Medications for Bipolar Disorder

Please note: In March, 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families, and caregivers of patients with depression to closely monitor both adults and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts, especially among children and adolescents at the beginning of treatment, or when there’s an increase or decrease in the dose. The medications of concern—mostly SSRIs (Selective Serotonin Re-uptake Inhibitors)—are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). Of these, only Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and Luvox (fluvoxamine) are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. For more information, please visit http://www.fda.gov/cder/drug/antidepressants .

Mood Stabilizers

Lithium stabilizes your mood and is often used as initial treatment for preventing manic and depressive episodes. It acts on the central nervous system and helps you to have more control over your emotions.

Do not drink large amounts of caffeinated beverages such as coffee, tea, and colas when you are taking lithium.

Possible side effects include:

• Frequent urination or loss of bladder control
• Increased thirst
• Nausea
• Shakiness of the hands

Anticonvulsants

• Valproate (Depakote)
• Carbamazepine (Tegretol)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)

Anticonvulsant medications, such as valproate (Depakote) or carbamazepine (Tegretol) can also have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was approved by the US Food and Drug Administration in 1995 for treatment of mania. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

Newer anticonvulsant medications, including lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax), are being studied to determine how well they work in stabilizing mood cycles.

Children and adolescents with bipolar disorder are generally treated with lithium, but valproate and carbamazepine are also used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormonal changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20.Young female patients taking valproate should be carefully monitored by their physician.

Possible side effects include:

• Stomach cramps
• Diarrhea
• Change in menstrual periods
• Nausea and vomiting
• Loss of appetite
• Indigestion
• Hair loss
• Weight loss or gain
• Trembling of arms, hands

Benzodiazepines

• Clonazepam (Klonopin)
• Lorazepam (Ativan)

A high-potency benzodiazepine medication such as clonazepam (Klonopin) or lorazepam (Ativan) may be helpful to promote better sleep and reduce agitation. However, since these medications may be habit-forming, they are best prescribed on a short-term basis.

Possible side effects include:

• Drowsiness
• Dizziness, particularly in elderly persons

Central Nervous System (CNS) Depressants

Zolpidem (Ambien) may be used to treat insomnia . You should take zolpidem just before going to bed since it works quickly. It may work faster if you take it on an empty stomach. You should not take it unless you can get at least 7-8 hours of sleep. If you must wake up before then, you may feel drowsy and experience memory problems because the medicine has not had time to wear off.

Selective Serotonin Reuptake Inhibitors (SSRIs)

*** see note above

• Citalopram (Celexa)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Escitalopram (Lexapro)

Selective Serotonin Reuptake Inhibitors (SSRIs) affect the concentration of the neurotransmitter serotonin, which plays a role in depression. They may occasionally be used in the treatment of bipolar disorder, in combination with other medications.

Possible side effects include:

• Nausea
• Diarrhea
• Insomnia
• Sexual dysfunction (ranging from decreased arousal, to erectile dysfunction, and/or delayed time to orgasm)

Atypical Antidepressants

Bupropion (Wellbutrin)

Atypical antidepressants affect the concentration of the neurotransmitter serotonin, which plays a role in depression. Bupropion is an atypical antidepressant that is sometimes used in the treatment of bipolar disorder, along with other medications.

Possible side effects include:

• Nausea
• Nervousness
• Diminished sex drive

Atypical Antipsychotics

• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Ziprasidone (Zeldox)

Atypical antipsychotic medications, including clozapine (Clozaril), olanzapine (Zyprexa), risperidone (Risperdal), and ziprasidone (Zeldox), are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants.

Olanzapine has recently been approved by the FDA for the management of acute mania. Olanzapine may also help relieve psychotic depression.

Special Note:

Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the harmful effects of some mood stabilizing medications on the developing fetus. If you are considering breastfeeding your baby and will be on medication at the time, discuss the possible risks and benefits with your clinician before you make your decision. It is very important to discuss the benefits and risks of all available treatment options with a clinician skilled in this area. If possible, these discussions should take place prior to a pregnancy. New treatments that have fewer side effects and present fewer risks during pregnancy and lactation are under study.

When to Contact Your Healthcare Provider

Contact your healthcare provider if your medication does not seem to be working after the allotted period of time or if you have any side effects that are troublesome and persistent.