Medications for bipolar disorder: List, types, and side effects

Antipsychotics

Low risk of weight gain: Lurasidone has a low risk of weight gain. Other side effects of this drug may include the development of breasts in men, low blood pressure, and fainting.

Risk of weight gain: Quetiapine can cause weight gain. Common side effects may also include:

  • changes in blood pressure
  • nausea
  • cataracts
  • development of breasts in men
  • reduced thyroid function

High risk of weight gain: Olanzapine is very likely to causeweight gain because it increases your appetite. Other common side effects can include:

  • dry mouth
  • thirst
  • frequent urination
  • constipation
  • dizziness
  • sleepiness
  • weakness
  • movement disorders and tremor

Case Reports

Case 1.

Ms. A, a 58-year-old white woman, had a 37-year history of bipolar affective disorder, manic type with psychotic features. She was admitted to the inpatient unit at the local community hospital because of marked symptoms of mania such as pressured speech and sexual inappropriateness. Ms. A had multiple previous psychiatric hospitalizations. Medical history included Parkinson’s disease, 2 seizures, obesity, and urinary incontinence. She had no significant alcohol or drug history. Family history included schizophrenia in her mother.

Ms. A was on treatment with divalproex sodium for several years and recently had compliance problems. She had experienced significant weight gain over several years, resulting in the discontinuation of divalproex. Previous trials of lithium carbonate and divalproex resulted in lack of response to either alone or to the combination; therefore, a trial of topiramate was considered. Laboratory data, including blood count, electrolytes, thyroid studies, serum cholesterol, lithium level, and results of urinalysis and urine drug screen, were within normal limits. Weight on admission was 284 lb (128 kg).

On mental status examination, Ms. A appeared her stated age. She was alert and oriented to all spheres (person, place, time). She had pressured speech and increased psychomotor activity. Ms. A’s mood was elevated, and her affect was manic. She had flight of ideas, tangentiality, and decreased concentration. Her judgment and insight were fair. Her YMRS score was 20.

Topiramate was started at 25 mg/day and was gradually adjusted upward in 25-mg increments to 125 mg in the morning and 150 mg at bedtime. Owing to persistence of symptoms, lithium carbonate, 300 mg at bedtime, was added in combination with topiramate and was increased gradually to 1200 mg at bedtime. This addition of lithium resulted in improved sleep and a decrease in manic symptoms. Ms. A’s plasma lithium level was 1.0 mEq/L. She was continued on olanzapine, 20 mg at bedtime. Her other medications included celecoxib, 200 mg/day; furosemide, 40 mg/day; potassium chloride, 20 mEq/day; conjugated estrogen and medroxyprogesterone acetate, 0.625/2.5 mg/day; carbidopa-levodopa 25/250 mg/day, half tablet twice daily; and oxybutynin, 5 mg twice daily. She improved and was discharged to a group home. Her YMRS score was 1, and her BPRS score was 18.

Ms. A was followed up as an outpatient for 2 months, and her symptoms and weight were monitored during visits. She continued to do well, with no reported side effects. Her YMRS score was 0, and her BPRS score was 18. Her weight continues to decline since discharge from the hospital. Her weight before topiramate was 284 lb (128 kg), which decreased to 242 lb (109 kg) at 1-month, 240 lb (108 kg) at 2-month, and to 228 lb (103 kg) at 3-month follow-up. She had a 56-lb (25-kg) weight loss on treatment with topiramate.

Case 2.

Ms. B, a 42-year-old white woman with a 27-year history of bipolar disorder, was followed in a continuing day treatment program. Her medical history included obesity, fibromyalgia, and diabetes. Her family history was significant for obesity, cardiovascular disease, diabetes mellitus, multiple sclerosis, and alcoholism, as well as depression with suicide attempts in her mother. Ms. B reported irritability and occasional depressed mood. She also reported concerns about taking divalproex because of weight gain. Her weight was 176 lb (79 kg) before topiramate was added, and she had a DSM-IV diagnosis of bipolar disorder.

On mental status examination, Ms. B was well dressed and groomed and had clear and coherent speech. She had anxious mood and affect. Her judgment and insight were fair. Her YMRS score was 4, and her HAM-D score was 8. Her medications included divalproex, 500 mg in the morning and 1000 mg at bedtime; zolpidem, 10 mg at bedtime; citalopram, 40 mg/day; and lithium carbonate, 900 mg at bedtime.

Various options were discussed, including switching back to carbamazepine (which she had received previously), lowering the dose of divalproex, or trying topiramate. Consent was given, and Ms. B was started on topiramate, 25 mg at bedtime. The divalproex dosage was lowered to 500 mg twice daily. The rest of her medications remained the same.

At 3-week follow-up, Ms. B reported problems at home that caused significant irritability and moodiness. Her weight had decreased to 165 lb (74 kg). Topiramate was increased to 25 mg twice daily for 2 weeks and then was gradually increased in 25-mg increments to 75 mg twice daily. Divalproex was tapered and then stopped. Several weeks later, Ms. B scheduled an intermittent appointment because of increased irritability, decreased sleep, and increased sex drive. Mental status examination revealed that her mood was extremely irritable. Her affect was also irritable. Her judgment and insight were fair. Her YMRS score was 8, and her HAM-D score was 7. Lithium carbonate was increased to 1200 mg at bedtime, and the other medications remained at the same dosages. Laboratory data, including a serum lithium level, serum cholesterol, fasting lipid profile, and complete blood count, were within normal limits.

Six weeks later at follow-up, Ms. B reported decreased irritability and better sleep. No manic symptoms were noted. Her YMRS score was 0, and her HAM-D score was 6. She denied any side effects from the topiramate. Her weight continued to decline. Her weight prior to topiramate treatment was 176 lb (79 kg), which decreased to 165 lb (74 kg) at 1-month, to 162 lb (73 kg) at 2-month, and to 156 lb (70 kg) at 3-month follow-up. She lost 20 lb (9 kg) on topiramate treatment.

Case 3.

Ms. C, a 35-year-old white woman with a 22-year history of bipolar affective disorder with rapid cycling, was followed as an outpatient. She had multiple previous psychiatric hospitalizations. Ms. C’s medical history included hypothyroidism and weight gain. Her weight was 180 lb (81 kg) before topiramate was added, and her DSM-IV diagnosis was schizoaffective disorder. Her maximum weight had been 199 lb (90 kg). She also had a history of alcohol and cannabis dependence. Family history included a sister who committed suicide and manic-depressive symptoms in a brother. Ms. C had cycles of manic as well as depressive symptoms. Previous medication trials included lithium, risperidone, and olanzapine, with poor results. Lithium in combination with divalproex resulted in minimal improvement, whereas divalproex in combination with lamotrigine resulted in a 30% improvement per patient report.

Ms. C was seen for follow-up. She reported that she had stopped taking the mood stabilizers 3½ months earlier. She reported feeling depressed and was concerned about her weight. On mental status examination, she presented with low mood, and affect that was appropriate to the mood with a full range. Her thought process was organized, and her judgment and insight were fair. Her YMRS score was 5.

Because of her numerous previous unsuccessful medication trials, the use of topiramate was discussed. Consent was obtained, and Ms. C was started on topiramate, 25 mg/day. This dosage was gradually adjusted up to 100 mg twice daily. Concomitant medications included levothyroxine sodium, 75 µg/day; zolpidem, 10 mg at bedtime; and bupropion sustained release, 100 mg/day. Laboratory data, including thyroid studies, complete blood count, and liver function test results, were within normal limits. At 2-month follow-up, Ms. C reported improved sleep. She had no manic symptoms. Her YMRS score was 2. She was not experiencing any side effects from the topiramate. Her weight was declining; her weight before topiramate treatment was 180 lb (81 kg), which decreased to 162 lb (73 kg) by month 3. She lost 18 lb (8 kg) on topiramate treatment.

Case 4.

Ms. D, a 43-year-old white woman with an 18-year history of bipolar affective disorder, depressive type, was followed as an outpatient. She had multiple previous psychiatric hospitalizations and had been out of the hospital for 10 years. Her medical history included weight gain. Family history included depression and alcoholism in her father.

At an outpatient follow-up visit, Ms. D reported irritability because of tension in the workplace. She felt out of energy and was also concerned about a 14-lb (6-kg) weight gain. Her affect was anxious, and her mood was irritable. Her YMRS score was 3. Her medications included divalproex, 500 mg in the morning and 1000 mg at bedtime; lithium carbonate, 600 mg at bedtime; and fluoxetine, 20 mg/day. Her serum valproate level was 76 µg/mL, and her plasma lithium level was 0.8 mEq/L. Divalproex was decreased to 1000 mg at bedtime. Lithium carbonate was raised to 900 mg at bedtime, and fluoxetine was continued at 20 mg/day. The possibility of monotherapy such as lithium carbonate alone or the combination of lithium with topiramate was discussed. Dietary management and exercise were also recommended.

Ms. D was seen for follow-up 2 months later. She reported increased irritability and depression. Weight gain was still a concern. Her weight was 196 lb (88 kg). Because of lack of efficacy with previous trials of lithium carbonate and divalproex either alone or in combination, the use of topiramate was discussed and consent was obtained. Ms. D was started on topiramate, 25 mg in the morning, which was gradually adjusted up to 50 mg twice daily. Lithium was continued in the same dose, and divalproex was tapered and stopped. Laboratory data, including a complete blood count and liver function test results, were within normal limits.

At follow-up, Ms. D was alert and oriented to all spheres. Her speech was clear, and her affect was bright, with improved mood. No irritability was noted. She reported that she felt better about herself and that her weight was decreasing. Her YMRS score was 2, her BPRS score was 19, and her HAM-D score was 1. Her weight before topiramate treatment was 196 lb (88 kg). Her weight decreased to 192 lb (86 kg) at 1-month and to 185 lb (83 kg) at 2-month follow-up. She lost 11 lb (5 kg).

Case 5.

Ms. E, a 38-year-old Native American woman with a 12-year history of schizoaffective disorder, was seen at a continuing day treatment program. She had multiple previous psychiatric hospitalizations. At a routine visit, she reported concerns of weight gain, difficulty sleeping, and low sex drive. Her YMRS score was 3, her BPRS score was 19, and her HAM-D score was 6. Her weight was 282 lb (127 kg). Ms. E’s medications included divalproex, 1000 mg twice daily; risperidone, 6 mg at bedtime; and venlafaxine, 75 mg 3 times daily. A detailed discussion about her medications was held. Risperidone was decreased to 3 mg at bedtime, and the divalproex dosage was changed to 500 mg in the morning and 1500 mg at bedtime.

One month later, Ms. E reported both improved sleep and sex drive, but her weight continued to be a concern. She was started on topiramate, 25 mg twice daily, which was gradually increased to 75 mg twice daily. Divalproex was tapered and stopped. Laboratory data, including a complete blood count, liver function test results, and fasting lipid profile, were within normal limits.

At follow-up a month later, Ms. E was alert and oriented in all spheres. Her affect was bright, and her mood was neutral. Her thought process was organized. Her YMRS score was 1, and her HAM-D score was 2. She reported no side effects from topiramate and denied depressive or psychotic symptoms. Her weight was decreasing; her weight before topiramate was 282 lb (127 kg), which decreased to 274 lb (123 kg) at 3-month follow-up. She had a weight loss of 8 lb (4 kg).

Medications for bipolar disorder: List, types, and side effects

Mood stabilizers

Low risk of weight gain: Lamotrigine (Lamictal) is most likely to cause weight loss. However, it can also cause weight gain. Other common side effects of this drug include:

  • headache
  • trouble sleeping
  • drowsiness
  • upset stomach
  • aches and pains throughout your body

Risk of weight gain: Valproate is likely to cause weight gain. It may also cause tremors, headaches, dizziness, and nausea.

High risk of weight gain: Lithium is known for causing weight gain. Common side effects of this drug also include:

  • sleepiness
  • fatigue
  • low blood pressure
  • slowed thyroid function
  • mild nausea

Case 1.

Ms. A, a 58-year-old white woman, had a 37-year history of bipolar affective disorder, manic type with psychotic features. She was admitted to the inpatient unit at the local community hospital because of marked symptoms of mania such as pressured speech and sexual inappropriateness. Ms.

A had multiple previous psychiatric hospitalizations. Medical history included Parkinson’s disease, 2 seizures, obesity, and urinary incontinence. She had no significant alcohol or drug history. Family history included schizophrenia in her mother.

Ms. A was on treatment with divalproex sodium for several years and recently had compliance problems. She had experienced significant weight gain over several years, resulting in the discontinuation of divalproex.

Previous trials of lithium carbonate and divalproex resulted in lack of response to either alone or to the combination; therefore, a trial of topiramate was considered. Laboratory data, including blood count, electrolytes, thyroid studies, serum cholesterol, lithium level, and results of urinalysis and urine drug screen, were within normal limits. Weight on admission was 284 lb (128 kg).

On mental status examination, Ms. A appeared her stated age. She was alert and oriented to all spheres (person, place, time). She had pressured speech and increased psychomotor activity. Ms. A’s mood was elevated, and her affect was manic.

Topiramate was started at 25 mg/day and was gradually adjusted upward in 25-mg increments to 125 mg in the morning and 150 mg at bedtime. Owing to persistence of symptoms, lithium carbonate, 300 mg at bedtime, was added in combination with topiramate and was increased gradually to 1200 mg at bedtime.

This addition of lithium resulted in improved sleep and a decrease in manic symptoms. Ms. A’s plasma lithium level was 1.0 mEq/L. She was continued on olanzapine, 20 mg at bedtime. Her other medications included celecoxib, 200 mg/day;

furosemide, 40 mg/day; potassium chloride, 20 mEq/day; conjugated estrogen and medroxyprogesterone acetate, 0.625/2.5 mg/day; carbidopa-levodopa 25/250 mg/day, half tablet twice daily; and oxybutynin, 5 mg twice daily. She improved and was discharged to a group home. Her YMRS score was 1, and her BPRS score was 18.

Ms. A was followed up as an outpatient for 2 months, and her symptoms and weight were monitored during visits. She continued to do well, with no reported side effects. Her YMRS score was 0, and her BPRS score was 18.

Her weight continues to decline since discharge from the hospital. Her weight before topiramate was 284 lb (128 kg), which decreased to 242 lb (109 kg) at 1-month, 240 lb (108 kg) at 2-month, and to 228 lb (103 kg) at 3-month follow-up. She had a 56-lb (25-kg) weight loss on treatment with topiramate.

Case 2.

Ms. B, a 42-year-old white woman with a 27-year history of bipolar disorder, was followed in a continuing day treatment program. Her medical history included obesity, fibromyalgia, and diabetes. Her family history was significant for obesity, cardiovascular disease, diabetes mellitus, multiple sclerosis, and alcoholism, as well as depression with suicide attempts in her mother. Ms.

B reported irritability and occasional depressed mood. She also reported concerns about taking divalproex because of weight gain. Her weight was 176 lb (79 kg) before topiramate was added, and she had a DSM-IV diagnosis of bipolar disorder.

On mental status examination, Ms. B was well dressed and groomed and had clear and coherent speech. She had anxious mood and affect. Her judgment and insight were fair. Her YMRS score was 4, and her HAM-D score was 8.

Various options were discussed, including switching back to carbamazepine (which she had received previously), lowering the dose of divalproex, or trying topiramate. Consent was given, and Ms. B was started on topiramate, 25 mg at bedtime.

At 3-week follow-up, Ms. B reported problems at home that caused significant irritability and moodiness. Her weight had decreased to 165 lb (74 kg). Topiramate was increased to 25 mg twice daily for 2 weeks and then was gradually increased in 25-mg increments to 75 mg twice daily.

Divalproex was tapered and then stopped. Several weeks later, Ms. B scheduled an intermittent appointment because of increased irritability, decreased sleep, and increased sex drive. Mental status examination revealed that her mood was extremely irritable.

Her affect was also irritable. Her judgment and insight were fair. Her YMRS score was 8, and her HAM-D score was 7. Lithium carbonate was increased to 1200 mg at bedtime, and the other medications remained at the same dosages.

Six weeks later at follow-up, Ms. B reported decreased irritability and better sleep. No manic symptoms were noted. Her YMRS score was 0, and her HAM-D score was 6. She denied any side effects from the topiramate.

Her weight continued to decline. Her weight prior to topiramate treatment was 176 lb (79 kg), which decreased to 165 lb (74 kg) at 1-month, to 162 lb (73 kg) at 2-month, and to 156 lb (70 kg) at 3-month follow-up. She lost 20 lb (9 kg) on topiramate treatment.

Case 3.

Ms. C, a 35-year-old white woman with a 22-year history of bipolar affective disorder with rapid cycling, was followed as an outpatient. She had multiple previous psychiatric hospitalizations. Ms. C’s medical history included hypothyroidism and weight gain.

Her weight was 180 lb (81 kg) before topiramate was added, and her DSM-IV diagnosis was schizoaffective disorder. Her maximum weight had been 199 lb (90 kg). She also had a history of alcohol and cannabis dependence.

Family history included a sister who committed suicide and manic-depressive symptoms in a brother. Ms. C had cycles of manic as well as depressive symptoms. Previous medication trials included lithium, risperidone, and olanzapine, with poor results.

Ms. C was seen for follow-up. She reported that she had stopped taking the mood stabilizers 3½ months earlier. She reported feeling depressed and was concerned about her weight. On mental status examination, she presented with low mood, and affect that was appropriate to the mood with a full range. Her thought process was organized, and her judgment and insight were fair. Her YMRS score was 5.

Because of her numerous previous unsuccessful medication trials, the use of topiramate was discussed. Consent was obtained, and Ms. C was started on topiramate, 25 mg/day. This dosage was gradually adjusted up to 100 mg twice daily.

Concomitant medications included levothyroxine sodium, 75 µg/day; zolpidem, 10 mg at bedtime; and bupropion sustained release, 100 mg/day. Laboratory data, including thyroid studies, complete blood count, and liver function test results, were within normal limits.

At 2-month follow-up, Ms. C reported improved sleep. She had no manic symptoms. Her YMRS score was 2. She was not experiencing any side effects from the topiramate. Her weight was declining; her weight before topiramate treatment was 180 lb (81 kg), which decreased to 162 lb (73 kg) by month 3. She lost 18 lb (8 kg) on topiramate treatment.

Case 4.

Ms. D, a 43-year-old white woman with an 18-year history of bipolar affective disorder, depressive type, was followed as an outpatient. She had multiple previous psychiatric hospitalizations and had been out of the hospital for 10 years.

At an outpatient follow-up visit, Ms. D reported irritability because of tension in the workplace. She felt out of energy and was also concerned about a 14-lb (6-kg) weight gain. Her affect was anxious, and her mood was irritable.

Her YMRS score was 3. Her medications included divalproex, 500 mg in the morning and 1000 mg at bedtime; lithium carbonate, 600 mg at bedtime; and fluoxetine, 20 mg/day. Her serum valproate level was 76 µg/mL, and her plasma lithium level was 0.8 mEq/L.

Divalproex was decreased to 1000 mg at bedtime. Lithium carbonate was raised to 900 mg at bedtime, and fluoxetine was continued at 20 mg/day. The possibility of monotherapy such as lithium carbonate alone or the combination of lithium with topiramate was discussed. Dietary management and exercise were also recommended.

Ms. D was seen for follow-up 2 months later. She reported increased irritability and depression. Weight gain was still a concern. Her weight was 196 lb (88 kg). Because of lack of efficacy with previous trials of lithium carbonate and divalproex either alone or in combination, the use of topiramate was discussed and consent was obtained. Ms.

D was started on topiramate, 25 mg in the morning, which was gradually adjusted up to 50 mg twice daily. Lithium was continued in the same dose, and divalproex was tapered and stopped. Laboratory data, including a complete blood count and liver function test results, were within normal limits.

At follow-up, Ms. D was alert and oriented to all spheres. Her speech was clear, and her affect was bright, with improved mood. No irritability was noted. She reported that she felt better about herself and that her weight was decreasing.

Her YMRS score was 2, her BPRS score was 19, and her HAM-D score was 1. Her weight before topiramate treatment was 196 lb (88 kg). Her weight decreased to 192 lb (86 kg) at 1-month and to 185 lb (83 kg) at 2-month follow-up. She lost 11 lb (5 kg).

Case 5.

Ms. E, a 38-year-old Native American woman with a 12-year history of schizoaffective disorder, was seen at a continuing day treatment program. She had multiple previous psychiatric hospitalizations. At a routine visit, she reported concerns of weight gain, difficulty sleeping, and low sex drive.

Her YMRS score was 3, her BPRS score was 19, and her HAM-D score was 6. Her weight was 282 lb (127 kg). Ms. E’s medications included divalproex, 1000 mg twice daily; risperidone, 6 mg at bedtime; and venlafaxine, 75 mg 3 times daily.

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