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.