How Many Meds Do You Take?

Have you noticed that at gatherings of people with bipolar disorder, that’s a common introductory question, along with “what’s your diagnosis?” It’s a way to gauge how seriously bipolar the other person is and, for once in a bipolar person’s life, take pride in the seriousness of their condition. It’s kinda weird and backward but I get it.

The world that people diagnosed with any form of bipolar disorder enter when they first hear the word “medication” is a swirling spiraling confusing ecosystem of psychiatrists, university researchers, pharmaceutical companies and their researchers, “patients,” critics and countless others. Together, this unique culture has created a vocabulary all its own: for example, “compliance” in this world is a loaded word and comes with many nuanced meanings, some of them disempowering and even disrepectful to people who have bipolar disorder.

Whole New World

Whole New World

The pharmaceutical world “serving” the bipolar community recognizes a delicate arrangement between players from psychiatrists to researchers and everyone in between. Ultimately, yes, the bipolar “customer” is the ultimate decision-maker in which drugs get purchased and which do not. But that customer is heavily influenced by “experts” because the decision whether to buy a drug and what dose to purchase is a very complicated one.

Once in a while you may meet someone (for me, always online, never in person) who says they are dealing with bipolar disorder without medication of any kind. At the other end of the spectrum there are anecdotal stories from the medical profession (if anyone has a cite to an actual study, please share it!) that “prove” that each unmedicated bipolar episode increases the frequency and severity of future episodes.  (By episode, I mean an attack of either mania or depression that takes you out of your “normal” daily life.)

Pharma to Doc to Patient

Pharma to Doc to Patient

We’ll come back to how this pharmaceutical industry works within the bipolar landscape in another post, but let me start today with the basics: with a gross generalization of the medication types that most people with bipolar disorder will discuss with their psychiatrist or prescribing physician at one time or another. I’ll mention some of the most common side effects but talk to any three people who’ve taken a given drug, and you will probably hear three very different experiences in effectiveness, side effect profile and severity, and how long the effectiveness lasted.

By that last phrase, “how long the effectiveness lasted,” I mean that many people with bipolar disorder find that a particular drug combination’s effectiveness wears off after a year or more and has to be adjusted, sometimes by replacing all of the drugs in the “cocktail” and sometimes by adjusting one or two.

So, as a basic intro, here are the four drug categories I’ve seen most people with a diagnosis of bipolar disorder encounter, including myself:

The Antidepressant (usually an SSRI)

Most people in the modern world think of SSRIs first when they hear that someone is depressed. Although SSRIs don’t have a fabulous track record, especially with bipolar disorder, they may be the best chance many depressed people have for help that works faster than talk therapy. With bipolar disorder, however, there is even more controversy. Some medical professionals believe that SSRIs may be completely ineffective against bipolar depression, especially acute bipolar depression. In fact, there is some evidence, growing, that SSRIs actually increase depression in the bipolar brain.  And it is an accepted truth that SSRIs can cause manic episodes with psychosis in some people when the SSRIs are not paired with another class of drugs: the mood stabilizer.

Mood Stabilizers

Mood Stabilizers are actually a term encompassing several different types of drugs. I combine them here because since they perform the same function and for many, if not most, people with bipolar disorder, only one drug from this class is necessary.

While non-traditional mood stabilizers are sometimes used to achieve the same effect, there are a handful of drugs that are well known for their mood stabilizing properties and not much else. Lithium is the granddaddy of them all. 1 After Lithium, anticonvulsant drugs may be the most commonly used for mood stabilization. These include Depakote, Lamictal, Tegretol, Trileptal, Topamax, Rilutek, Neurontin and, as is usually the case, all their many generic forms.2 And, finally, I will cover them as a class all their own but antipsychotics are sometimes also used as mood stabilizers.

The Antipsychotics

For sufferers of bipolar disorder who experience hallucinations or full-blown psychotic episodes, its obvious why a

how many pills do we have to take?

how many pills do we have to take?

doctor would prescribe an antipsychotic.  However, if your doctor proposes antipsychotic drugs, it does not mean s/he thinks you’re psychotic. The “atypical antipsychotics” as they are called to distinguish them from a class of much older and more problematic drugs, have anti-anxiety properties, mood-stabilizing properties and, perhaps, antidepressant properties. They are a common tool in many people’s bipolar disorder survival kit. Atypical antipsychotics include: Abilify, Zyprexa, Invega, Seroquel, Risperdal, Geodon, Saphris and many others that you can find listed at Wikipedia’s List of Atypical Antipsychotics.

Tranquilizers/Anti-Anxiety Medications

Nearly every person I know with bipolar disorder who takes any medication at all, takes some sort of medication for anxiety. There is a high comorbidity 3rate between bipolar disorder and anxiety disorders. Like many other people eventually diagnosed with bipolar disorder, I started out with anxiety disorder then moved “up” to panic disorder and finally bipolar disorder.

As with mood stabilizers, anti-anxiety medications come from many different classes of drugs. Some people break them down into “major tranquilizers” which are basically just the antipsychotics by another name and “minor tranquilizers” which are all other anti-anxiety (or “anxiolytic”) drugs. We’ll just assume for our discussion here that we’ve already addressed the major tranquilizers under antipsychotics and we’re talking about the rest of the drugs under the anti-anxiety label.

Perhaps the most common is the benzodiazepine class. These are very effective medications which vary from each other in how quickly they become effective in relieving the person’s anxiety and how long their effectiveness lasts (their “half-life” in your body). They also vary in how difficult it is for a given person to stop taking them because they are physically addictive for many people.4 The commonly prescribed benzodiazepines are: Xanax, Librium, Klonopin, Valium, Ativan and Serax.

SSRIs, which you’ve already read about under antidepressants are, at higher doses, sometimes considered to have anti-anxiety properties. But they can also cause the opposite response in some people. Similarly, some doctors are still prescribing old-school anti-depressants called tricyclic antidepressants. These go by the names Imipramine, Amitriptyline and Trazodone.

Wikipedia has a long list of alternate prescription medications used for anxiety that are not typically prescribed in the circles I run in. I’ll provide it here:

Adaptol (Mebicarum / Mebicar) is an anxiolytic produced in Lativa and used in Eastern Europe. Mebicar has an effect on the structure of limbic-reticular activity, particularly on hypothalamus emotional zone, as well as on all 4 basic neuromediator systems – γ aminobutyric acid (GASS), cholineserotonin and adrenergic activity. Mebicar decreases the brain noradrenaline level, exerts no effect on the dopaminergic systems, increases the brain serotonin level, and does not elicit cholinolytic action.

Afobazole is an anxiolytic drug launched in Russia in the early 2000s. It produces anxiolytic and neuroprotective effects without any sedative or muscle relaxant actions, making it more selective in action than many currently used drugs for this application. Its mechanism of action remains poorly defined however, with GABAergic, NGF and BDNF release promoting, MT1 receptor antagonism, MT3 receptor antagonism, and sigma agonism all thought to have some involvement. Clinical trials have shown afobazole to be well tolerated and reasonably effective for the treatment of anxiety, although it has yet to be introduced into widespread clinical use outside of Russia. The compound has not been evaluated by the FDA. It is unscheduled in the US and legal to import by private citizens for personal use.

Selank (Russian: Cеланк) is a nootropic, anxiolytic peptide based drug developed by the Institute of Molecular Genetics of the Russian academy of sciences. Selank is a heptapeptide with the sequence Thr-Lys-Pro-Arg-Pro-Gly-Pro. It is a synthetic analogue of a human tetrapeptide tuftsin. As such, it mimics many of its effects. It has been shown to modulate the expression of Interleukin-6 (IL-6) and affect the balance of T helper cell cytokines. It has been shown to influence the concentration of monoamine neurotransmitters and induce metabolism of serotonin. There is evidence that it may also modulate the expression of Brain-derived neurotropic factor (BDNF) in rats.

Bromantane is a stimulant drug with anxiolytic properties developed in Russia during the late 1980s, which acts mainly by inhibiting the reuptake of both dopamine and serotonin in the brain, although it also has anticholinergic effects at very high doses. Study results suggest that the combination of psychostimulant and anxiolytic actions in the spectrum of psychotropic activity of bromantane is effective in treating asthenic disorders compared to placebo. The absence of “withdrawal syndrome” demonstrated a lack of addictive potential in this drug. It is considered novel having both stimulant and anti-anxiety properties.

Tenoten is a Russian anxiolytic and antidepressant based on antibodies to brain-specific protein S-100B. S100 proteins are small calcium-binding proteins interacting with numerous intra- and extra cellular targets involved in diverse physiological functions. In particular, S100 proteins may be involved in the regulation of anxiety-related behavior

Azapirones are a class of 5-HT1A receptoragonists. Currently approved azapirones include buspirone (Buspar) and tandospirone (Sediel). Gepirone (Ariza, Variza) is also in clinical development.

Barbiturates exert an anxiolytic effect linked to the sedation they cause. The risk of abuse and addiction is high. Many experts consider these drugs obsolete for treating anxiety but valuable for the short-term treatment of severe insomnia, though only after benzodiazepines or non-benzodiazepines have failed. They are rarely prescribed any more.

Hydroxyzine (Atarax) is an old antihistamine originally approved for clinical use by the FDA in 1956. It possesses anxiolytic properties in addition to its antihistamine properties and is also licensed for the treatment of anxiety and tension. It is also used for its sedative properties as a premed before anesthesia or to induce sedation after anesthesia.[7] It has been shown to be less effective than benzodiazepines in the treatment of generalized anxiety disorder, while producing less side-effects.[8]

Pregabalin‘s therapeutic effect appears after 1 week of use and is similar in effectiveness to lorazepamalprazolam, and venlafaxine, but pregabalin has demonstrated superiority by producing more consistent therapeutic effects for psychic and somatic anxiety symptoms. Long-term trials have shown continued effectiveness without the development of tolerance, and, in addition, unlike benzodiazepines, it does not disrupt sleep architecture and produces less severe cognitive and psychomotor impairment; it also has a low potential for abuse and dependence and may be preferred over the benzodiazepines for these reasons.[9][10]

Validol: Sublingual administration of Validol produces a sedative effect, and has moderate reflex and vascular dilative action caused by stimulation of sensory nerve receptors of the oral mucosa followed by the release of endorphins. Validol is typically administered as needed for symptom relief.[11][12][13]

 

Wikipedia also lists a bunch of herbs that people can use for anxiety. Always be careful when trying prescription and nonprescription drugs together because no one has done a clinical test on whether there are any dangerous conflicts when using those two agents together. There are deadly conflicts between some prescription drugs and some everyday food items, so be careful. Try to talk to people who’ve used the combination you’re thinking of trying already.

I’m not going to make this post any longer by getting into any philosophy about medications or any of my experiences with them.  There will be room for that in another post.

I invite you, dear readers, to please share your comments about drugs you were prescribed that are not listed above and what class those drugs might be in, whether included in this blog or not. Please also share your thoughts about the classifications I chose. Do those classifications fit with what you’ve seen your doctors prescribing you since you received your diagnosis? If not, what set of classifications would make more sense to you?

Thanks, always, for stopping in.

Strength. Hope. Appreciation for each day. Those are my three wishes for you and for me.

Notes:
1. First discovered as a psychoactive agent in 1948, it was a welcome alternative to the mainstream treatments of the time: Lobotomy and Electroconvulsive Treatment. John Frederick Joseph Cade discovered the effects of Lithium as a mood stabilizer. He was a trained psychiatrist who served and was injured in WWII. While recovering in a military hospital, a series of tests led him to try lithium in fellow patients with manic symptoms with success.
3. the presence of more than one diagnosis occurring in an individual at the same time
4. Their addictive qualities can be so severe that trying to stop taking them (or being forced to stop taking them by circumstance, a clueless doctor or some other ill luck can cause Benzodiazepine Withdrawal Syndrome which can, at its worst last a lifetime and be completely debilitating.