Ask the Doctor: Medication Management

Last Updated: 11 Oct 2020

Antianxiety medications. Antipsychotics. Antidepressants. Mood stabilizers. Why so many meds? The advantages (and risks) of combining medications in managing a complex mood disorder.

ask doctor medication management prescriptions bipolar disorder

Over several years of medical management of a chronic illness such as bipolar disorder, it is common to see people taking pills from several different classes of medications. For example, an antipsychotic added during an acute episode of mania, mixed state, or depression, or for longer-term management of symptoms; an antianxiety medication added at a time of particular stress; an antidepressant added at a time when depression was a substantial problem; a mood stabilizer as a mainstay and preventive strategy to keep all episodes at bay.

There are advantages to combining medications in the management of a complex pattern of mood instabilities, but there are also risks that need to be considered.

How come whenever I am hospitalized, a new medication is added?

During hospitalization, there is pressure to find solutions to immediate problems, and adding a new medication that helps—if only in the short term—is common … yet existing medications are often continued. The result is a plethora of medications upon discharge. The outpatient team will often touch base to make sure renewal scripts are in place but may not have sufficient time for a comprehensive review of the overall treatment plan and strategy.

Do I really need all these meds?

The management of bipolar, as with any medical condition, involves a collaboration between the health-care team and the individual (and the family). A successful management strategy combines the expertise of the care team with the engagement of the individual to form a therapeutic alliance to treat the illness over time. At regular intervals it is wise to review the overall medication management plan and simply ask: Are we on the right track? This is particularly true if there are multiple medications from several classes that are taken on a regular basis. The questions to ask the treatment team are straightforward: Why am I taking medication “x”? What are the risks and benefits?

Occasionally one medication may interfere with the metabolism of another, so be sure to ask about interactions. An additional consideration is age: older people are often more sensitive to medications, and too many medications can cause confusion and delirium.

What else should I ask my treatment team about?

As you review your treatment strategy with your care providers, you may want to know not only if all the medications you are taking are necessary, but also whether any could be causing problems. Antipsychotic medications can be a lifesaver in the case of an acute manic or depressive episode, and continued use of this class of medications can be highly successful in ongoing care and maintenance; however, if the doses are kept too high or if the individual is taking more than one medication from this class, the result can be over-sedation. The use of antidepressants requires caution, as these may cause unstable moods or irritability, or precipitate an episode of mania. The use of stimulants, likewise, may cause mood instability. The mainstay of the maintenance of bipolar treatment is mood stabilization, and there are many medication options available that should be discussed with the treatment team.

How can I learn more about medication management?

These days, it is easier than ever to remain informed. Two authoritative and credible websites I can recommend are (Canadian Network for Mood and Anxiety Treatments) and (National Institute of Mental Health).

If you have a question for your treatment team, write it down and ask it early in the appointment to allow time for discussion. Don’t be shy about asking for clarification or advice.

What if I don’t agree with my doctor?

If you have a disagreement with your providers, ask them to explain their recommendations. It is a good idea to ask for a second opinion. It is not a good idea to do something (e.g., stop medication) on your own—but if you do, always inform your treatment team.

Printed as “Ask the Doctor: Medication Management,” Fall 2020

About the author
Melvin G. McInnis, MD, FRCPsych, is Thomas B. and Nancy Upjohn Woodworth Professor of Bipolar Disorder and Depression and professor of psychiatry in the Department of Psychiatry, University of Michigan School of Medicine. He is also principal investigator of the Heinz C. Prechter Bipolar Research Program and associate director of the University of Michigan Depression Center.
  1. I have come to terms with the fact that it is going to take more than 1 med to keep me stable but I have a really hard time accepting that it will be for the rest of my life.
    Just a note on getting a second opinion, it may be possible in big cities but where I live you can’t even get one in person. I tried to change and was told they were so backlogged with requests they would not see me if I was currently seeing someone. So I am stuck with teleconferencing. My other big frustration is there are no groups for mental health. We are drowning out here with no relief in sight. We need to make mental health a priority in this country and find a way to encourage more doctors to go in to psychiatry

  2. To Middle Name Game…it is unfortunate that nothing works as well as klonopin. I can see how your wife appeared to feel wonderful. That is what klonopin does. It makes everything ‘ok’ is unfortunate that it is so addictive. I personally have not found anything that works as well…unfortunately. I hope your wife is recovering. If there only there was a substitute for klonopin that worked as well without being addictive. We would all be cured,

  3. My wife was taking multiple medications as part of an adjunctive therapy for the treatment of her bipolar disorder She began to have a shift towards mania and stop taking a lot of the medications and really gravitated to as the benzodiazepine which was Klonopin she continued filling all the Scripts as if she was taking all the medications and they were working great and she was feeling great but it really was just the the mania and the excessive use ok Klonopin. After she was sectioned I went to the house to clean up all the bottles of medication and almost every bottle of Abilify and lamictil was completely unopened. Not a Klonopin to be found.. after to having gone through the entire year long experience not knowing that she was bipolar and seeing the miss use of drugs and alcohol I feel that bipolar disorder should be treated with a single pill with the medications combined into that single pill so that the person being treated is not able to pick and choose what medications they want to take because some of them have addictive properties and play into the mania very much

  4. I have an add on medication to my lithium, trintellex. I recently went off it with my Doctors concent but I am finding i need to go back on it. It is only 5mg but without it I am finding i can’t tolerate life’s little hurdles as well and my emotions are not as stable. So in my opinion add on medications are needed and effective!

    1. I’ve also had great success with Trintellix. It was first prescribed to me before my BP diagnosis, when my Lexapro stopped working and it has been amazing for my anxiety. Once the Lamictal was added, it was like I was back to normal, or what I remember normal being anyway. I would definitely NOT be the same without it, that’s for sure.

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