Bipolar Hypersexuality or Sex Addiction?
What is metabolic syndrome and how does it relate to mood stabilizers?
If you have three or more of the following you are diagnosed with metabolic syndrome:
• A waistline of 40 inches or more for men and 35 inches or more for women (measured across the belly)
• A blood pressure of 130/85 mm Hg or higher
• A triglyceride level above 150 mg/dl
• A fasting blood glucose (sugar) level greater than 100 mg/dl
• A high-density lipoprotein level (HDL) less than 40 mg/dl (men) or less than 50 mg/dl (women)
This syndrome is important to mental health for the following reasons. Metabolic syndrome, more often than not, is caused by obesity. Bipolar disorder may increase the risk of obesity and metabolic syndrome due to changes in energy related to mood variability.
The severity and chronicity of bipolar disorder may also affect the incidence of obesity. The number of previous episodes is positively correlated with being overweight or obese. The greatest gain in weight for bipolar patients is during the acute phase of their treatment. Obese individuals tend to have a more severe and intractable type of illness. There is some preliminary evidence that treating severe obesity may improve mood, at least depression. At Danbury Hospital in Connecticut, the bariatric surgery department has been following its patients for several years now and documenting the changes in medication as a result of weight loss. They have found that with the reduction in weight, and the resulting reduction in fasting blood sugars, triglycerides, and cholesterol, a significant number of the patients eventually no longer require antidepressant medication. It is not clear if the same effect occurs with bipolar patients, as there are just too few of these patients in the program to have any reliable numbers.
Finally, the medications used to stabilize mood may cause weight gain and/or metabolic syndrome. It appears that just about all the medications used to treat bipolar disorder, old and new, lead to weight gain. Of the atypical antipsychotics, the medications that cause the most weight gain, in order of most significant to almost negligible, include Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Geodon (ziprasidone), and Abilify (aripiprazole). These medications have also been implicated in elevated fasting blood sugars, elevated cholesterol and triglycerides, and rarely the development of diabetes (again in descending order).
Although these two risks are related, it is possible to develop any one of them without the others. The traditional mood stabilizers lithium and Depakote (valproate) can also cause weight gain, but have not been shown to cause metabolic syndrome. In fact, some evidence suggests that adding Depakote (valproate) to Risperdal (risperidone) lowers the cholesterol in Risperdal (risperidone) users. These weight changes are most dramatic in thinner individuals. But being overweight prior to treatment conveys its own risks, particularly the risks of precipitating or worsening metabolic syndrome. You should work with both your internist and psychiatrist to choose medications that are most effective with the fewest side effects.
Strategies you can take to reduce the chances of weight gain during treatment include changing your diet, increasing exercise, and/or choosing medications less associated with weight gain. These include mood stabilizers such as Trileptal (oxcarbamazepine) or Lamictal (lamotrigine), or the lowest-risk atypical antipsychotics such as Geodon (ziprasidone) or Abilify (aripiprazole). In addition, a combination of medications can be taken that can either reverse or reduce the risk of weight gain. These combinations include a variety of off-label strategies such as adding Topamax (topiramate), Symmetrel (amantadine), metformin, or Pepcid to Zyprexa (olanzapine). All of these strategies carry a degree of risk, and to date none have proven to be universally effective.
Why did my doctor prescribe an antipsychotic for me when I am just depressed?
Antipsychotic medications are often prescribed for patients suffering from psychotic symptoms resulting from their depression. Such symptoms often revolve around false beliefs that the patient deserves some horrible punishment for a minor transgression the patient believes to be a major sin or crime. Antipsychotics specifically target those symptoms, thus relieving patients of those painful thoughts and feelings. With the introduction of newer antipsychotic medications, however, their use as augmenting agents to antidepressants even in the absence of psychosis has become a new option for psychiatrists.
The newer antipsychotic medications, called atypical antipsychotics or second-generation antipsychotics (SGAs), were developed because of increasing concern regarding the risk of developing a severe, potentially irreversible movement disorder known as tardive dyskinesia. Patients suffering from mood disorders are at greater risk for developing this movement disorder than patients who suffer primarily from psychotic disorders.
SGAs have reduced this risk dramatically. They are, as a result, generally safer to use than their predecessors, although recently there have been growing concerns about their metabolic effects on the body, including the potential for weight gain, increased blood sugar, and increased cholesterol and lipids.
Despite these concerns, they remain an effective strategy when patients are showing only a partial response to their antidepressant medication or have a history of bipolar disorder and need medication to prevent the possibility of mania while undergoing treatment with an antidepressant medication.
How does generic medication differ from trade names?
The generic name of a medication is the international scientific name for the molecule that constitutes the active form of the medication. The company that develops the medication applies for a patent and obtains exclusive rights to sell the medication. They then give the medication a trade name. This trade name can change from country to country and from its intended use. For example, the medication with the generic name paroxetine is marketed under the trade name Paxil in the United States and Seroxat in the United Kingdom. The medication with the generic name bupropion is used as an antidepressant under the trade name Wellbutrin and as a smoking cessation medication under the name Zyban. The medication with the generic name fluoxetine is used under the trade name Prozac as an antidepressant and as Sarafem, a medication prescribed by obstetricians, for women suffering from premenstrual symptoms. Once a medication goes off patent, other companies obtain the right to make it and sell it. At this point generic forms of the medication that may be less expensive become available. These medications are sold under their generic names. As physicians first know the original form of the medication by its trade name, the physicians often continue to write prescriptions under that name. By law pharmacies must fill the prescription with the less-expensive form of the medication unless the physician specifically indicates to the pharmacy not to substitute. As a result the filled prescription will come back to the patient under the generic name rather than the trade name.
Are there differences between generic medications and medications under the trade name? The active ingredients of the medication are identical. The “fillers” or inactive ingredients making up the rest of the medication may differ. There may also be more percentage variations between the amounts of active ingredients from pill to pill in generic medications than in trade medications as the requirements for quantity control are more stringent with trade medications than with generic medications. Generic medications can vary by +/- 20% in bioavailability (the amount of medication that reaches the bloodstream).
Different companies can manufacture generics so each time you get a refill on a generic you may get a different one with different bioavailability. For many medications, these differences are so minute as to be negligible, and with repeated dosing the differences cancel each other out. However, some drugs used to treat bipolar disorder, such as Depakote, Depakot ER, Eskalith, Lithobid, and Equetro have a narrow therapeutic index (NTI). With NTI drugs, small variances in the blood levels may cause changes in the effectiveness or toxicity of that drug. Many insurance plans will cover both the brand name drugs and the generics, although some drugs have no generic substitution. Physicians may indicate “dispense as written” to ensure a brand name drug is dispensed by the pharmacist.
