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Understanding Bipolar Disorder - Mood stabilizers and other medications

Mood stabilizers

Mood stabilizers are medications that are effective in treating mania and depression and prevent the occurrence of new episodes during maintenance treatment. The main mood stabilizers are lithium carbonate and certain anticonvulsants.

Lithium carbonate

Lithium carbonate is a simple salt which was discovered to be effective in treating manic depressive illness in 1949. It became widely used in the 1960s and has been in use in the United States since 1970. It is rapidly eliminated from the body through the kidneys and so it needs to be taken at least twice a day to maintain an adequate blood level, unless you take it in a slow-release form, like Eskalith CR, when it can be taken once a day. Lithium can upset the digestion unless it is taken with food, so many people take the slow-release preparation once a day with their dinner.

The correct therapeutic blood level is known with some accuracy. Doctors aim to maintain the blood level between 0.6 and 1.2 milliequivalents per liter. Your blood level of the medication may need to be checked a few times and the dose adjusted until it is at the correct level. After that, the blood level does not usually vary much and blood tests do not need to be checked very often.

Lithium works well in treating about 60-70% of people suffering from bipolar disorder. In those cases where it is ineffective, one of the anticonvulsants will often be effective, alone or in combination with lithium. Lithium is most effective in treating and preventing episodes of mania, but it can often be effective in treating depression also.

Some people get side effects from taking lithium. Some of the more common ones are:

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hand tremor

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stomach upset

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acne

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fluid retention with swollen ankles

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metallic taste in the mouth.

Lithium can also, at times, lead to suppression of the thyroid gland and, over the course of decades, a very gradual decrease in kidney function. For this reason, every 6 -12 months, your doctor will want to check some simple blood tests to assess your thyroid gland and kidney function. Thirst and increased frequency of urination can also be a problem which you should report to your doctor.

Lithium toxicity

If the blood level of lithium gets too high you can develop lithium toxicity. The signs and symptoms of lithium toxicity are severe sedation, unsteadiness, poor coordination, diarrhea and stomach upset, slurred speech, hand tremor, confusion and disorientation. Lithium toxicity is dangerous, so your doctor will want to order a lithium blood level test every few months to check that the lithium level is remaining in the proper therapeutic range.

A few things can push up your lithium level and put you at risk of lithium toxicity:

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dehydration

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taking frequent doses of ibuprofen (in Advil and other over-the-counter medications)

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being prescribed certain diuretics and blood pressure lowering medication.

Let your family doctor know that you are taking lithium and let your psychiatrist know when another doctor starts you on a new medication. Avoid taking over-the-counter ibuprofen-containing drugs like Advil for extended periods. Try not to get dehydrated if you are taking lithium (but donít drink excessive amounts of fluid either).

Anticonvulsants

Several anticonvulsant medications are effective in treating and preventing the different phases of bipolar disorder, though they are usually more effective in mania than in the depressed phase. They were first introduced into the treatment of bipolar disorder in the 1970s as an answer to rapid cycling Ė a form of bipolar disorder in which the person with the illness experiences several cycles a year from mania into depression and back. The anticonvulsants are still the treatment of choice for rapid cycling, but they can also be very effective when the course of illness is not disturbed in this way. The most common and effective anticonvulsants are valproate or valproic acid (brand name Depakote), carbamazepine (brand name Tegretol) and oxcarbazepine (brand name Trileptal).

Another anticonvulsant is sometimes used, but should be reserved for a special purpose; the anticonvulsant is lamotrigine (brand name Lamictal) and its special value is in helping to lift people with bipolar disorder out of a treatment-resistant episode of depression. Given in too high a dose, however, it can provoke the appearance of manic symptoms. It can also, rarely, cause a serious, potentially fatal, skin condition known as Stevens-Johnson syndrome, so it must be prescribed with great care by doctors who are familiar with its use and the dose must be increased quite slowly. If you are taking Lamictal and you develop a painful rash you should let your doctor or treatment team know about it immediately.

Side effects of any of these anticonvulsants include sedation, stomach upset, tremor, headache, dizziness and unsteadiness. Weight gain is more common with Depakote. Tegretol carries a remote chance of a catastrophic drop in a personís white blood cell count, which is dangerous. Both Tegretol and Trileptal can lead to a drop in the amount of sodium in your blood, which can have negative consequences, and may mean that the medication has to be discontinued.

We know with some accuracy the blood level of the different anticonvulsants that is likely to be effective in treating bipolar disorder. A complication in the use of these medications, however, is that they are excreted through the liver, and your liver will get better and better at eliminating the drug from your body. This means that, as you are getting started on the medication, though you may have an adequate blood level this week, next week it may be too low. Your doctor will have to keep ordering blood tests for a few weeks and adjusting your dose of the medication, until the level finally reaches a plateau and remains steady.

Other medications

Antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa) and haloperidol (Haldol), may be necessary, especially during the acute phase of illness, if you are experiencing such psychotic symptoms as hallucinations or delusions. When the acute phase of illness is over, these antipsychotic medications may no longer be necessary and, at times, they can be reduced and discontinued. Indeed, sometimes, when the mood stabilizer has done its job and has dramatically reduced the symptoms of mania, the antipsychotic medications, which were previously necessary to control agitation and other symptoms, may lead to overwhelming sedation and slowing, and may have to be reduced at a fairly rapid rate.

Antidepressants such as fluoxetine (Prozac), paroxetine (Paxil) and citalopram (Celexa) should generally be avoided in the treatment of bipolar disorder. They may cause the person with the illness to switch into a manic state and they may also precipitate a period of rapid-cycling (several cycles of mania and depression a year). Occasionally, when a person is in a severe episode of depression and the previous episodes of mania have not been severe, it may be reasonable to use an antidepressant for a while, in combination with a mood stabilizer, to see if it can lift the person out of his or her depression. If it is successful, the antidepressant may then have to be discontinued before it leads to the patient into becoming more manic and psychotic.