First published in Bipolar Life's April 2020 newsletter
Most people living with bipolar disorder understand the importance of medication in the management of their condition. We know that medications are to be taken lifelong, with a few exceptions. We also understand that they are taken in addition to, not as a replacement for, other treatments such as psychotherapy, healthy lifestyle and a good routine; this includes a good sleep pattern, regular exercise, good nutrition and strong social support.
So, what happens if we don’t treat bipolar disorder in the right way, for instance self-treating? The following scenarios could happen :
Therefore, it makes sense for you to work with your doctor to ensure the medications prescribed are right for you. As all medications can cause side effects, it is essential to be open and honest with your prescribing doctor if you are experiencing any problems. It is inadvisable to reduce or stop a medication without consulting with your doctor first.
In this article we are going to look at:
Bipolar disorder is treated with three main classes of medication: mood stabilisers, antipsychotics and antidepressants. Sometimes your doctor may prescribe (usually short term) anti-anxiety and sleep aids–benzodiazepines and Z drugs. In this article we won’t go into much detail how they are used, such as acute treatment versus maintenance, or what is used for mania versus depression. Instead we’ll just concentrate on the side effects aspect to keep the article reasonably short.
MOOD STABILISERS – LITHIUM [1,5]
Around 75% of people of people taking lithium for bipolar disorder get side effects . It is effective for mania, and is gold standard for maintenance therapy, and may help bipolar depression .
Important note on lithium toxicity
This can be caused by various factors such as taking too many tablets, dehydration, or having a sudden drop in kidney function. This can be a dangerous condition and needs urgent medical attention. Symptoms can include nausea, vomiting, diarrhoea, drowsiness, unsteadiness, confusion, agitation, blurred vision, severe tremors, muscle jerks or seizures .
People taking lithium are recommended to have regular blood tests to check lithium levels, kidney and thyroid function .
How to avoid dehydration
To avoid dehydration, it’s important to keep well hydrated especially if exercising, or in hot weather. Try not to have too much caffeine or alcohol as they can dehydrate. Medications such as diuretics and non-steroidal anti-inflammatory drugs (such as ibuprofen) can also cause lithium levels to rise so care is needed.
We’ll now look at the anticonvulsants which are also used as mood stabilisers.
MOOD STABILISERS – ANTICONVULSANTS [1,6]
Important note on Stevens-Johnson syndrome
This is a rare, serious disorder of the skin and mucous membranes. It usually begins with flu-like symptoms (such as fever, fatigue, cough), then a red or purplish blistering rash that spreads over the body. The mouth, eyes, nose and genitals can be affected . You must seek immediate medical attention if you suspect you are having this reaction to a medication.
The first antipsychotics developed, now known as first-generation typical antipsychotics (FGA), were used to treat people with schizophrenia in the 1950s. The second-generation antipsychotics (SGA) came out in the 1980s, and are commonly known as atypical antipsychotics . The SGAs are helpful in reducing mania and in strengthening antidepressant treatment .
The SGAs generally are far less likely to cause a particular class of side effects, the extrapyramidal side effects such as restlessness, muscle stiffness, involuntary neck spasm, Parkinson’s like movements, involuntary facial and mouth movements .
It is recommended that people taking antipsychotics should have 6-12 monthly monitoring to check weight, blood pressure, fasting glucose and cholesterol, and ECG (heart trace) .
Treating depression in someone with bipolar disorder is less straightforward than for unipolar depression. For instance, in type 1 bipolar, antidepressants may be less effective . Also, mania can be triggered by use of an antidepressant, particularly if the person is not also taking a mood stabiliser. There are several classes of antidepressant. Some of their brain actions are similar, some are different, and this is reflected in the differing side effect profiles in the table below.
There are some less commonly used antidepressants available in Australia. These include mirtazapine, trazodone, the Tricyclic Antidepressants (TCAs, such as amitriptyline and nortriptyline) and MAOIs (monoamine oxidase inhibitors such as phenelzine and tranylcypromine). You can read more about TCAs here  and MAOIs here .
ANTI-ANXIETY AND SLEEP MEDICATIONS
Anti-anxiety medications (anxiolytics) and sleep aids (hypnotics) can be immensely helpful in the acute phase of depression and mania treatment. These are generally within the class of benzodiazepines (such as diazepam, temazepam, lorazepam) or Z drugs (such as zopiclone, zolpidem).
Both benzodiazepines (“benzos” for short) and Z drugs pose a risk of dependence, so these medications are usually prescribed for as short a time as possible. Some people do require them longer term, but this requires strict monitoring by their doctor.
Side effects can range from mild to severe. This can include daytime sedation, or impaired ability to drive, operate machinery or perform certain tasks.
In overdose, or if taken with certain other drugs (prescribed, over-the-counter or illicit), or alcohol, adverse effects can be severe and even result in coma or death. The elderly are also at particular risk from these medications.
It is possible to become dependent after just a few weeks of taking them regularly . Signs of this process happening include:
Withdrawal from benzos needs to be done with regular review by your doctor. Some people can feel unwell if reducing too quickly, and may experience agitation, insomnia, hallucinations and seizures .
WHO MIGHT BE AT INCREASED RISK FOR SIDE EFFECTS?
Older people are less able to metabolise their medications through the kidney and liver. At any age, but often more commonly seen in the elderly, being on a cocktail of medications can increase the risk for drug interactions and adverse effects. This is an important issue that needs regular monitoring by their doctor .
People who have pre-existing medical conditions may find them aggravated by weight gain, increased glucose or cholesterol. These conditions include high blood pressure, heart disease, history of stroke, diabetes, liver disease, kidney disease and arthritis.
Substance use disorder can be seen in one-third to one-half of people with bipolar disorder . People who drink alcohol, particularly if in excess of recommended levels, or take illicit drugs, may be at higher risk for side effects–in addition to the drugs and alcohol potentially worsening control of their bipolar disorder. Alcohol may cause dangerous interactions, especially when taken with lithium and benzodiazepines .
WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTS
Keeping a journal when you start or change a drug regimen can be helpful in working out if a symptom is really a side effect or whether it is the illness, or something else entirely.
If you think you are getting side effects, regardless of whether they are new or longstanding, it is a good idea to check in with your doctor. It might be decided that they side effects are mild and non-serious, and the benefits of the medication outweigh the adverse effects, in which case you could opt to continue.
Possible other scenarios include:
TIPS FOR SPECIFIC SIDE EFFECTS
Here are some tips for specific issues. Once again, these are ideas for you to discuss with your doctor first.
MEMORY AND COGNITIVE ISSUES 
HAIR LOSS (SODIUM VALPROATE]
Medication is vital to most people’s bipolar treatment plan. It is important to be aware of possible side effects and to bring them to your doctor’s attention as soon as possible, so that you can both decide on the best course of action for your health.
If you think this article might help someone else too, please like and share.
All content within this article is for informational purposes only and is not intended to serve as a substitute for individual consultation with a qualified physician.
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Dr Alice Lam
I'm a doctor who is passionate about writing quality health content.