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Posted on September 11, 2007 by Dr. Fink

Sometimes, you may begin to wonder what’s worse—the depression and mania or the side effects from the medications used to control the depression and mania. In fact, one of the main reasons that people with bipolar disorder stop taking their medications is because they simply can no longer tolerate the negative side effects. And who can blame them? Nobody likes to gain 30 pounds, feel groggy all day, become forgetful, walk around feeling dizzy, shake, twitch, feel nauseous, or have an anxiety attack. Yet, all of these side effects and more are possible with one medication or another used to treat bipolar symptoms.

Fortunately, there are a number of techniques for controlling some of the worst side effects. Not all of them are perfect, but the strategies described here, which you and your doctor may consider, can frequently reduce or even eliminate negative side effects.

Warning: Do not try any of the techniques offered here without first consulting with your physician/psychiatrist. We offer these only as possible ideas for discussion. Never make adjustments on your own.

Consult your doctor

When you experience a particularly unpleasant side effect, a common impulse is to stop or change the medications on your own. Try to avoid this at all costs—talking to you doctor is the best way to manage the side effects without causing further problems. Something else completely unrelated to the medication may be going on, and your doctor can help you sort it all out. If a medication adjustment is required, he or she can also assist you with making those changes.

Tip: Before you begin taking a new medication, ask your doctor to explain the most common and serious side effects, so you know what to watch out for and what to do if you notice a particular side effect.

Ramp up slowly

When you first start taking a medication, side effects tend to be more common, because your body must get acclimated to the new substance you’re ingesting. Just as ramping up your exercise routine too fast can make you feel ill, starting out with full doses of a medication can cause imbalances in your system.

Your doctor will probably increase the dosage gradually to help you avoid or diminish the intensity of the side effects. Don’t increase the medication any faster than is recommended. And if you don’t feel well as you are increasing the dose, ask your doctor if you can increase even more slowly.

Change medication times

If you typically take a medication in the morning, and it makes you too drowsy for work, your doctor may recommend that you take it in the afternoon or evening. If you cannot sleep when you take a particular medication at night, your doctor may recommend taking it earlier in the day.

Reduce the medication dose

One of the most common strategies used to reduce side effects is to reduce dosage. After adjusting medication doses upward to get the desired effect, you can sometimes back down a bit without losing the benefit. This isn’t always possible, but it is often one of the first things your doctor will suggest.

Switch to an extended-release version of a medication

Many medications come in extended-release tablets that release the medication to your bloodstream gradually rather than all at once. Consult your doctor concerning your options.

Tip: If no extended-release version of the medication exists, your doctor may recommend that instead of taking one large dose, you take two or more smaller doses throughout the day. This makes taking the medication less convenient, but it may help alleviate the side effects.

Add another medication to counteract the negative side effect

For example, if you experience weight gain on Depakote, your doctor may prescribe Topamax in an attempt to reduce weight gain.

We’ve read other articles that recommend dieting and exercising more, which is certainly an option, but such suggestions usually come from people who haven’t experienced a persistent weight problem or don’t know just how frustrating it is to gain 30 or 40 pounds due to a medication that’s supposed to make you feel better.

However, if you are uncomfortable adding more medications and want to pursue more dietary and exercise strategies, then your doctor may have you consult with a nutritionist or physical therapist, who can give you some ideas on small changes that you might be able to make to at least reduce some of these effects.

Change medications

If a medication causes intolerable side effects, your doctor may wean you off your current medication and prescribe a new medication that’s less likely to produce the same side effect.

Sip water

Some medications can dry out your mouth, and if you have to talk during the day (as most people are wont to do), this can become very annoying. Sucking on a sugar-free lozenge or sipping water throughout the day can help, but if it becomes too much of a problem, you may want to consult your doctor about other options.

Tip: Your local pharmacy probably has some over-the-counter products specifically developed for reducing dry mouth—dental rinses and such. Ask your pharmacist about what is available.

Caution: If you are on lithium, be very cautious about changing your water intake drastically in any direction—up or down. Even taking small sips, if you are doing it all day, could be enough to change the lithium concentration in your blood and change the effects. Reducing your fluid intake can increase the blood level and create lithium toxicity, a potentially life-threatening situation.

Including the full range of interventions

Although medication is the first-line treatment for bipolar depression and mania, it is not the only treatment. By combining medication with various types of therapies, including psycho-education (books, tapes, and so on), cognitive behavioral therapy, interpersonal and social rhythm therapy, and relationship and family therapy, you may be able to reduce your reliance on medications alone, which could result in fewer side effects.

Knowing when to call your doctor

In this article, we address some common, annoying side effects and advise you to contact your physician to discuss any side effects and possible adjustments to deal with these. There are some situations, however, that are potential emergencies. If you experience any of the following side effects, call your doctor immediately:

Overheating or dehydration: If you feel hot, dizzy, or faint, head to a cooler area or take a cool shower or bath and drink plenty of fluids. Call your doctor to report your symptoms.
Chest pain, shortness of breath, or persistent elevated or irregular heart beats: These symptoms could be related to a number or possible side effects or blood level problems and are medical emergencies.
Skin reactions: Allergies and skin reactions can happen with any medication and should be reported immediately. Some medications can cause severe and dangerous skin conditions.
Seizures or loss of consciousness: Seizures and loss of consciousness may be related to various medication side effects and should be considered a medical emergency.
Involuntary muscle movements: Some medications can cause muscle reactions that need to be addressed before they become long-term problems.
Suicidal thoughts, severe agitation or worsening of your symptoms: Although these are not necessarily side effects of any medication, some medications may aggravate your bipolar symptoms or simply fail to treat them, leading to thoughts of suicide or other negative emotional and behavioral symptoms.

Remember, you don’t have to simply tough it out when you experience side effects. Call your doctor and see if there is anything else you can do to reduce or eliminate the ill effects of your medication.

Comments

21 Responses to “Managing Bipolar Medication Side Effects”

Anonymous on September 17th, 2007 12:28 pm

Do some medications used to treat bipolar disorder actually cause anxiety attacks as a side effect?
Dr. Fink on September 20th, 2007 4:02 pm

It is an interesting question and one that comes up often. I always tell my patients that even if I have never seen a certain side effect from a medication in the past, it is still something to consider, because individual brains are so different in how they respond to different medications. However, some side effects are more or less common with different medications and it is worth looking at these trends.

It is uncommon for the mood stabilizing agents Lithium and Depakote to cause panic or anxiety. In fact, Depakote is sometimes used as an adjunctive treatment for anxiety.

The atypical antipsychotics – Risperdal, Zyprexa, Abilify, Geodon, and Seroquel are also unlikely to have the side effect of anxiety or panic – they tend to “cool down” the brain responses rather than rev them up. But I have seen some paradoxical anxiety reactions with some of these medications including Seroquel and Geodon.

Lamictal, another mood stabilizer that has anxiety listed as a potential side effect, but I have not seen Lamictal increase anxiety very often in my patients.

The antidepressants all carry some risk of exacerbating anxiety in certain individuals, in addition to the risk of triggering mania.

If you are concerned that anxiety has started or increased after beginning any new medication or increasing the dose of a medication, be sure to go over this with your prescriber. As I said, even if it isn’t a common side effect, your body and brain are different from anyone else’s and so could have a unique response.
Anonymous on September 21st, 2007 12:18 am

Thank you for that detailed and clear reply. My bipolar teenager has experienced panic attacks while taking lithium, seroquel (high dose), and anafranil (small dose to treat OCD). The panic attacks began suddenly after she had been stable on the same doses of the above meds for a year. We will continue to discuss it with her psychiatrist.
Feeling Like a Guinea Pig? on October 24th, 2007 1:46 pm

[...] Side effects may be intolerable. Some medications can produce undesirable side effects that certain patients find intolerable, such as excessive weight gain, muscle aches, or grogginess. See “Managing Bipolar Medication Side Effects.” [...]
Bipolar Blog | Bipolar | Medication | Therapy | Effectiveness on March 28th, 2008 8:55 pm

[...] Answer: ____________________________________________________ Tip: Make a copy of this form for your doctor, so he or she can keep a copy in your file for future reference. This can help you and your doctor avoid trying a new medication that you already tried and had problems with in the past. Important: Always consult your doctor before you stop taking a prescribed medication. If a medication is producing undesirable side effects, your doctor can often recommend ways to reduce or eliminate those side effects without having to discontinue the medication. For more about dealing with undesirable side effects, check out our post, “Managing Bipolar Medication Side Effects.” [...]
scared for my sister-in-law on April 5th, 2008 1:00 pm

My sister-in-law keeps cycling, she is on lamictal and wellbutrin, and has been for about a year, when do you try different medications.
The doctor just keeps increasing the two she is on, but it’s not working. She has a family Hx of bipolar and her brother is controlled on lithium. hOW CAN I HELP?
Joe on April 5th, 2008 6:24 pm
Dear “Scared for my sister-in-law”:

Where do I begin? You can do many, many things to help. It’s best if your sister-in-law wants help. If she doesn’t, she’s just likely to get upset with you and become even more stressed out if you try too hard to intercede.

If you are afraid of her safety (suicidal) or the safety of those around her, and she will not agree to hospitalization, you will have to try to work with the system to get her the help she needs. That may include calling social services or even law enforcement. (Most counties, I believe, have mental health services; check the county services listing in your phone book.) Be careful, though. Not all law enforcement officers are accustomed to dealing with people experiencing a full blown manic episode. They could end up harming your sister-in-law or causing more problems for her. I’d try working through social services or a local branch of a mental health advocacy group like NAMI.

If your sister-in-law is not posing a danger and does not want your help, you may want to back off. This is really a tough call to make and is entirely your decision. I can’t give you advice either way on this.

If your sister-in-law does want help, you can help in numerous ways:
- Take some of the daily burden off of her – watch the kids, cook, pay the bills… whatever she finds most stressful, try to remove the stressors from her life.
- Attend doctor visits with her (requires her permission). Take copious notes and do what you can to help her follow the doctor’s orders, such as taking her meds.
- Attend therapy sessions with her. A good therapist can suggest all sorts of practical strategies for making life more manageable and reducing stress.
- Offer mood feedback without being a nag about it. My wife often can’t see when she is cycling. I have to point it out.
- Offer to do something fun with her. When life is all about bipolar disorder, it gets pretty annoying. Sometimes, you need to forget abou the disorder.
Part V of our book Bipolar Disorder For Dummies is called “Assisting a Friend or Relative with Bipolar Disorder” and has three chapters on what you can do to help. Another popular book that many people seem to find helpful is Loving Someone with Bipolar Disorder by Julie A. Fast and John D. Preston. I have a copy but haven’t gotten around to reading it, so I can’t exactly recommend it, but Julie writes a column for bp Hope magazine and has a solid reputation in the bipolar community, so I expect it is good.

We wish you and your sis-in-law the best.
Bipolar Blog | Bipolar Disorder | Self-Help Tips on April 22nd, 2008 2:51 pm

[...] Take your medications as prescribed. Most of the medications used to treat depression or mania need to be taken daily, not just when you feel depressed or manic or think you need them. Warning: If you can’t tolerate the side effects of a particular medication, consult your doctor – he or she may have suggestions on how to reduce or eliminate the side effects without stopping the medication. See the previous post, “Managing Bipolar Medication Side Effects.” [...]
Bipolar Blog | Bipolar Disorder | Improving Effectiveness of Antidepressant on May 15th, 2008 11:03 am

[...] Stick with it. Antidepressants usually don’t kick in until you’ve been taking them for about two to six weeks. (Yes, when you’re depressed, two to six weeks can seem like an eternity.) Because side effects can occur almost immediately while the benefits may take longer to appear, people often stop taking their antidepressant before it has a chance to work. Most side effects should dissipate over the course of a few days or weeks. For tips on how to minimize the negative side effects, see “Managing Bipolar Medication Side Effects.” [...]
confused on August 1st, 2008 5:07 am

My dr wants me to start Abilify. I asked for a generic and she says that this drug does not have one. I asked about an older same drug that does come in generic. She said that she could perscribe one of those but they more side effects then the new drugs. Is this true?

The non generic drugs are so expensive.
Joe on August 4th, 2008 2:40 pm

Hi, Confused–

I have a couple ideas. One is to ask your doctor for samples. When we were strapped for cash, one of my wife’s doctors pulled samples out of her cabinet and handed them to my wife for free.

Another option is to check out the Partnership for Prescription Assistance.

We have a chart in Bipolar Disorder For Dummies (on pages 120-121) that compares the side-effect profiles of various “atypical antipsychotics” including Abilify. They all have their side effects. The main potential side effects of Abilify are Akathisia (severe restlessness) and insomnia or sedation. A couple others in this class are notorious for weight gain – primarily Zyprexa and Risperdal, but side effects always can vary a great deal from one person to another.
» Feeling Like a Guinea Pig? - Bipolar Beat on August 5th, 2008 1:47 pm

[...] Side effects may be intolerable. Some medications can produce undesirable side effects that certain patients find intolerable, such as weight gain, muscle aches, or grogginess. See “Managing Bipolar Medication Side Effects.” [...]
Nosara on August 6th, 2008 1:29 pm

I’m on tegretol and very rarely read anything negative on this drug. The problem particularly with me is that I never feel enthusiastic or motivated while on tegretol. I keep wondering if it’s because I’m bp I, meaning I’m not entirely manic and lean more towards the depression spectrum and tegretol is used mostly to control manias. Could it be possible that I’m genuinely under the baseline? I just thought maybe I was used to being manic and need to get used to ‘normal,’ but normal feels pretty lousy! A few weeks ago, the town I live in ran out of my Rx, and being in a secluded place there was really nothing I could do but wait.

A week after I’d stopped taking it I felt like ‘myself’ again, focused, driven, optimistic and getting things done. I HATED going back on Tegretol. I keep looking for info on Tegregol so I can go to my doctor with some ideas before they turn me into a guinea pig, but I honestly can’t find anything other than the side effects that affect people the first few weeks. Any input would be inmensely appreciated.
» Improving the Effectiveness of Your Antidepressant - Bipolar Beat on August 22nd, 2008 11:57 am

[...] Stick with it. Antidepressants usually don’t kick in until you’ve been taking them for about two to six weeks. (Yes, when you’re depressed, two to six weeks can seem like an eternity.) Because side effects can occur almost immediately while the benefits may take longer to appear, people often stop taking their antidepressant before it has a chance to work. Most side effects should dissipate over the course of a few days or weeks. For tips on how to minimize the negative side effects, see “Managing Bipolar Medication Side Effects.” [...]
» Is Your New Bipolar Medication Working? - Bipolar Beat on August 26th, 2008 7:50 am

[...] Answer: ____________________________________________________ Tip: Make a copy of this form for your doctor, so he or she can keep a copy in your file for future reference. This can help you and your doctor avoid trying a new medication that you already tried and had problems with in the past. (Yes, your doctor should be keeping track of this, but sometimes if you have to change doctors details can get overlooked during the transition.) Important: Always consult your doctor before you stop taking a prescribed medication. If a medication is producing undesirable side effects, your doctor can often recommend ways to reduce or eliminate those side effects without having to discontinue the medication. For more about dealing with undesirable side effects, check out our post, “Managing Bipolar Medication Side Effects.” [...]
Jon on September 11th, 2008 2:29 pm

I have started Depakote 2 months ago and it’s done more bad than good. I get aggressie and angry on it so I don’t know how well it’s helping my mania. I also get alot of anxiety from it. I am only on 750 mg a day and the anxiety is terrible. Also a melancholy feeling of depression (hopeless feeling) developed with after beginning it. My Psyc says it will take longer to work but I know 2 months I can feel its full effect and it isnèt good. What do you reccomend. I cant take lithium because of serious side effects. Someone shed some light on my situation. There has to be something out there to make me feel good again. this is ridiculous. tks
Joe on September 13th, 2008 12:52 pm

Hi, Jon-

Feeling aggressive and angry on Depakote seems a little out of the ordinary to me… does your doctor think it’s working? As Dr. Fink says in her post “Can My Bipolar Medication Be Increasing My Anxiety?” it’s not likely that Depakote or Lithium will cause anxiety. The “melancholy feeling of depression” you describe would be a more common side effect.

At 750 mg a day, you’re still on the low end of the range for Depakote.

We’re doing a biweekly series on medications used to treat bipolar mania, depression, and other conditions on Bipolar Beat. We started with lithium and Depakote and are currently working through common anti-seizure medications used to treat bipolar mania and reduce mood cycling.

In Bipolar Disorder For Dummies we cover the anti-anxiety medications. We’ll be addressing those in our biweekly series (called Bipolar Medication Spotlight), but probably not until later in the year.

Once we’ve covered several meds and I have some time, I’ll be posting our Bipolar Medication Spotlight entries here as a quick reference to bipolar meds.
dustin on October 14th, 2008 2:54 am

i take limotrigine, lithium, buspar for my mental state n trazadone for insomnia…. i get horrinble panic attacks to where i breathe heavy n fast, my mind goes all over n i shake and sweat. its effecting my job, they even sent me home today. one more time n i get terminated. what should i do
? call my psychiatrist?
Dr. Fink on October 21st, 2008 5:31 pm

dustin -

You are absolutely right to contact your psychiatrist to discuss the panix attacks – those can be treated.
Are you seeing the psychiatrist for therapy too or do you have someone else that you see for therapy? If not, i would encourage you to seek out a counselor or therapist who can help you manage the panic attacks – there are some specific techniques that can be used in therapy – cognitive behavioral therapy in particular – to help reduce panic attacks.

You may want to think about talking to your boss or human resources department. Panic is a medical illness -and they cannot fire you for having the disorder. But if you don’t tell them you don’t have those rights.
Marylou Ewen on November 13th, 2008 12:21 pm

I was on lithium for 37 years and was stable. taught school effectively for 30 years. However, it turns out that the lithium ate up my kidneys, so I had to change meds. Depakote and aabailify have caused severe gastro problems. I wonder which meds do not cause gastro problems.
My shrink is getting upset with me. I have a high tolerance for pain, but simply cannot take either depakote or abilify.Marylou EWen
Kim on November 10th, 2010 1:00 pm

I am a newlywed that just experienced for my first time – my husbands “low” after almost 18 mos of pure bliss. He said I was attacking him verbally but I was talking to our dog and when I tried to discuss this he decided to pack his clothes and leave. I was traumatized but spoke with his family and a mental health counselor about bipolars and I got him to return after 2 days and waited a day and good nights sleep before discussing things. For the past 18 months he’s been wonderful and we married 2 months ago. He’s been off meds (Ive found out) for at least 2 years due to side effects that were basically killing him health wise – we met a year after he’d been off. Now he has heart probs, kidney probs and diabetes as well as high BP so he develops chest pains and has to take a trip to the ER. This is why he’s not on any meds he’s been put on in his past. He seems fine cept for this first misunderstanding that I wasnt prepared for and he knows enough when he gets racing thoughts to focus on his PS3 Video games to settle them and we were without his game that week. Does every person with bipolar have to be on meds? Ive been reading some horror stories here and Im not sure I want to continue being signed up for this supporting role.

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