Add-on Treatments

Bipolar disorder is often treated with more than one medication. In addition to mood stabilizers, other treatments, such as antidepressants, anti-anxiety medications, antipsychotic agents or medications for sleep disturbance, may be needed for a period of time. Medications added to the mood stabilization treatment may be used throughout an episode and then decreased to lower doses or some may be removed after the episode has passed. How long these medications are needed varies with each individual. Duration depends on the type, frequency, severity, and pattern of a person?s episodes. It is important when new medications are added to treatment for patients to report side effects that are concerning to their healthcare provider. Patients should also remain on all medications until their healthcare provider believes it is safe to begin withdrawal.

Antidepressant treatment: When depression is severe or a mood stabilizer is not enough to bring a depressive episode under control antidepressants may be added. Antidepressant medications can trigger a manic episode. Therefore, the choice of medication will be based on depressive symptoms, the likelihood of triggering mania, and any other medical conditions. Mood stabilizers help decrease the chances of switching to a manic episode when being treated with an antidepressant. Tricyclic antidepressants are generally avoided because of their increased risk of triggering a manic episode. Antidepressants commonly chosen include bupropion, selective serotonin reuptake inhibitors (SSRIs), venlafaxine, and monoamine oxidase inhibitors (MAOIs).

SSRIs

SSRIs are one of the more commonly used groups of antidepressants. They are effective in treating a broad range of symptoms and are generally well tolerated. They have fewer side effects than some of the older medications. Patients tolerate these medications better when they start them at low doses and build up slowly. It is also important to withdraw these medications slowly when you are about to stop taking them to avoid withdrawal effects.

SNRI

Venlafaxine is a commonly used antidepressant today. Like the SSRIs patients tolerate it better if they start on a low dose and build up slowly. People taking venlafaxine should have their blood pressure monitored regularly because this medication can cause an increase in blood pressure. The medication should be taken with food to reduce the chance of an upset stomach. When venlafaxine is discontinued the dose should be reduced slowly.

Tetracyclic Antidepressants

Mirtazapine is a relatively new antidepressant on the market. It is sometimes used in depressed patients who experience difficulty sleeping, because it causes sedation. It has less nausea and anxiety associated with it than other new agents. Because of the side effect of sedation, it is important to be careful to wait until drowsiness has disappeared before operating a motor vehicle or dangerous machinery, or participating in an activity requiring good focus. Sedation problems decrease after patients have been on the medication for a while and, contrary to what one might expect, with increased doses. It is important to monitor for weight gain and increased cholesterol levels.

Tri-cyclic antidepressants

This is an older group of antidepressants still in use today. They are very effective and generally cheaper than the newer medications. However, they are less popular because they have more side effects, such as, dry mouth, drowsiness, dizziness and constipation. These medications should be started at low doses and built up slowly. When being stopped, they should be tapered gradually. These medications are not used very frequently for depressive episodes in patients with Bipolar Disorder because of how frequently they trigger a ?switch? from a depressed episode to a manic episode.

Irreversibile MAOIs

MAOIs are one of the oldest classes of antidepressants. Like most antidepressants they are tolerated best when a patient goes on the medication at a low dose and builds up slowly. These medications are very effective, but are usually chosen only when other newer medications have not worked; this is because of their side effects and drug-food interactions. When combined with food containing high amounts of tryamine a patient can experience what is known as ?hypertensive crisis.? A hypertensive crisis is a rapid rise in blood pressure which can precipitate a stroke.

• aged cheese
• smoked meat
• sour cream
• pickled herring
• Soya sauce
• canned figs
• meat prepared with tenderizers
• chocolate
• Red wines and beer
• Decongestants (pseudephedrine, phenylephrine)

• a severe headache at the back of the head, possibly radiating forward
• stiff neck
• nausea, vomiting
• sweating or cold and clammy skin
• rapid heart rate
• agitation
• pale skin and then flushing
• photophobia (extreme sensitivity to light)

It is important to withdraw MAOI medications slowly to prevent withdrawal effects.

Reversible Monoamine Oxidase Inhibitors(RIMA)

Unlike the irreversible monoamine oxidase inhibitors, reversible monoamine oxidase inhibitors do not require strict dietary restrictions. It is recommended that large quantities of foods containing tyramine be avoided, and that the medication be taken immediately after meals to minimize any tyramine related response to food. For a list of tyramine containing foods see Irreversible Monoamine Oxidase Inhibitors.

Norepinephrine-Dopamine Reuptake Inhibitor(NDRI)

A side effect of many antidepressants is sexual dysfunction. Bupropion does not cause sexual dysfunction and may even improve sexual function. It may lower seizure threshold and therefore should not be used in people with seizure disorders or those who are at risk for seizures, including people with bulimia or anorexia, or those undergoing withdrawal from alcohol or benzodiazepines. If you take more than 150 mg daily of this medication you should space the doses eight hours apart to prevent seizures. Bupropion can interfere with sleep so the last dose of the day should be taken no later than 4 PM to minimize sleep problems. The drug should be taken with food to avoid nausea. Tablets are formulated for slow release of the medication and therefore patients should not break, crush or chew them.

Antipsychotic treatment: Antipsychotics are used for their mood stabilizing effects and psychotic symptoms when psychosis is present. Atypical antipsychotics such as Olanzapine, Risperidone, Quetiapine, Ziprasidone, and Aripiprazole are most frequently chosen.