier-than-thou" or martyr-like attitude.
It is possible to create this impression without saying a word.
A person suffering from a mood disorder has an emotional
sensitivity such that he/she judges other people's attitudes
toward him/her more by actions, even small ones, than by spoken
words.

4. Don't use the "if you loved me" appeal. Since persons with mood
disorders are not in control of their affliction, this approach
only increases guilt. It is like saying, "If you loved me, you
would not have diabetes."

5. Avoid any threats unless you think them through carefully and
definitely intend to carry them out. There may be times, of
course, when a specific action is necessary to protect children.
Idle threats only make the person feel you don't mean what you say.

6. If the person uses drugs and/or alcohol, don't take it away from
them or try to hide it. Usually this only pushes the person into
a state of desperation and/or depression. In the end he/she will
simply find news ways of getting more drugs or alcohol if he/she
wants them badly enough. This is not the time or place for a
power struggle.

7. On the other hand, if excessive use of drugs and/or alcohol is
really a problem, don't let the person persuade you to use drugs
or drink with him/her on the grounds that it will make him/her
use less. It rarely does. Besides, when you condone the use of
drugs or alcohol, it is likely to cause the person to put off
seeking necessary help.

8. Don't be jealous of the method of recovery the person chooses.
The tendency is to think that love of home and family is enough
incentive to get well, and that outside therapy should not be
needed.

Frequently the motivation of regaining self respect is more
compelling for the person than resumption of family
responsibilities. You may feel left out when the person turns
to other people for mutual support. You wouldn't be jealous
of their doctor for treating them, would you?

9. Don't expect an immediate 100 percent recovery. In any
illness, there is a period of convalescence. There may be
relapses and times of tension and resentment.

10. Don't try to protect the person from situations which you believe
they might find stressful or depressing. One of the quickest ways
to push someone with a mood disorder away from you is to make them
feel like you want them to be dependent on you.

Each person must learn for themselves what works best for them,
especially in social situations. If, for example, you try to
"shush" people who ask questions about the disorder, treatment,
medications, etc., you will most likely stir up old feelings of
resentment and inadequacy. Let the person decide for THEMSELVES
whether to answer questions, or to gracefully say "I'd prefer to
discuss something else, and I really hope that doesn't offend you".

11. Don't do for the person that which he/she can do for him/herself.
You cannot take the medicine for him/her; you cannot feel his/her
feelings for him/her, and you can't solve his/her problems for
him/her; so don't try. Don't remove problems before the person
can face them, solve them or suffer the consequences.

12. Do offer love, support, and understanding in the recovery,
regardless of the method chosen. For example, some people
choose to take meds; some choose not to. Each has advantages
and disadvantages (more side-effects versus greater possibility of
relapse, for example). Expressing disapproval of the method
chosen will only deepen the person's feeling that anything
they do will be wrong.


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5.2 What to do (and what not to do) if you suspect that
someone you care about needs help, but resists
seeking it for themselves.
--------------------------------------------------------

First, re-read section 5.1. Now, re-read it again. :-)

Okay. Now that you're back with us...

One of the most frightening and frustrating aspects of this illness, for
friends, family, and loved ones, is that many bipolar people resist seeking
help.

When you're depressed, you may not believe that help is possible...
so why bother?

When you're hypomanic or manic, you may well be irritated or offended when
someone suggests that you need help. If the mania is euphoric in nature,
then you don't WANT help... at least initially, it feels GREAT (though it's
hell for the people around you.)

Some bipolar people refuse to seek help for their entire lives. Others resist
at first, but ultimately acknowledge that they cannot control this illness all
by themselves.

This happens for a variety of reasons--fear, mistrust, denial--but here's what
it boils down to:

If someone doesn't want treatment, there are only very limited circumstances in
which it can be forced upon them.

In most places in the civilized world, unless the person with bipolar disorder
presents an imminent danger to his or her own health and safety, or to the
lives of others, THEY CANNOT BE FORCED INTO TREATMENT.

This is bitter medicine to take when you love someone and are watching them
seemingly self-destruct. The hard truth is, you can't live someone else's life
for them, as much as you might want to... and as much as you might think that
what you're doing, you're doing for their own good.

Another, related issue--what if the person that you're concerned about is
seeking a form of help that you fear won't be useful?

The vast majority of bipolar people who decide to pursue treatment utilize
traditional, allopathic medicine and/or conventional psychotherapy as treatment
resources; the outcomes in these cases are generally much more positive than if
the illness is left untreated.

However, this is by no means a universal truth.

Some bipolar people pursue alternative therapies and treatments--either after
medical treatment has seemingly failed, or due to a general mistrust of doctors
and drugs. These therapies may range from outright quackery (Reichian "orgone
boxes" and similar silliness) to therapies for which some interesting and
promising anecdotal evidence exists (such as orthomolecular/nutritional
therapy) but no studies conclusively proving efficacy have been published and
reviewed. The outcomes in these cases vary widely... but if you *believe* that
something will help you, often it does; the mind is funny that way. :-)

Some bipolar people pursue spirituality as part of their treatment/coping
regiment; others eschew it entirely.

Again: as loopy as some of this stuff might sound, you can't live someone
else's life... and the fact that the bipolar person is taking some
responsibility for his or her own care is a very promising sign.

A final note: If you're a friend, family member, or loved one of a person with
bipolar disorder, you need to remember to look out for yourself. As much as
you might love the person, don't let yourself become a financial or emotional
victim. There are family support groups and other resources available to you:
take advantage of them, and network with people who are in similar situations.

See "Resource Organizations" for groups that meet in your area.

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6.0 Resources for education and support
-----------------------------------------------------------------------------

This section details Internet, print, and other resources available to
people with Bipolar Disorder and their friends and family.


-----------------------
6.1 Internet Resources
-----------------------

see: Bipolar Disorder Focus at www.moodswing.org

BIPOLAR DISORDER FAQ 1.1 - FILE 3 OF 4

Continued in Part 4...

Part 1 - Part 2 - Part 3 - Part 4

 

 


 

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