mental health mondays :: manic panic, part two

and now... the pills!

before anti-manics? or after?

unlike anti-depressants, you're not going to get these from your family doctor. putting someone on medication to control mania is something that's done by a specialist in the area, because the meds are pretty serious. the good part is, they're effective. the bad part is, the side effects suck worse than finding out the ex who stole all your belongings also gave you herpes. some are worse than others and what exactly you have prescribed depends on how off your rocker you've become, what other meds you're on or have tried and what your doctor is comfortable recommending. that last one can have a lot more to do with it than anything else, actually.

depending on what state you're in and what states you tend to reach when you're at your most agitated, the drugs serve different purposes:

1. to calm you down
2. to keep you stable
3. to make you rational



drugs to calm you down are ones that can taken to counteract the effects of a full-on manic episode. our friends the benzodiazepines are commonly used for this, although the dosages can get a lot higher than what's recommended for your standard anxiety attack and chances are greater that they won't be prescribed for long. they don't have much of an effect beyond that and we've already dealt with in detail a couple of weeks ago, so no more to say about that.

next are the drugs that clear up what doctors like to call "dissociative symptoms". that's a nice-sounding term for all the things that people associate with the worst parts of bipolar disorder- hearing voices, becoming extremely paranoid, delusional thinking, etc. they even have a nice, reassuring name: anti-psychotics. there are old (typical) and new (atypical) anti-psychotics, but their purpose is the same: to get you to stop acting weird. they may be administered short-term, if you're having a particularly bad episode, or they may be part of long-term maintenance, if you're prone to drifting off into the waters of irrationality. 

and finally we have mood stabilisers. these are often drugs that are used to combat the convulsive effects of epilepsy, but where mania/ bipolar is concerned, they rein in your lows and highs so that you aren't bouncing quite so much. this is the base therapy for dealing with bipolar disorder and, if that's your diagnosis, this is the medication that your doctor will prescribe long-term in order to moderate your mood swings.

so here's a brief look at the medications that are likely to be prescribed. it isn't exhaustive and information is always changing, but chances are, if you're diagnosed with bipolar disorder, these will be a part of your life for quite a while.

lithium :: when you comb the internet for information on the treatment of bipolar disorder, this is the word that keeps coming up. it's been around for two hundred years and has been used for psychiatric applications since the late 1800s. it's available basically everywhere in the world and, because it's so well-known, it's covered by pretty much every public health care plan (if you live somewhere that has one). even without a plan, it's damn cheap, which is important, since patients with serious mania problems tend to have issues earning and saving money. oh, and it works. studies continue to confirm what doctors already know: lithium is extremely effective and reliable at moderating mood swings and containing bipolar mania. problem solved! except...

you're probably going to hate being on lithium. it's widely known that it facilitates weight gain (anything that messes with your serotonin levels is likely to do this). it has a tendency to cause acne and breakouts. it gives you twitches and tremors from time to time (which is bizarre for something that decreases agitation, but them's the breaks). if you take it long-term, it's likely to make you pee your pants. it can mess with your thyroid function, which means you constantly have to be on the lookout for symptoms of that. it reacts badly with over-the-counter pain medications like ibuprofen and naproxen and it can react really badly to other drugs commonly taken by people with bipolar disorder- anti-depressants and anti-psychotics.

it also has a very tight window in which it's effective. too little and it's useless. too much and it becomes toxic. the proper dosage is different for everyone and can vary with diet and other medications, whether taken regularly or occasionally.

in short, lithium is not merely a drug, but a lifestyle. many of your decisions about what to do, what to eat, etc. are going to be dictated by the drug rather than what you want. but hey, at least the mood swings will be under control.

anti-convulsants
these are medications that were first used for epilepsy, but that showed the beneficial side effect of regulating mood while they reduced seizures.  i've broken them into two categories, but you could easily deal with them all individually. i'm trying to do this simply. all medications are different and warrant further research on their own.

the valproates:
these are apparently widely used in the u.s., but i'm not so sure about canada. like lithium, they've been around forever, but up until 1962, valproic acic was only used as a solvent. feel better? i'm not sure how you go from using something to clean your industrial machinery to discovering it can make your mood swings better and your seizures stop and i don't really want to know. but they are effective at controlling both epilepsy and bipolar disorder, plus the fact that they've been around a long time means that doctors have been able to study their long term use. and, hey, anything's better than lithium, right? not exactly...

not a common side effect

valproates are different, but pretty much just as awful as lithium. like lithium, they'll make you gain weight. they can flatten your moods a little too much and make both uninterested in basically anything and too lethargic to do much about it. they cause hair loss and the the hair you get to keep can be... weird. (hair growth is one of the ways that your body pushes out the stuff you put in, so it makes sense that if you're taking a powerful drug, it comes out this way.) valproates also hit you with every type of gastrointestinal problem you've ever heard of. you're likely to get heartburn, nausea and diarrhea, possibly all at once. and these drugs can do a number on your liver, so your doctor needs to know to monitor that and if you have any history of liver disease, you shouldn't be taking these drugs. unlike lithium, these drugs do not interact with ibuprofen and naproxen. in fact, you'll want to stick to those for pain management, because valproates do interact with aspirin.

like lithium, you need to get within a certain window to find the proper dosage and that can be quite variable depending on your weight, how robust your liver is and how crazy you really are. you might have to play around a little.

other anti-convulsants
these are becoming more and more common, because they tend to have lower side effect profiles. there are a number of them and they vary in effectiveness, but they are all shown to help with bipolar symptoms, particularly in cases where manic episodes are not psychotic.

these are generally a lot easier to deal with than either lithium or valproates, which means that patients are more likely to stay on them. gabitril will make you turn blue, lamictal will give you rashes, tpoamax will make you blind, give you kidney stones and turn your blood to acid (not as cool as it sounds)... but the good news is that none of these side effects are experienced as regularly as those with mood stabilisers. you might even get away with no side effects at all. all of them tend to make you clumsy, but none of them make you fat.

for the most part, these drugs are still being studied for their effectiveness in treating mania and bipolar disorder, so whether or not your doctor wants to prescribe them depends on how much s/he trusts in the studies that have been done. they're reliable enough, though, that they're likely to be prescribed as a first line medication (even though they're not supposed to be) if you seem pretty high-functioning.

anti-psychotics

doesn't it just make you feel good to be able to tell people you're on an anti-psychotic? these drugs have a lot of stigma about them because the second you hear what they're called, it's like someone is telling you you're really crazy. nonetheless, when it comes to containing the "irrational" parts of mania- where you think everyone is out to get you, or you're talking to the friends in your head- these are about the only thing that'll do the trick. not everyone who is bipolar needs an anti-psychotic and a lot of doctors are reluctant (with reason) to prescribe them because they all carry long-term risks of extrapyramidal symptoms (a whole set of effects, including parkinsons-like twitches, involuntary eye and tongue movements, inability to start moving and inability to stop moving) and tardive dyskenisia, a movement disorder which can be permanent. they're more or less necessary for people suffering from hallucinations or serious delusions, but other types of bipolar disorder can usually be controlled otherwise.

atypical antipsychotics

anti-psychotics are almost always divided into two categories: typical (old) and atypical (new). the older ones are riskier but proven effective and extremely cheap. the newer ones are less risky (although less researched) but extremely expensive (plus many public health plans won't cover a lot of them for bipolar disorder).

because they're meant to control mania, the most important effect of these drugs is that they will slow you down. that means that they can make you extremely sleepy or simply sap your energy. confusion is a common side effect, because your brain is moving slower than it's used to doing. they can make you seem a bit slow or a bit stunned, because they are a powerful sedative not only for the brain, but for the body as well.

anti-psychotics, particularly older ones, can cause weight gain on their own. if you're also taking an anti-depressant that predisposes you to weight gain, taking any amount of an anti-psychotic, even a small daily dose, can kick that side effect into high gear. combine them with something like lithium or a valproate and you have someone who's no longer crazy, but at high risk for developing type 2 diabetes.

they can also cause those pesky "sexual side effects" that anti-depressants are famous for- decreased libido and sexual dysfunction.

atypical anti-psychotics tend to have milder side effects (although some will make you even more tired than the older ones), but they have a nasty risk of messing with your heart. they also each have their own weird symptoms, so it's best to research each one as much as you can.  

as you might guess from these descriptions, one of the most difficult aspects of giving medications for mania is actually keeping people on them. new drugs continue to be developed (abilify is touted as the first "third generation anti-psychotic" and seems to have a lower side effect profile than even the atypicals, but it's still pretty new, so...), but for the moment, drugs for bipolarism are a pretty questionable lot. plus, you can bounce around from one to another before you find a combination that works for you.

you need a new coat

this is where therapy comes in. contrary to what many people believe, bipolar disorder is not necessarily permanent. when treated properly, especially if it's treated soon after symptoms begin to manifest (usually in early adulthood/ late adolescence when the personality begins to stabilise), it can recede within a matter of years. doctors and especially psychiatrists, are more concerned with managing symptoms and may be reluctant to recommend therapy. insist on it. therapy is actually your best shot at being able to identify the source of symptoms and learning to manage them. finding a good therapist is actually a lot harder than finding an effective drug cocktail, but worth it in the long run.

so that wraps up our look at depression and mania and their medications. like i said, these are prologues only, but i believe in going into every discussion informed. mental disorders are challenging, but they are not death sentences. the important thing is to get them properly identified and to start treating them. good luck.