To allow your pharmacotherapy for bipolar disorder the best chance to work, identify what’s interfering with your medication adherence and explore simple solutions.
Tricia received a diagnosis of bipolar disorder II less than a year ago, in January 2019. She took it as good news, since it opened new treatment avenues.
It was still a daunting prospect for Tricia, though. She’d had a rocky ride with antidepressants she’d been prescribed a few years back for depressive symptoms.
“I was terrified of taking medication,” admits Tricia, a Missouri mother of two.
With her eyes on the prize of stability, Tricia plowed ahead despite her reservations. Like many people with bipolar, she has had to test-drive a number of new prescriptions in pursuit of the best results.
“We are still trying to find perfect combination of medication for me,” she says.
In the bipolar community, having a conflicted relationship with your psychiatric meds is a familiar story. For one thing, many people resist their diagnosis at first and dismiss the need for pharmacological treatment. Others simply don’t want to rely on pills on principal.
Writing in the January 2018 issue of U.S. Pharmacist, a team of North Carolina pharmacists report that an estimated 50 percent of people with any type of chronic illness either don’t take prescribed medication properly or don’t take it at all.
That figure includes those who go off their medication or take it inconsistently, for reasons ranging from cost and side effects to inconvenience and human error.
The issue of “medication compliance” or “medication adherence” is much discussed in the medical field in general—whether it applies to an antipsychotic for bipolar, insulin for diabetes, or an antibiotic for strep throat.
As the authors of the 2018 article note, “medication adherence can have a more direct impact on patient outcomes than the specific treatment itself.”
The bottom line: The more you give your meds a chance to work, the better your chances of getting better. The odds of strengthening your overall wellness improve once you figure out what gets in the way of medication adherence and come up with solutions that work for you.
TAKE YOUR TIMING
Synching when you take your medication with where you need to be and what you need to do at any given time is a common challenge.
Tricia ran into problems taking her nighttime med because it was making her drowsy.
“My kids are normal 13- and 11-year-old farm boys. If I took it too early, I didn’t have family time,” she explains.
Wait too long, though, and she would fall asleep without taking her dose. Wake in the night and take the med then, and she would oversleep or feel groggy in the morning.
“It’s been a real trial to figure out the right times,” she says.
Things went better after Henke started setting a reminder alert on her phone for the ideal evening hour. She also switched over to meds that had a less sedating effect.
She’s prepared to make whatever accommodations it takes to stick with her treatment plan.
“You gotta do what you gotta do to stay healthy for your family, if not for yourself. They are what kind of keeps me going,” Henke says.
Fear of side effects may be the biggest factor pushing people away from medication. Inability to tolerate side effects, meanwhile, may lead to going off a med in midstream. At the least, it calls for starting from scratch with another option.
Paul of Rhode Island can tell quite a story about that, thanks to an evolving diagnosis (ultimately arriving at bipolar I) and a susceptibility to side effects. He spent more than a decade cycling through a multitude of medications at different dosages. Earlier this year, he and his doctor figured out an approach that’s been working for him.
People naturally vary in their reactions to medications of all kinds. Paul falls at the far end of the response spectrum. There didn’t seem to be a mix that would bring his symptoms to a manageable level without causing him undue distress.
Paul kept searching for a formulation that would keep his mood from spiraling upward and prevent psychosis, but not result in nausea, sluggishness, and other side effects he couldn’t live with. In his case, the answer was to pare back his regimen to a single mood stabilizer and establish safeguards against infrequent manic eruptions.
“This is the best I have ever felt,” he says. “It’s still a struggle, no doubt, but nothing else has worked. This is what I need to do … and I will do it with every ounce of my being.”
His experience illustrates how standard treatment protocols often need to be adapted and individualized. The hard truth is, there may not be a “perfect” pharmacological solution.
Holistic recovery emphasizes finding your personal sweet spot—able to pursue a fulfilling life with the least possible disruption from bipolar symptoms. Psychotherapy and self-care play vital roles in fostering stability, along with medications.
Paul has made his peace with incomplete symptom control in exchange for improvement in his overall quality of life.
“I am more alert now. I have rediscovered my love of piano, as well as enjoying a more creative and artistic lifestyle,” he says. “I am also able to communicate better and maintain a solid relationship with the love of my life.”
You should have the final vote on what goes into your body. Still, it’s not wise to skip doses or stop taking a med altogether without looping in your prescribing practitioner.
If your practitioner doesn’t know you’re not taking the full course of a medication, it’s impossible to properly evaluate how well the treatment is working, notes Chris Bojrab, MD, a distinguished fellow of the American Psychiatric Association who heads a private behavioral health care practice in Carmel, Indiana.
Without the full story, a practitioner may increase the dose of the current med rather than look at other choices that might better suit your situation.
Ideally, your input should be met with respect and a willingness to problem-solve and explore alternatives. If not, you need to find a way to be an assertive self-advocate.
In his own practice, Bojrab encourages asking questions and airing concerns. As he sees it, “You are the captain of the boat. I am the expert navigator.”
If remembering to take medication makes it hard to follow your regimen, ask about options such as a long-lasting injection. A new innovation, known as digital medication or “smart meds,” incorporates a sensor to electronically track (via a phone app) whether you’ve taken your daily dose.
You could also enlist allies from your support circle who will back up your wellness efforts and step in when you’re slipping off course. Be aware that this kind of relationship can be tricky to establish, Bojrab says, because you are inviting someone to place their judgment of how you’re doing on par with, or sometimes above, your own.
Psychotherapy can be a good place to problem-solve around issues with your meds, including body image issues from weight gain. It may even be a more comfortable setting for airing your discontents, says Elisabeth Bennett, PhD, a professor of counselor education and director of clinical mental health at Gonzaga University in Spokane, Washington.
“The therapist often sees [you] far more than the doctor does,” Bennett says, so the relationship may feel more personal.
Having more in-depth knowledge of an individual’s changes and challenges week to week means “the therapist can provide important input … that can help the prescriber to adjust meds accurately,” Bennett adds.
Your pharmacist can be helpful resource, says Megan Ehret, PharmD, an associate professor of pharmacy at the University of Maryland School of Pharmacy—for example, if a tried-and-true medication becomes unavailable.
“We’ve had a lot of shortages come and go with older medications,” Ehret says.
In those cases, the pharmacist would work with the prescriber to find a suitable replacement.
IN IT TO WIN IT
Setbacks sometimes occur from giving up on a prescription too soon—either from discouragement or overconfidence.
“Many medications take several weeks to reach effectiveness … and [people] get hopeless before the meds have a chance to work,” Bennett says.
People also overlook the fact that medications for chronic illness—conditions that can be managed but not cured, such as bipolar disorder—need to be continued on a maintenance and preventive basis, not just during an “acute” episode.
Denise, who lives in Southern California, observed that phenomenon while attending a peer support group at her church.
“There were about 10 to 12 of us. Several stopped taking their medicine because they were feeling good,” she recalls. “Then they relapsed.”
Denise herself has stuck with a successful mélange of four medications since her bipolar diagnosis 20 years ago, although she’s had to make some adjustments in her routine along the way.
After years of misdiagnosis and ineffective treatment before her bipolar disorder was identified, Hynes wasn’t going to waffle about staying on meds that actually helped.
“I have never really had a problem with taking my medication,” she muses. “Once it helped me, I felt like, ‘This is the magic here.’”
• • • • •
Chances are you’ll need to try a number of medications, in different doses and groupings, before hitting on a winning combination.
Some bipolar meds work better on either elevated mood or depressive symptoms. Others, known as mood stabilizers, effectively control both ends of the bipolar spectrum. Mood stabilizers typically are the first class of medications to be considered after a bipolar diagnosis.
The class of mood stabilizers includes some anticonvulsants and antipsychotics Different mood stabilizers may be prescribed together, or in tandem with one or more other types of meds. In addition, the treatment “cocktail” often incorporates meds used to calm anxiety and agitation, including benzodiazepines, as well as meds that target insomnia.
Here’s a primer on the basics:
Lithium, a naturally occurring salt that was the original mood stabilizer, remains a primary first-line treatment for bipolar.
Antipsychotics are effective for mania and hallucinations, delusions, or other psychotic symptoms. Newer formulations have been approved for bipolar depression and mood episodes with mixed features (co-occurring depressive and manic symptoms). Second-generation or atypical antipsychotics are generally considered an advance on first-generation or typical antipsychotics because they tend to have fewer side effects.
Anticonvulsants, originally developed to controls seizures, often are prescribed for frequently recurring mood episodes. The drug’s action regulates electrical impulses in the brain.
Antidepressants should be paired with a mood stabilizer—if prescribed at all—when treating bipolar depression.
• • • • •
A weighty topic
The issue of food cravings and weight gain from certain medications looms large (so to speak) in the bipolar community. It’s definitely worth bringing up with your practitioner if this troubles you.
The two of you will need to balance the med’s potential contribution to your stability against the physical and psychological impact of getting heavier. The same type of discussion with your therapist could be helpful in coming to terms with body image issues. There are also a number of online support groups and forums specific to weight gain from bipolar treatment, as well as the Healthy at Every Size (HAES) community.
A 2017 analysis by Sri Lankan researchers, published in Neuropsychiatric Disease and Treatment, concludes that individuals taking psychiatric medications associated with weight gain “should be routinely provided with nutritional counseling and advice about a healthy lifestyle.”
Look into coaching about weight management, working with a dietitian or nutritionist, and checkups to track your risk for various weight-related medical conditions. You could also review alternate medications to consider. Some of the second-generation antipsychotics don’t have the same association with weight gain as the older formulations.
• • • • •
Be medication savvy
There are things an informed consumer will want to know about a medication prescribed to treat bipolar disorder.
Does this med work primarily to control mania, depression, mixed states, or some combination? What symptoms typically should improve, and how long before I should see some results?
What side effects can I likely expect, and how quickly should they settle down? Which should I worry about enough to call for an immediate consult? Will blood tests or other monitoring be necessary, and how frequently?
Should this med be taken at a specific time of day? Should it be taken with food? Are there interactions with other medications (including birth control) to be aware of?
Your first source for information, naturally, should be your prescriber. Don’t hesitate to come in with your own background information and your list of questions.
Indiana psychiatrist Chris Bojrab, MD, supports educating yourself about bipolar and treatment options—but notes that “you can find anything to support anything” on the Internet. He recommends giving due consideration to your practitioner’s specialized knowledge and experience.
“Let me be your filter,” Bojrab says.
Here are some other places to look for answers:
HEALTH CARE PORTALS: Many medical and behavioral health care practices nowadays are linked to an online information network. Questions emailed through the portal generally get addressed within 24 hours.
PHARMACISTS: An especially good resource in off-hours, since you can speak in person or by phone for more immediate answers. Walgreens (in partnership with Mental Health America), CVS, and other chains also offer 24-hour online access via email or a request for a phone call.
REPUTABLE WEBSITES: Pharmaceutical companies post information about their products (if given the option, select “patient information” for less technical jargon). MedlinePlus, an initiative of the National Institutes of Health and the National Library of Medicine, has a useful “drugs and supplements” silo.
The National Alliance on Mental Illness (NAMI) provides a solid body of information about “mental health medications” (what to expect, what to avoid, medication adherence, and more). Some health care systems, including the Mayo Clinic and Kaiser Permanente, have a wealth of doctor-approved material across a range of topics related to specific medications and treatment in general.
Sasha Kildare, a feature writer, speaker, and educator, is also the author of the upcoming memoir and information guide Intact: Untangle the Web of Bipolar Depression, Addiction, and Trauma. Her blogs about storytelling can be found at DrivenToTellStories.com, and you can find her on Twitter @sashakildare and Instagram @sashakildare562.
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