Antianxiety medications. Antipsychotics. Antidepressants. Mood stabilizers. Why so many meds? The advantages (and risks) of combining medications in managing a complex mood 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 canmat.org (Canadian Network for Mood and Anxiety Treatments) and nimh.nih.gov/health/topics/bipolar-disorder (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
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