Monday, February 1, 2010

Bipolar Disorder Part 5

This is the fifth in a series about bipolar disorder. I have been talking about the dilemma of finding effective medication without undue side effects or toxicity and talked before about lithium which remains the "gold standard". Today I will discuss three more medications, carbamazepine (Tegretol), valpoate (Depakote), and lamotrigine (Lamictal). All three belong to the class of medications referred to as AED's or antiepileptic drugs. They initially were designed to stop seizures in epileptic patients before they were found to have significant mood stabilizing properties. Again, like lithium we do not know the mechanism of action in bipolar disorder.

Tegretol was the first one of these three medications found to be effective in bipolar disorder. It does a good job of treating mania and preventing further manic episodes, is not so good at preventing depression and does not at all treat depression. It generally is fairly well tolerated in terms of day to day side effects and blood levels can be monitored. There is sometimes an allergic rash,it can cause hyponatremia or low sodium levels, and is teratogenic, potentially causing congenital abnormalities if taken while pregnant. It also reduces the effectiveness of birth control pills. The most serious potential side effect though is the possibility of bone marrow suppression, impairing the ability to make white blood cells needed to fight off infections so the white blood cell count needs to be monitored on a regular basis.

Depakote was the next AED available to treat bipolar disorder. Like Tegretol it is a very effective antimanic medication, can prevent mania from recurring but does less well in preventing depression and does not at all treat depression. It is as effective as lithium in treating mania and sometimes more effective. Common side effects can be weight gain (at times quite significant) and tremor. It can cause some hair loss, alter menses, increase risk of polycystic ovary syndrome and is very teratogenic. Like Tegretol it can be monitored with blood levels. Rare but serious side effects can be drug induced hepatitis or pancreatitis or quite rare liver failure. Liver function tests need to be routinely monitored.

Lamictal is much different than any other bipolar medication. It does not treat mania nor depression but is very effective in preventing further manic episodes as well as further depressed episodes. It is extremely well tolerated day to day, is not associated with weight gain, is not teratogenic, and is not associated with the risk of bone marrow suppression or liver problems. It has a rare (but potentially fatal) risk of inducing a Stevens - Johnson reaction which is a severe rash affecting not only the skin but the mucous membranes as well. Because of it's properties of preventing mania and depression it is often used as a second medication in many cases.

As I mentioned before these medications can sound quite bad in terms of side effects and risks but in most cases the benefits of preventing the devastating consequences of untreated bipolar disorder outweigh the risks. Tomorrow I will talk about the third group of bipolar medications, the second generation antipsychotic medications.

Thought for the day

"The thought never came to mind that I too am a brief and passing thing and so, through hatred ,lust, and ignorance I have committed many sins".

The Way of the Bodhisattva

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