A Bipolar Disorder Medication Guide

Medication is the most important aspect of treatment for Bipolar Disorder (BD), but can be confusing, overwhelming, or even scary. I have assembled a Bipolar Disorder medication guide and some of my observations to help prepare you for finding the right medications. Please keep in mind that medication decisions will ultimately be decided by you and your psychiatrist.

Medication Goals

Your goal should be to find medication that is completely effective at stabilizing your moods (no depression or mania) and has minimal side effects that are tolerable, if any. If you continue to experience mood episodes or you have side effects that are affecting you so much that you don’t want to take it, it is worth continuing to experiment with medication types or dosage. With a wide number of medications available, assume that you can expect a satisfying outcome of a life without mood swings or side effects you don’t like.

There are several challenges with bipolar medications:

1. Everyone with BD has varying levels of highs and lows. Some people get only a little manic (hypomanic), other can have a manic psychosis where they have a break with reality. This will play a role in medication; how much of an “anti-manic” effect do you need? The same is true with depression. Also, how fast do you cycle from one state of mood to another?
   
   
2. Everyone has different biology due to genetic variations that effect the way medication is handled by their body. A medication that is effective for one person may not be in another, or it might need to be at a higher or lower dose. A medication that is generally well tolerated (no side effects) may cause horrible side effects in some people. There is also age, weight, sex, risk of pregnancy, medication interactions, and other health conditions that are important factors in your decision.

• People may need different medications to address immediate mood issues to help them stabilize quickly, but those may not be the right meds for them to maintain stability in the long run.

• While a third of people with BD will do well with one medication (monotherapy), most will need two or more medications to achieve their goals. This again speaks to the complexity of the disorder and genes that can make finding the right “cocktail” a journey. 

Mood Stabilizers

The term “mood stabilizers”is actually not a real category of Bipolar Disorder medication, but an overall term that refers to various medications used for BD. Let’s break them down into a few categories.

Lithium

Dosage 150mg- 1500mg/day

Lithium is the oldest and best-known mood stabilizer and the original Bipolar Disorder medication. A natural element similar to sodium, it has been in use since the 1950’s. It has been shown to grow certain areas of the brain (neurotrophic effect), has an incredible anti-suicide profile, and is well understood compared to most psychiatric medications.

Lithium is a very effective medication and continues to be widely used. While most side effects from lithium are minor, it does have a chance at causing kidney or thyroid damage in some people. For this reason, it’s essential that blood work is done every 6 months to monitor if there are any problems being created. Fortunately, if there are, it can be discontinued with little risk of long-term damage to the organs. 

Blood work is also used to determine if the lithium itself is at the proper “therapeutic” dose between 0.6 and 1.2 mEq/l, and not past 1.5 mEq/l which can be toxic. The idea that it needed to be higher than 0.6 was originally for people with severe manic histories to remain stable. Achieving blood levels may not be necessary if it’s being used as an adjunct (additional medication) or for BD II.  “Low Dose lithium” (600mg or below) can be a good addition to Lamotrigine or an atypical anti-psychotic. 

Pros

• Effective, both depression and mania
• “1^st line” defense (one of first meds to try) 
• Anti-suicide effects- reduces suicidal ideation and risk
• Can be used alone (monotherapy)
• Neurotrophic 
• Doesn’t cause metabolic issues
• Can work quickly- days to weeks
• Cheap

Cons

• Needs blood monitoring
• “Therapeutic” range is just below toxic range (unless using low dose)
• Risk of organ damage if not monitored
• Small risk of weight gain (2lbs), though everyone gains weight
• Some complaints of “cognitive dulling” at higher doses
• Frequent need to urinate

Anti-Seizure Medications

There’s a number of medications that were originally developed for seizure disorders (i.e. epilepsy) that have turned out to be effective “mood-stabilizers” for BD, though usually at lower doses.

Lamotrigine/Lamictal 

100-400mg/day

This is one of the greatest medications for BD. It is virtually side effect free, especially of weight gain, which makes it an anomaly for BD medications. It has a strong anti-depressant effect, and also slow down cycling between moods, which some psychiatrists consider the first goal of mood stability. I highly recommend asking your prescriber about it.

The only catch with lamotrigine is that it has a 1/3,000 chance in causing a very serious rash that can be life threatening (don’t Google images of this rash). For this reason, it must be started at a low dose and then “titrated” up by doubling the dosage every few weeks, meaning it takes 4-6 weeks before it will reach a therapeutic dose. While long by BD medication standards, it’s just as long as anti-depressants! 

Pros

• No weight gain
• No other major side effects
• Strong anti-depressant effect
• Anti-cycling effect
• Good choice for BD II or not even full BD
• Good for hormone regulation in women over their cycle; reduces PMS and Premenstrual Dysphoric Disorder 

Cons

• No anti-manic effect- almost always combined with other med to treat mania
• Takes a little longer than some meds to become effective 
• Risk of rash

Divalproex/ Depakote/Valproic Acid

750mg-2000mg/day

Another older and widely used medication, Depakote is a potent anti-manic medication that can have minimal side effects for most people.

Pros

• Quick, strong anti-manic effect
• Decreases agitation, mixed states
• Good for anxiety
• No weight gain for some, though appetite/weight increase for others at higher dose
• Overall minor side effects
• Considered 1^st line defense 

Cons

• Shouldn’t be used by women who may get pregnant 
• Less effective as an antidepressant 
• Side effects include hair loss, tremors, nausea 

Carbamazepine/Tegretol

Not a 1^st line defense but an option if some other medications aren’t tolerated. 

Pros

• Good for agitation
• Good for sleep 
• No weight gain
• Overall minor side effect profile 

Cons

• Rare risk to blood, skin, liver
• Less effective as an antidepressant 
• Tricky get right dosage 
• Decreases reliability of birth control
• Requires blood tests

Oxcarbazepine/Trileptal

A newer medication that is similar to Tegretol but with less side effects, including no weight gain. Unfortunately, it’s not as effective either which is why it is not commonly used. It could be an option if weight gain is a concern and other anti-seizure meds haven’t been tolerated. 

Anti-Psychotics

First of all, don’t freak out about the name; these are very helpful medications and are worth considering. While these medications were originally developed for psychotic disorders like schizophrenia, they also have some fantastic mood stabilizing properties. They all work by affecting how dopamine works in the brain. At this point, they are probably more commonly used than lithium or anti-seizure medications (besides lamotrigine) because they work fast, are effective, and don’t require ongoing blood work. 

All of the meds here technically 2^nd generations atypical anti-psychotics, commonly referred to just as “atypicals”. They are distinguished from earlier anti-psychotics (such as Haldol) that were used prior to the 1990’s and had high amounts of sedation and a rarely used now. (I have seen one client on Haldol recently due to not tolerating these newer meds well.) 

All of the anti-psychotics have similar side effect concerns, a few of which are serious. The first is the weight gain and metabolic syndrome, which can cause increased cholesterol, blood sugar, and triglyceride levels. This is a serious health consideration, not to mention that weight gain can create shame, the last thing people struggling with bipolar depression need. Second, they can cause a lot of side effects that are similar to Parkinson’s disease, such as tremors, restlessness, and least desirable, tardive dyskinesia, which causes involuntary muscle ticks that can be permanent, even after discontinuing the medication. (If you experience this side effect, let your prescriber now right away.) All the reason to contemplate the previous medications listed above, though some atypicals have fewer side effects than others. 

Quetiapine/Seroquel

One of the first and widely used of the atypicals, this medication has strong anti-depressant effects, though is sometimes used as monotherapy. I commonly see it being used more at low doses as a sleep aid than as the main mood stabilizer.

Pros

• Strong anti-depressant effect
• Good for sleep/insomnia
• Can be used as adjunct/add-on med for sleep 
• Good for anxiety

Cons

• Can cause significant weight gain, metabolic effects; more than most

Olanzapine/Zyprexa

This medication can work fast to reduce mania, delusions, dysphoria (the opposite of euphoria), racing thoughts, delusions, and more. It can work in 20-30 minutes in some cases. It is commonly used in psychiatric hospitals because of its reliability to bring people down reliably. It’s also available as an injectable that lasts for 30 days. However, due to its weight gain, it is rarely used as a maintenance medication after its immediate treatment of acute, crisis level mania or mixed states. (Mixed states combine symptoms of mania and depression simultaneously.) 

Pros

• Works fast for mania, psychosis, and dysphoria
• Reliably effective 
• Injectable- good for people who are prone to going off meds due to instability

Cons

• Can cause lots weight gain, metabolic effects; more than any
• Should only be used briefly 

Lurasidone/Latuda

One of the newest atypicals, Latuda is only available in the US as a brand name medication. (I’m not saying check Canada if not covered by your insurance . . .). It is one of only two drugs that is FDA approved for treating bipolar depression, and it can do so well. It also has good evidence for being effective in eliminating manic episodes over the long run, though probably won’t be a first line choice for an acute manic episode.

Pros

• Strong anti-depressant effect
• Effective for mania
• Can be used as monotherapy or with low dose lithium or Depakote
• Less weight gain and metabolic effects than most atypicals 

Cons

• Expensive 
• Still has risk of Parkinsonian type effects, though less than most 
• Needs to be taken with 350 calories of food at night

Cariprazine/Vraylar

The newest atypical (4 years old), Vraylar has several unique features. It works slightly differently in the brain’s dopamine system, giving it the lowest side effect profile, and has the claim that it is FDA approved for bipolar mania, bipolar depression, and the only med for bipolar mixed states. That’s right, less side effects and it treats all of the mood states, both acutely and as a maintenance choice. 

For these reasons, it is the go-to choice of the intensive outpatient program I work at a few days a week, The Wellness Treatment Center. We treat a lot of BD, and the staff joke is that we know that the psychiatrist will start everyone one Vraylar and Lamotrigine so reliably that we don’t ask about what meds he’s started them on. I see good improvement over the weeks I work with our clients. The only reason people occasionally discontinue it is that it can cause some restlessness (akathisia) they find uncomfortable. 

The one thing I find confusing about this med is that many psychiatrists seem hesitant to use it. I think they may be concerned about not knowing the really long-term side effects, though my overall impression is that most prescribers have not been educated on this new, very attractive med. What a pity. 

Pros

• Effective for mania, depression, and mixed states
• Can be used as monotherapy or with Lamotrigine 
• Little or no weight gain or metabolic effects compared to most atypicals 
• Less side effects overall

Cons

• Expensive 
• Can cause an agitated restlessness
• Possible nausea at beginning, though this usually passes
• Your psychiatrist may not be familiar with it and would prefer older meds

Aripraprazole/Abilify

This is a medication you may have heard of and it relatively recent, though now generic and very commonly prescribed. It has less weight gain than some, though more than others. It works well for mania, but it was unable to achieve FDA approval for bipolar depression, though is approved for Major Depressive Disorder. 

Pros

• Effective for mania
• Probably sufficient for depression, but not for everyone
• Can be used as monotherapy or other meds
• Less weight gain, metabolic effects than most atypicals 
• Generic
• Common 1^st line defense 

Cons

• Still has risk of Parkinsonian type effects, though less than most 
• Some weight gain, metabolic effects 

Respiridal/Risperidone

This med appears to lack strong data for BD, especially depression, though I have seen it prescribed to many of patients, apparently due to its effectiveness in treating OCD. That being said, I’ve seen my clients continue to struggle with depression, mixed states, and significant weight gain on this med. Keep in mind that’s anecdotal evidence, but I would ask why your prescriber is recommending it based on the data. 

Pros

• Useful for OCD
• Generic
• Good for the elderly
• Could be choice if other meds don’t work 

Cons

• Lacks strong data for BD mood stability
• More weight gain, metabolic effects than most atypicals

Anti-Depressants

Anti-depressants can be a useful part of a Bipolar Disorder medication regimen; however, they need to be used cautiously for several reasons. First, because they are trying to increase activity in a depressed mind, they can cause people with BD to become manic or mixed. While it is sometimes the euphoric kind (I’ve seen this most with Prozac), it frequently is more of a dysphoric, agitated, restless, insomnia, racing thoughts, rapid speech kind of effect. Worse, I’ve seen the dreaded black box label that “Anti-Depressants can cause suicidal thoughts in some people” come true. Most of these effects come on quickly, though sometimes months. (There is some thinking that depressed people who get suicidal when they first start taking antidepressants likely have BD and are being put in mixed states, which have a high risk of suicide.)

That being said, if you’re currently on another BD medication that is sufficiently anti-manic enough to keep you from getting manic due to an anti-depressant, it could be worth a try if you’re still struggling with depression. Some antidepressants seem to be less likely to cause mania than others. 

The ones that seem safest are:

• Bupropion/Wellbutrin
  • Nice side effect profile of weight loss, energy, but can cause restlessness

• Fluoxetine/Prozac

• Escitalopram/Lexapro

• Less sexual side effects than most SSRI’s

• Venlafaxine/Effexor
  • Only SNRI that’s safe for BD

All that being said, I’ve seen all of these cause mania or mixed states, so proceed with caution.

Conclusion

I hope all of this information is empowering to you in your journey to stability and wellness. Please keep in mind I am not a psychiatrist and would always defer to your medication prescriber for ultimate decisions in your treatment. I have gathered this bipolar medication information from reading research studies, professional articles and books, discussions with psychiatrists, and anecdotal information from my clients.

I want to encourage you be patient and open minded as you try to find medications that work for you. It is a process of experimentation that takes months or years for most people but is well worth the trial and error!

In case you’re wondering my top recommendations, I think lamotrigine is a no-brainer to consider due to its lack of side effects and anti-depressant and cycling benefits, as long as you’re also taking something with an anti-manic effect. Don’t be afraid of lithium, especially at lower doses, as its side effects are likely to be less than antipsychotics, but only if you’re willing to do the bloodwork every 6 months. Depakote could be considered if you want an anti-manic punch without many side effects. If you are looking to try an anti-psychotic, Vraylar would be my first choice given its low side effects and ability to cover the entire mood spectrum. After that, Latuda seems promising, especially if you’re struggling with depression. A little Seroquel can be helpful for sleep and depression. The others I’d consider only if you don’t respond well to the aforementioned drugs.

A final thought for you is that if you’re wondering how you can avoid medications that give you unpleasant side effects and are effective, there are gene assay tests such as Genesight and Genomind you can get from some psychiatrists. Your psychiatrist takes a spit swab sample for analysis and they generate a report on medications that you’re likely to respond to well (or not) based on your particular gene profile. It’s especially worth considering if you’ve tried more than a few medications without luck.