Will I gain weight from the medication?
Weight gain is a very real concern for most patients. Unfortunately, the majority of medications used to treat bipolar disorder have some degree of weight gain associated with them. Both lithium and Depakote (valproate) are associated with weight gain, the mechanism of which is not understood. The weight gain from Depakote (valproate) may be associated with polycystic ovarian syndrome, but mostly it occurs independently of the condition. Weight gain from the anticonvulsants may not occur in everyone, so it need not immediately rule out a potentially effective treatment. It is important to maintain good nutrition and healthy eating habits, as well as partake in regular exercise, to help offset the weight gain risks. Being cognizant of any appetite-inducing effects of the medicine can help you resist urges to eat more as well. Of the atypical antipsychotics, Geodon (ziprasidone) and Abilify (aripiprazole) appear to have the least overall risk for weight gain, while Clozaril (clozapine) and Zyprexa (olanzapine) appear to have the highest risk. Aside from obesity, there is the associated risk of metabolic syndrome with atypical antipsychotics as well. Anticonvulsants with lower risk for weight gain include Lamictal (lamotrigine) and Topamax (topiramate), although topiramate does not have FDA approval for bipolar disorder. Topamax (topiramate) has also been studied independently as a potential weight loss agent and has been reported to reverse the weight gain caused by other agents.
In terms of the antidepressants, the older antidepressants have been classically associated with weight gain (tricyclics, monoamine oxidase inhibitors).When the SSRIs first entered the market, they were believed to have no associated weight gain as a group, and some even were found to cause weight loss (e.g., Sarafem [fluoxetine]). Keep in mind that side-effect profiles are typically developed from the early studies of medications, which are conducted over the short term (i.e., several weeks). In clinical practice, however, many physicians have found that SSRIs can be associated with weight gain over the long term. Although clinical trials have typically found that weight gain does not differ significantly from placebo, uncontrolled studies have noted weight gain over the long term. Paxil (paroxetine) appears to be more associated with weight gain clinically than the other SSRIs. Celexa (citalopram) has been reported to have early weight gain. There may be an increase in carbohydrate craving associated with SSRIs as a possible mechanism.
Bupropion is one antidepressant that does not have weight gain associated with it and can be considered as one treatment option. More long-term controlled studies are needed to compare weight gain over time between antidepressant users and those who are not. Keeping in mind the potential for weight gain, good nutrition and exercise should be part of the treatment with antidepressants as well.
Ultimately, the risk for weight gain needs to be balanced against the risk for untreated bipolar disorder. Close monitoring of weight and vigilant efforts to prevent the initial weight gain can be very effective in limiting the amount that is gained. Weight gain on one agent does not necessitate the same on another agent, so different trials may be needed as well.
How long will I have to stay on medication?
It is important to understand that medications for bipolar disorder are used for treatment of the acute illness as well as to maintain remission of the illness. Remission may be partial or full, full remission occurring when there are no longer any symptoms. An acute manic episode is typically brought under control more quickly than an acute depressive episode. Full remission of symptoms, however, does not mean it is time to stop the medication. Many people stop their treatment prematurely because they either feel better or are experiencing side effects. It may be thought that the medication is not needed anymore or even questioned whether the medication had anything to do at all with the improvement (particularly if there were no side effects). Close monitoring by your doctor can help to address questions of efficacy as well as to provide the feedback as to level of improvement. When medication is discontinued prematurely, a relapse or recurrence is likely to occur soon thereafter. A relapse occurs if there is a return of symptoms of your previous episode within the period of time known as remission, which is within six months of resolution of symptoms.
Recurrence occurs if the symptoms of either depression or mania return during the period of recovery, which is after six months of remission. Statistically speaking, after remission of either a manic or depressive episode, there is highest risk for recurrence within the first year.While the standard recommendation following one major depressive episode (unipolar) is to continue pharmacologic therapy for at least one year after remission, maintenance therapy will more likely be indefinite for bipolar disorder. The more episodes of either mania or depression you have over time increases the risk for future episodes. Bipolar disorder tends to worsen with time, particularly if left untreated, which is why indefinite treatment with a mood stabilizer is recommended. If an antidepressant is used, many clinicians recommend it be discontinued as soon as depressive symptoms have remitted, to reduce risk for a manic switch. Long-term management, however, will be guided by the frequency, severity, and consequences of past episodes.
Are both medication and therapy necessary in the treatment of bipolar disorder?
Both medication and therapy are necessary and effective treatments for both the depression and manic phases of bipolar disorder. In contrast to unipolar depression, therapy alone would not be adequate for the treatment of bipolar I disorder. And while medication is likely a necessary part of treatment for bipolar disorder, therapy too is usually a necessary adjunctive treatment to address the multitude of issues that can arise in treatment. Therapy can focus on potential precipitating stressors. In developing coping mechanisms and problem-solving abilities, the risk of recurrence under stressful circumstances in the future can be minimized.
There may be situations when medication needs to be avoided during the depressed phase of the illness-the use of therapy, in particular cognitive behavioral or interpersonal therapy, can sometimes make this possible.
The most important factor in determining a positive outcome from either modality is that both forms of treatment require commitment to the treatment in order for it to work. Therapy requires regular attendance to appointments; communication with the therapist during the session; and for some forms of therapy, work on assignments between sessions. The process of therapy is not easy. It can be anxiety provoking and one does not necessarily feel relief after each individual session. Relief comes over time with hard work on the issues. It may feel easier to cancel sessions or to terminate treatment prematurely, but then the therapy is not given a chance to be effective.
As for medication, its use requires daily compliance and regular communication with your doctor. It is often difficult for many people to remember to take a medication daily, twice a day, or more. Doses may be skipped. Missing doses regularly results in reduced efficacy of the medication. Sometimes a medication doesn’t work right away. It becomes frustrating, and the medication treatment is abandoned prematurely.
Often, when a person has a list of “ineffective” medications, many of them did not get adequate trials.
Term:
Remission – complete cessation of all symptoms associated with a specific mental illness. This occurs within the first six months of treatment, after which the term used is recovery.
