Friday, January 29, 2010

Bipolar Disorder Part 4

This is the fourth in a series of didactic posts on bipolar disorder. I want to talk a bit about medication treatment as it is an essential component of treatment For patients making informed decisions about these medications requires education as many of the medications that we use to treat this disorder have significant adverse side effects, can be toxic, and can have long term negative effects on different organ systems. I call it the bipolar medication dilemma as there are no easy answers, there is no one size fits all treatment, and decisions need to be made on an individual basis taking into account health risks and other health conditions that a patient may have. It is a true dilemma as these medications that I will talk about have a lot of problems and yet without medication an untreated course of bipolar disorder is a disaster. So for now we have to use them. I would like readers to keep that in mind when I discuss all the potential negative effects.

There are four goals in medication treatment of bipolar disorder. We need to treat mania without causing depression, treat depression without causing mania, prevent depression, and prevent mania. It is unusual for one medication to carry out all four of these tasks so combination medication is the rule, rather than the exception which increases the potential for medication side effects. There are three different types of medication which have clearly shown effectiveness; lithium, anti epileptic drugs used to treat seizure disorders, and the second generation anti psychotic medications. I will talk about lithium to day and cover the others later.

Lithium remains the "gold standard " for treatment of bipolar disorder. No medication has been shown to more effective than lithium which we have had available to use since the mid 70's. Lithium is not a drug. It is a basic element which binds to other molecules to become a salt just as the sodium we use for table salt does. Usually the lithium we use comes in the form of lithium carbonate. The mechanism of action is unknown. It effectively treats mania and does work to prevent mania and depression but by itself is not a good antidepressant. We have more medications available to treat mania than we do bipolar depression. There is a narrow range between therapeutic levels and toxic levels so lithium blood levels do need to be obtained. Toxic lithium levels can result in kidney failure which is not always reversible. Lithium can cause diabetes insipidus which is the inability of the distal tubules in the kidney to reabsorb fluid resulting in excessive urination. Fortunately this can be treated strangely enough by adding a diuretic. Lithium also interferes with the release of thyroid hormone leading to hypothyroidism so thyroid levels need to be monitored. The most worrisome effect though is the evidence that long term lithium use (30 years or more) results in some kidney damage and impaired kidney function. We are now beginning to see this since we have had lithium available now for 35 years. No one really knows whether or not this will result in progressive renal failure or not. Some common day to day side effects are nausea, tremor, development of acne and weight gain.

So you can see that lithium has a lot of problems but I want to state again that it is very effective. It to me is still a "miracle" in that it can stabilize a disorder that otherwise would result in chronic mental illness and difficulty or inability to live in the community. I do not like to use lithium though for milder cases of bipolar disorder but for the more serious cases with the most complications or to use lithium when other treatments are not effective. I will talk about some of the other medication treatments in my next post.

Thought for the day

"Live a life worthy of the calling to which you have been called".

St. Paul

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