Hi, I'm Dr. Tracey
Marks, a psychiatrist, and I make mental health education videos. Today, I'm answering a viewer question about how you can still
have mania or depression in bipolar disorder when
you're on medication. It's like, if you're on medication, you should be stable, right? Here are excerpts from
the question from Jay, and I've edited just to
make it a little shorter. "I'm 23 years old. I have
bipolar II disorder and ADHD. I'm on Lamictal 300,
Rexulti three milligrams, and Adderall 20 milligrams. I have been hospitalized four times in the last eight months,
including attempt of hanging six months ago. My most recent hospitalization was in May, shortly after I experienced
a hypomanic episode that felt great, then felt leveled out. Now I'm experiencing a depressive
episode, and it hit hard. I do every June. My question is how much cycling is normal while on medication? Should I be getting this depressed still? It's pretty intense and came on suddenly. Tried to add in an
antidepressant in the past, made things 10 times worse,
and I went off the deep end. Is it possible that I'm still
not on the right meds for me? Med changes terrify me after what happened with the antidepressants." Thank you, Jay, for this question. What you're describing sounds like rapid
cycling bipolar disorder. I talk more about rapid
cycling bipolar disorder in this video. Rapid cycling happens when you
have more than four episodes of either depression or mania in a year. And this can happen when
you recover from an episode, and then have like two months
where you're feeling fine, and then have a recurrence
of the same mood state, or you can switch directly from
one mood state to the next, without any break in between. So you can go from being
hypomanic to depressed, to hypomanic again, without
any period of feeling normal. There are things that can contribute to switching or cycling, like your thyroid state,
antidepressants, drugs, or even stimulant use. So Jay is on Adderall for his ADHD, but the use of Adderall
can increase your risk of cycling or switching. It doesn't have to, some people with bipolar disorder can successfully take
stimulants without a problem, but it is something to keep in mind if you're having this problem
and you also take stimulants. And it's also something to keep in mind if you're having this problem
to check your thyroid levels with blood work. Your doctor can write a request
for you to get blood work to check this, but here's
another big factor, and that's the choice of
medication that you're on. Most times, people with bipolar disorder require a combination of
medications that you take at the same time. Why, because the medications
treat different aspects of the disorder. The main four phases that we target in treating bipolar disorder
are acute depression, acute mania, mixed states,
and the maintenance phase. Acute means that it's the
active state that you're in, and it's relatively recent. Maintenance phase is the
period between episodes, when things have stabilized. Not all of the medications
work for every phase, so you could be put on a
medication because you're manic, and then once that mania goes away, you could have a depressive episode pop up because that original
mania drug isn't doing a good enough job keeping
your depression away. Let me show you how this
works with the actual drugs. The medications we use
to treat bipolar disorder fall into two categories, the anticonvulsant medications and the antipsychotic medications. We use antipsychotic medications even if you're not psychotic. That's just the original classification that the drugs fell under
when they were first developed and later became used as mood stabilizers for bipolar disorder. The anticonvulsant medications
are called anticonvulsants because they treat seizures, so neurologists will use
them for seizure management, they can also use them for migraines, some doctors will use them
for pain management as well, like nerve pain. Psychiatrists will use them for bipolar disorder predominantly. There are some off label uses like anxiety, and that's
a different video. Off label means that it's
not the original purpose that the drug was approved for. So here's how this breaks down. I'm gonna use the brand names because they're easier to say, but I do have a handout for
you that you can download from my website that
will have the brand name and the generic name for you. You can use this handout
as your own reference, and as a top talking
point with your doctor about the medications that
you might be interested in. So these are the medications
that have been approved by the Food and Drug
Administration for acute mania. The antipsychotic medications are Abilify, Saphris, Vraylar, Zyprexa, Seroquel, Risperidol, and Geodon. The anticonvulsant medications
that have been approved for mania are Tegretol,
lithium and Depakote, and technically lithium
is not an anticonvulsant. It's really in its own category. All three of these medications require blood level testing though, so if you do take them, you're signing up for a commitment of having your blood
level regularly checked, fairly frequently at first, maybe like every couple
of weeks or monthly, until you get a level
that's in the correct range, and then about once or twice a year. For bipolar depression, the
only medications approved to treat this phase are Vraylar, Latuda, Seroquel and Symbyax,
which is a combination pill that includes Zyprexa and Prozac. Notice there are no
anticonvulsants on this list. For mixed episodes, the approved
medications are Abilify, Saphris, Vraylar, Zyprexa,
Seroquel, Risperidol, and Geodon. Again, there are no
anticonvulsants on this list. The maintenance phase is
when you're pretty much out of your depression or mania, you can have some residual symptoms, meaning there's still a little
bit of something going on, but you're over the hump
of the intense symptoms that were causing you
a lot of dysfunction. Most people don't have 100%
resolution of everything, but they are improved enough to where whatever they have is manageable. So maintenance medications
work best to extend the length of time between episodes or prevent them from occurring altogether or decrease the intensity of the episode that does come back. Think of these medicines
as having armed guards protecting your perimeter to
keep the enemy from coming in. The antipsychotic medications approved for the maintenance phase
are Abilify, Saphris, Seroquel, Geodon, and Zyprexa. The anticonvulsants are lithium,
and then there's Lamictal. Now I keep saying approved, FDA approved means that when
these drugs were tested, they were shown to work
for a specific phase, and that's what they
got their approval for. Your doctor can still
prescribe medications that are for a non-approved purpose, like using Abilify to help
with your bipolar depression, but it may not work as well because it doesn't have
a track record for that, but it's still possible that it could work well enough for you. So let's go back to
Jay's medication regimen. For bipolar disorder, he's
taking Lamictal and Rexulti. Rexulti is an anti-psychotic that's only approved to treat
schizophrenia and depression. It's not approved for bipolar disorder. Lamictal works best when
you're in the maintenance phase and it really does its best job of preventing depressive episodes or lessening the intensity of them. So Jay, you're really not on something that has a track record of treating mania or even treating acute bipolar depression. Lamictal is not great for a
current depressive episode. So if you're taking
Lamictal, it's like having a lot of armed troops
protecting your perimeter, but if the enemy is able to break through that
barrier, Lamictal's done, and another medication has
to swoop in and take control. So we tend to use Lamictal
along with another medication, which is most commonly an
antipsychotic medication. Why, because the antipsychotic medications are the main ones that
do the heavy lifting in treating mania, depression,
and mixed symptoms. From the list that I went through, there's only one medication
that treats all four phases, and that's Seroquel. So if Seroquel is such magic, why wouldn't everyone take
it and never get sick again? Because everyone can't take Seroquel. Seroquel has a lot of side effects. It causes a lot of weight gain and it may make you very tired. Some people can't wake
up until they've had at least 12 hours of sleep, and with this medication, you can't just get up and shake it off. You can spend hours feeling like your head just doesn't clear up until mid-day. So if you have an early morning job, that's not gonna work well. The next drug that's the
most versatile in treating three out of four of
the phases is Vraylar. The only thing Vraylar
has not been shown to do that well with is the maintenance phase. So because of that, if you take Vraylar, you will probably need to
take another medication like Lamictal or lithium
to protect your perimeter and keep the enemy from coming back. So the moral of this story
is that combination therapy is very common in bipolar disorder because different medications
have different purposes. The medication that gets
you better may not be the same medication that keeps you better. So often treatment with bipolar disorder requires changing
medications because of things like side effects or insurance coverage. The newer medications, the
newer antipsychotic medications that are still brand name
only can cost on an average of a 1,000 to $1,500, if you have no insurance, and even if you do have insurance, your insurance may eliminate more of the more expensive
medications from the list of drugs that they'll cover. When they do this, they'll
request that your doctor use an equivalent, but there
may not be an equivalent that will do the job
that we want it to do, and that you can tolerate. Gaining 50 pounds is
not a minor side effect, and it's very appropriate
to eliminate that medication from your available list because of that. Fortunately, many of these
medications are generic and therefore more affordable. In the handout, I'll show
you which ones are generic. So we do the best we can with
what we have to work with, and if that means taking
a medication off label, so be it, if it works, but at least now, you know the reasoning behind combining certain
medications together and why only taking one may not be enough to keep you from cycling. Watch this video for more
information on mixed symptoms and bipolar disorder. I also have a bipolar playlist
where you can learn more on some of the things that I
talked about in this video. Thanks for watching. See you next time.
Love her videos. She has some other great ones on various bipolar topics.