These are the top 25 psychiatric medications by number of U.S. prescriptions dispensed in 2011, according to IMS Health. I’ve also provided their 2009 and 2005 ranking (you can view the 2009 list here).

To put the percent changes below into perspective, the U.S. total population rose approximately 1.6 percent from 2009 to 2011. That suggests that anything above 1.6 percent change was driven by other factors — more people seeking treatment, more pharmaceutical advertising and marketing, or some other factor.

The biggest movers and shakers on the list were Celexa — moving up 15 spots to grab the second most-prescribed psychiatric drug in 2011 — and Wellbutrin XL, moving from 22 to 13.

Drugs used to treat attention deficit hyperactivity disorder (ADHD) — generic amphetamine salts and methylphenidate — enjoyed big gains as well.

Notes:

If no percentage change is listed, we did not track it in 2005.

NA – Rank not available for this year.

* – This is not a psychiatric medication, but is often prescribed for a mental health issue.

How This Data is Derived

Information in the National Prescription Audit (NPA) is derived from IMS Health’s Xponent service, one of the most complete, national-level prescription databases in the U.S. Xponent captures roughly 70% Market Share of all prescriptions in the U.S. IMS then uses a patented projection methodology from a stratified and geographically balanced sample to represent 100% Market Share coverage of U.S. prescription activity at retail, mail service, long-term care, and managed care outlets.

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

The reality is that it is possible to safely discontinue any medication, including psychiatric ones.

Stop your medication for the right reasons.

“Timing is everything,” according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of the book Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting. Just because someone wants to stop taking their medicine doesn’t mean they’re actually ready, he said.

There are many reasons individuals decide to stop taking medicine. For instance, they might feel better and think they don’t need treatment anymore. Their family might be pressuring them to stop, they read something about a drug that scares them, or they’re afraid that the drug will affect their personality, Banov said. Sometimes people want to stop after making major changes in their lives, such as getting a divorce, moving or changing jobs. But, according to Dr. Banov, this is actually “the worst time” to stop.

Also, some mental health conditions require taking medicine indefinitely. Ultimately, how long a person takes a psychotropic drug depends on his or her individual illness, its responses to treatment and their personal situation, according to Dr. Ross J. Baldessarini, professor of psychiatry and neuroscience at Harvard Medical School and director of the psychopharmacology program at the McLean Division of Massachusetts General Hospital. For instance, some individuals struggling with depression may take an antidepressant for nine months to a year and get better; others may need two to five years; and still others, may be “so genetically loaded for depression, that they may need to stay on them indefinitely,” Dr. Banov said.

Don’t stop your medication abruptly.

“Stopping abruptly is especially dangerous,” Baldessarini said.

Depending on the medicine, stopping abruptly or “cold turkey” can cause a variety of distressing reactions, ranging from mild to moderate early discontinuation symptoms with antidepressants, rapid return of the illness being treated, or even potentially life-threatening seizures with a high dose of benzodiazepines.

Consult your doctor before stopping any medicine, and never attempt to do it on your own.

Consider if you’ve received a thorough assessment.

A comprehensive assessment is required prior to stopping medicine. Among other indicators, your doctor needs to consider “your current clinical condition and life circumstances, your past clinical history, reasons to consider stopping versus continuing treatment, side effects and the presence of stressors and supports, as well as the dose and the length of time you’ve been taking a medicine,” Baldessarini said. You and your doctor should talk about these indicators along with how he or she plans to discontinue the drug.

There are no firm, established rules for discontinuing psychiatric medicines. However, there is one major rule of thumb: Reduce the dosage gradually whenever possible. “We still do not know for sure how long is long enough to reduce doses safely,” Baldessarini said. Still, the “slower the dose-reduction, the greater the chances of preventing return of symptoms of the illness for which treatment was started. Very slow discontinuation is especially important when a person has been taking high doses of a medicine over a long time,” he said.

Discontinuing multiple drugs is like peeling an onion, Baldessarini said. He usually leaves the most essential medicine for last. He then reduces doses of one or more optional or supplemental drugs slowly and gradually. Stopping all medicines at once is not safe.

Dealing with small final doses is tricky when dropping from a low dose to nothing. Sometimes doctors decrease the dose to one pill a day or one every two days or split the pill in half, he said. Pill-splitting can be very helpful. You can find pill splitters at your pharmacy.

Don’t expect stopping medication to be a quick process.

Gradually and safely discontinuing a drug doesn’t happen in a few days. Some drugs, including antidepressants, don’t show benefits for several weeks when they’re started; it seems best to avoid discontinuing faster than over several weeks, Banov said.

If you’ve been taking a medicine for years, Banov recommended reducing the dose, stepwise, over at least six weeks. While this may be a conservative practice, he said that “sometimes, you might not detect a change for a few weeks, but later, problems may arise.” Discontinuation symptoms usually occur within days of stopping a medicine, but relapse of the illness being treated can be delayed for weeks after initially feeling well.

In bipolar disorder, Baldessarini and his research team found years ago that the rate of discontinuing ongoing treatment determines the risk and timing of relapse, he said. Initially, their research found that risk for relapse after discontinuing lithium was reduced by one half or more when slow dose-reduction over several weeks was compared to abrupt discontinuation (Baldessarini et al., 2006). Gradual discontinuation of antipsychotic drugs also resulted in lower risk of relapse in schizophrenia (Viguera et al., 1997). In a recent study, he and his colleagues found that stopping an antidepressant abruptly or only over several days resulted in a much greater risk for depression or panic than gradual discontinuation over two weeks or more (Baldessarini et al., 2010).

If you’re switching from one medicine to another, you can be more aggressive than when discontinuing altogether, Banov said. Usually you switch drugs because of ineffectiveness or side effects, and commonly a new drug is introduced as the previous one is gradually removed. This way, there’s little concern about either withdrawal symptoms or relapse, assuming that both drugs have similar effects or belong to the same class, he said. If you’re switching classes, it’s usual to “cross-taper” the medicines: You take both drugs for a while, and then, the doctor reduces the dose of one and ups the dose of the other.

Your doctor may prescribe another medication.

If you’re taking a relatively short-acting antidepressant, such as paroxetine (Paxil) or venlafaxine (Effexor), and you experience bothersome symptoms, “your doctor may prescribe a long-acting antidepressant such as Prozac for a time, and then gradually discontinue the long-acting drug to limit risk of discomfort of withdrawing,” Baldessarini said. “The principal byproduct of the metabolism of fluoxetine has an extraordinarily long half-life or duration of action,” he said, and can take weeks to leave your system.

This method is not well established for discontinuing other classes of psychotropic drugs, including antipsychotics and mood stabilizers, so the best option usually is to “discontinue such drugs gradually, with close clinical monitoring by your doctor,” Dr. Baldessarini said.

Dr. Jacqueline Frayne from the King Edward Memorial Hospital for Women in Perth, Western Australia, says, “Although pregnancy and childbirth can be a time of great joy, for some women and their families it may also be a time of turmoil.” She explains that the rate of serious mental illness, such as schizophrenia, is fairly low but up to one in five women will experience “clinically diagnosable depression or anxiety” during pregnancy and the postpartum period.

Taking medication for these conditions can be a cause of anxiety for both the patient and her physician. The pros and cons of medication to mother and baby need to be considered, alongside many other factors that impact on maternal and fetal wellbeing.

Dr. Frayne recommends that “specialist opinion is sought early and a multidisciplinary approach with access to specialist care offered if possible. Continuity of care, especially in the context of a trusting therapeutic relationship, is optimal,” she adds.

She says the treatment plan during pregnancy should be based on the woman’s current mental state and medication, as well as her history of past mental illness and previous treatment, and family history of mental illness during pregnancy. Her support network, pregnancy-related fears, drug and alcohol use should also be considered.

A recent study found that “medications with potential for fetal harm” were being taken by 16 percent of women treated for depression. There is a lack of pregnancy safety data for many medications. However, stopping treatment suddenly is not recommended as this can cause side effects and possible relapse.

For example, in the case of bipolar disorder, relapse is often due to the discontinuation of preventive drugs. Although mild manic episodes can often be managed without drugs, severe manic episodes need to be treated because the possible consequences of injury, stress, malnutrition, profound sleep deprivation and suicide could pose more risk to the fetus than the side effects of the drug.

Lithium should be avoided in the first trimester of pregnancy, whenever possible, as it has been linked to a small but significantly increased risk of birth defects, particularly of the heart. The normal maintenance dose should be re-established as soon as possible following delivery, or if lithium is the only medication that controls symptoms, it can be re-introduced in the second trimester.

Other bipolar medications such as carbamazepine (Tegretol) and sodium valproate (Depakote) also carry some risks of fetal malformation, but physicians may still consider using these medications on the minimum effective dose, alongside regular monitoring.

For generalized anxiety disorder and panic disorder, low-risk medications are available. As an alternative to drugs, patients should be offered cognitive behavioral therapy or psychotherapy, as should those with obsessive-compulsive disorder or post-traumatic stress disorder.

The selective serotonin reuptake inhibitor (SSRI) antidepressant paroxetine (sold as Seroxat, Paxil) is not considered safe during pregnancy. The prescribing information says, “Epidemiological studies have shown that infants born to women who had first trimester paroxetine exposure had an increased risk of cardiovascular malformations.

“If a patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant.”

Antidepressant medications cross the placental barrier and may reach the fetus, but research has shown that most other SSRIs are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.

Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) have not been found to have any serious effects on the fetus, and have been safely used thoughout pregnancy for many years. On the other hand, monoamine oxidase inhibitors (MAOIs) have been associated with increased risk of malformations and may interect with drugs used in labour (e.g., meperidine).

Nevertheless, there have been reports of neonatal withdrawal symptoms after the use of SSRIs, SNRIs, and tricyclics during late pregnancy. These include agitation, irritability, a low Apgar score (physical health at birth) and seizures.

Benzodiazepines should not be used during pregnancy, particularly in the first trimester, as they may cause birth defects or other infant problems. The U.S. Food and Drug Administration has categorized benzodiazepines into either category D or X meaning potential for harm in the unborn has been demonstrated.

If used in pregnancy, benzodiazepines with a better and longer safety record, such as diazepam (Valium) or chlordiazepoxide (Librium), are recommended over potentially more harmful benzodiazepines, such as alprazolam (Xanax) or triazolam (Halcion).

Pregnancy outcomes for antipsychotic medications vary widely depending on the type of drug. Exposure to low-strength antipsychotics during the first trimester is associated with a small additional risk of congenital anomalies overall. Haloperidol (Haldol) has been found not to cause birth defects.

The National Institute of Mental Health states, “Decisions on medication should be based on each woman’s needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.”

Women taking these medications and who intend to breastfeed should discuss the potential risks and benefits with their physicians.

References

Frayne, J. et al. Motherhood and mental illness: Part 1 – toward a general understanding. Australian Family Physician, Vol. 38, August 2009, pp. 594-600.

Cleary, B. J. et al. Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Pharmacoepidemiology and Drug Safety, Vol. 19, April 2010, pp. 408-17.

Medication, Pregnancy and Breastfeeding

Antenatal Mental Health Problems

Rubinchik, S. M., Kablinger, A. S. and Gardner, J. S. Medications for Panic Disorder and Generalized Anxiety Disorder During Pregnancy. Primary Care Companion to the Journal of Clinical Psychiatry, Vol. 7, 2005, pp. 100-105.

Mental Health Medications

Howard, L., Webb, R. and Abel, K. Safety of antipsychotic drugs for pregnant and breastfeeding women with non-affective psychosis. The British Medical Journal, Vol. 329, October 23, 2004, pp. 933-34.

In contrast to the earlier drugs, atypicals usually work on serotonin receptors in addition to dopamine receptors. Drugs in this group include olanzapine (Zyprexa), clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify) and paliperidone (Invega).

The drugs are prescribed for conditions such as schizophrenia and bipolar disorders and may also be given for agitation, anxiety, psychotic episodes and obsessive behaviors. Their off-label use is increasing, and the Food and Drug Administration has now approved Abilify for use in adults who do not respond to antidepressants alone.

The most common side effects include dry mouth, blurred vision and constipation, dizziness or lightheadedness, and weight gain. Sometimes atypical antipsychotics can cause problems sleeping, extreme tiredness and weakness.

With long-term use, atypical antipsychotics can also carry a risk of tardive dyskinesia, a condition involving repetitive, involuntary movements often of the mouth, tongue, facial muscles and upper limbs. Physicians aim to prevent its development by using the lowest effective dose of antipsychotics for the shortest time.

When possible the medication should be stopped, or reduced, if tardive dyskinesia is diagnosed. But the condition may remain for months, years, or even permanently. Its symptoms may be reduced with the drug tetrabenazine (Xenazine), but this drug has been linked with its own side effects, including depression, dizziness, drowsiness, insomnia, fatigue and nervousness.

Other medications may also help tardive dyskinesia, including ondansetron (Zofran) and several anti-Parkinsonian drugs. Benzodiazepines have been tried, but a 2006 review found this treatment “did not result in any clear changes” so routine clinical use is not recommended. Changing to a newer form of atypical antipsychotic might be beneficial.

Associate Professor Thomas Schwartz from the Department of Psychiatry at the State University of New York says that the lower-potency atypical antipsychotics, Seroquel, Abilify and Geodon, “are probably associated with the smallest risk for tardive dyskinesia.”

Another possible side effect of atypical antipsychotics is Parkinsonism, a neurological condition involving tremors, hypokinesia (decreased bodily movement), rigidity, and unsteadiness. The risk is lower on Abilify than Geodon, due to their mechanisms of action.

These drugs are also linked with a common neurological movement disorder called dystonia. It involves involuntary and uncontrollable muscle spasms which can force affected parts of the body into abnormal, sometimes painful, movements or postures. Dystonia can be generalized throughout the body, or occur in one place such as the neck muscles, the muscles around the eyes, the face, jaw or tongue, or the vocal cords.

There is currently no cure for dystonia, but there are several popular treatments depending on the type of dystonia and age of onset. As dystonia is a complex and personal condition, the effectiveness of treatment options can vary widely between patients.

One common treatment is regular injections of botulinum toxin, usually repeated every three months. Some oral drugs are also available, including anticholinergic drugs such as trihexyphenidyl which helps control muscle spasms and the tremor by blocking the effect of a chemical messenger in the brain called acetylcholine.

Benzodiazepines are frequently used in the treatment of dystonia. They work by boosting levels of a chemical which inhibits nerve signals in the brain, so act as muscle relaxants. They may trigger sleepiness and sedation if the medication is stopped too rapidly. The GABA agonist baclofen is another muscle relaxant which may ease the muscular spasms and cramps of dystonia, but may cause lethargy, upset stomach, dizziness and dry mouth.

Akathisia, another possible side effect of atypical antipsychotics, is often described as an “inner restlessness” that makes it difficult to sit still or remain motionless. Unfortunately it is often misunderstood and misdiagnosed, sometimes leading to patients reducing or stopping their medication without advice from the physician.

It may be reduced by decreasing the dose or by changing drugs, but this should always take place under medical supervision. Treatment may include beta-blockers such as propranolol or metoprolol, or benzodiazepines such as clonazepam.

A 2010 review concluded that, “Effective and well-tolerated treatment is a major unmet need in akathisia.” But author Michael Poyurovsky, of the Tirat Carmel Mental Health Center in Israel, added, “Accumulating evidence indicates that agents with marked serotonin-2A receptor antagonism may represent a new class of potential anti-akathisia treatment.” These drugs include cyproheptadine, ketanserin, mirtazapine, nefazodone, pizotifen and trazodone, although none are yet specifically indicated for akathisia.

Rarely, atypical antipsychotics may trigger diabetes. The cause seems to involve an increase in insulin resistance and changes to insulin secretion. Metabolic syndrome can also be produced by the drugs. The FDA requires all manufacturers of atypical antipsychotics to include a warning about the risks of diabetes and hyperglycemia (high blood pressure).

The risk appears to be highest with Zyprexa and Clozaril. Geodon and Abilify are thought to have the smallest risk. Experts from the Texas Tech University Health Sciences Center in Dallas, say that “periodic monitoring of glucose should be considered” for all patients on atypical antipsychotics.

References

Bhoopathi, P. S. S. and Soares-Weiser, K. Benzodiazepines for neuroleptic-induced tardive dyskinesia. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD000205

Schwartz, T. and Raza, S. Aripiprazole (Abilify) and Tardive Dyskinesia. Pharmacy and Therapeutics, Vol. 33, January 2008, pp. 32-34.

http://en.wikipedia.org/wiki/Atypical_antipsychotic

www.dystonia.org.uk

Poyurovsky M. Acute antipsychotic-induced akathisia revisited. The British Journal of Psychiatry, Vol. 196, February 2010, pp. 89-91.

Mathys, M., Blaszczyk, A. and Busti, A. Incidence of abnormal metabolic parameters and weight gain induced by atypical antipsychotics in elderly patients with dementia. The Consultant Pharmacist, Vol. 24, March 2009, pp. 201-9.

From her work in primary care settings, Risa Weisberg, Ph.D, assistant professor (research) and co-director of the Brown University Program for Anxiety Research at Alpert Medical School, has seen “firsthand how a great many patients accept a prescription from their provider without asking many questions about it, or often, without even knowing for what symptoms/disorder it is being prescribed.”

Such a scenario can stall or sabotage your treatment. Confused, you’re likely left with tons of questions, unaware of what you’re taking and how it’s supposed to help. You may be feeling helpless — a spectator in your own recovery — and hopeless, if the medication doesn’t seem to work or has bad side effects. Your doctor likely is clueless about your real concerns, not having all the information to guide his or her decision-making process.

But you don’t have to feel like a powerless bystander, on the outskirts of your own treatment. In order to become a sharp self-advocate, you just need some information. Here’s some hints for for taking medication safely and effectively. At the end, you’ll also find a basic glossary of common medication-related terms.

1. Haven’t picked a physician yet? Do your homework and conduct an interview. Before you decide on a doctor, whether it’s a primary care physician or a psychiatrist, ask some questions about qualifications and see if he or she is a good fit for you. Questions to get you started: Where did you go to school and do your training? Do you specialize in a specific mental illness? Do you have hospital privileges? Here’s a list of excellent questions to ask a psychiatrist during and after your first appointment. They focus on bipolar disorder, but you can easily adapt them to any disorder.

2. Ask the doctor about your diagnosis. You have the right to know precisely what you’re diagnosed with and how the doctor came to that conclusion. Making a diagnosis doesn’t happen in a 5-minute interview. You want to make sure that the doctor conducted a thorough evaluation. Did the doctor get your medical and mental health history? Did you complete a standardized test? Did the doctor ask about your symptoms and recent experiences?

3. Seek out psychotherapy. Medication isn’t your only option. Depending on the disorder, you may only need psychotherapy or you may take medication and see a therapist. Psychotherapy provides lasting benefits, whereas a medication’s effects stop as soon as you stop taking it. Cognitive-behavioral therapy effectively treats depression, anxiety disorders and bipolar disorder. To find a therapist, you can ask your doctor for a recommendation, browse the Web or check with universities and medical schools. Be sure the therapist specializes in your mental illness. For advice on finding a good therapist, check out this eBook.

Some Web sources for finding a therapist:

• Psych Central’s therapist finder
• The Association for Behavioral and Cognitive Therapy for CBT-trained therapists
• Children and Adults with Attention Deficit/Hyperactivity Disorder
• Anxiety Disorders Association of America
• National Eating Disorder Association

4. Before taking the medication, ask specifics. Peter Roy-Byrne, M.D., professor and chief of psychiatry at the University of Washington at Harborview Medical Center, and Michael R. Liebowitz, M.D., professor of clinical psychiatry at Columbia University and managing director of The Medical Research Network, suggest asking:

• How will I know if this medication is working?
• What are the side effects, and what do I do if I experience them?
• When will the medication start to work?
• How long will I have to take it?
• If I take it for X amount of time, what’s the likelihood of reducing symptoms?
• What are the dose requirements?
• Will you be monitoring me throughout the course of this medication?
• When will you talk to me next?

The Agency for Healthcare Research and Quality has a basic handout with more questions. Here’s a thorough list if your child is taking medication, which you can easily revise for your situation.

5. Unsure about medication? Explore why. Are you on the fence because of potential side effects, the stigma of having a disorder or taking medication, a bad past experience, fears of addiction or uncertainty about the validity of your diagnosis? Talk to the doctor about your concerns before making the decision to take or refuse the medication.

Approximately 2.6 percent of American adults have bipolar disorder (formerly called manic depression and manic depressive disorder), according to the National Institute of Mental Health. These mood swings include “highs” (mania), when individuals feel either on top of the world or on edge, and “lows” (depression), when they feel sad and hopeless. Suicide attempts are common in bipolar disorder, especially during depressive episodes.

Bipolar disorder can be effectively treated with medication and psychotherapy. With proper treatment, individuals with bipolar can lead fulfilling, productive lives. This is why it’s so important to recognize the symptoms and see a mental health professional for an evaluation.

What Causes Bipolar Disorder?

There is no single cause for bipolar disorder. Indeed, like all psychological disorders, bipolar disorder is a complex condition with multiple contributing factors, including:

• Genetic: Bipolar disorder tends to run in families, so researchers believe there is a genetic predisposition for the disorder. Scientists also are exploring the presence of abnormalities on specific genes.
• Biological: Researchers believe that some neurotransmitters, including serotonin and dopamine, don’t function properly in individuals with bipolar disorder.
• Environmental: Outside factors, such as stress or a major life event, may trigger a genetic predisposition or potential biological reaction. For instance, if bipolar disorder was entirely genetic, both identical twins would have the disorder. But research reveals that one twin can have bipolar, while the other does not, implicating the environment as a potential contributing cause.

What Are the Different Types of Bipolar Disorder?

• Bipolar I is considered the classic type of bipolar disorder. Individuals experience both manic and depressive episodes of varying lengths.
• Bipolar II involves less severe manic episodes than bipolar I; however, their depressive episodes are the same.
• Cyclothymia is a chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.
• Mixed episodes are ones in which mania and depression occur simultaneously. Individuals might feel hopeless and depressed yet energetic and motivated to engage in risky behaviors.
• Rapid-cycling bipolar individuals experience four or more episodes of mania, depression or both within one year.

What Are the Risk Factors for Bipolar Disorder?

Risk factors include having:

• Cyclothymia (see definition above). About half of individuals with cyclothymia will experience a manic episode.
• Any other psychological disorder
• A family history of bipolar or other psychological disorders
• Alcohol and substance abuse
• Medication interactions. For instance, antidepressants may trigger mania.
• Major life changes
• Severe stress

Symptoms of Bipolar Disorder

There are four possible bipolar states:

1. Mania
2. Hypomania
3. Depression
4. A mixture of mania and depression (called a “mixed episode”).

Mood states are highly variable. Some people can experience mood changes in one week, while others can spend months or even years in one episode.

What Does Mania Look Like?

• Feelings of euphoria and elation or irritability and anger
• Impulsive, high-risk behavior, including grand shopping sprees, drug and alcohol abuse and sexual promiscuity
• Aggressive behavior
• Increased energy and rapid speech
• Fleeting, often grandiose ideas
• Decreased sleep (typically the individual doesn’t feel tired after as few as three hours of sleep)
• Decreased appetite
• Difficulty concentrating; disorganized thoughts
• Inflated self-esteem
• Delusions and hallucinations (in severe cases)

What Does Hypomania Look Like?

Hypomania is less severe than a full-blown manic episode. Hypomanic individuals can seem pleasant, friendly, energetic and productive. Though it doesn’t sound problematic, increasing hypomania can lead to risky behaviors and full mania.

What Does Depression Look Like?

• Feelings of hopelessness and sadness
• Inability to sleep or sleeping too much
• Loss of interest in formerly enjoyable activities; loss of energy (sometimes to the point of inability to get out of bed)
• Changes in appetite and weight
• Feelings of worthlessness and inappropriate guilt
• Inability to concentrate or make a decision
• Thoughts of death and suicide

What Does a Mixed Episode Look Like?

Mixed episodes involve simultaneous symptoms of mania and depression, including irritability, depressed mood, extreme energy, thoughts of suicide and changes in sleep and appetite.

A Note about Suicide

Because of the high suicide risk in those with bipolar disorder, it’s important to note the warning signs. In addition to those mentioned in the depression symptoms above, others include:

• Withdrawing from loved ones and isolating oneself
• Talking or writing about death or suicide
• Putting personal affairs in order
• Previous attempts

For more information about suicide, check out Frequently Asked Questions about Suicide.

How Is Bipolar Disorder Diagnosed?

There are no medical tests to diagnose bipolar disorder. However, a psychologist, psychiatrist or other trained mental health professional can diagnose the disorder by conducting a face-to-face clinical interview. Your clinical interview will include detailed questions about your and your family’s medical and mental health history and your symptoms.

What Treatments Exist for Bipolar Disorder?

Bipolar disorder can be effectively managed with a combination of medication and psychotherapy to help in reducing both the number of episodes and their intensity. Treatment also can help prevent future episodes if the individual is willing to work on personal issues and develop healthy habits.

What Kinds of Medication Are Used for Bipolar Disorder?

• Mood stabilizers. These medications are prescribed to help stabilize manic symptoms, prevent future episodes and reduce suicide risk. The most well-known of these is lithium, which is effective in 60 to 80 percent of manic and hypomanic episodes. Anticonvulsant (or anti-seizure) medications also have mood stabilizing effects. These include valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurotin) and topiramate (Topamax).

  Every medication has its own set of potentially serious side effects. For instance, Lamictal can cause Stevens-Johnson syndrome, a potentially fatal skin disease, though this is rare and is entirely avoidable by careful, slow dose titration.

• Atypical antipsychotics. The newest medications, atypical antipsychotics were originally developed to treat psychosis (a symptom of schizophrenia). Like the mood stabilizers above, atypical antipsychotics help to control mood swings. These seven medications are commonly prescribed for bipolar: aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), clozapine (Clozaril) and olanzapine/fluoxetine (Symbyax).

  Contrary to popular belief, these medications aren’t without significant side effects, including rapid weight gain, high cholesterol and risk for diabetes, which occurs most commonly with olanzapine and clozapine. In some cases, atypical antipsychotics have been associated with a life-threatening condition known as diabetic ketoacidosis (DKA).

  In June 2004, the U.S. Food and Drug Administration (FDA) requested that all companies who manufacture atypical antipsychotics include a warning about the elevated risk for hyperglycemia and diabetes (see here ).

  In addition, several organizations, including the American Diabetes Association and American Psychiatric Association, have published recommendations for doctors on how to treat patients taking these medications. For more information, read the press release at the American Diabetes Association website.

• Calcium-channel blockers. Used to treat angina and high blood pressure, these medications — including verapamil (Calan, Isoptin, Verelan) and nimodipine (Nimotop) — also have mood stabilizing effects. They have fewer side effects than other bipolar drugs but aren’t as effective.
• Combination therapy. When one medication isn’t working, a doctor might prescribe two mood stabilizers or a mood stabilizer along with an adjunctive medication to treat symptoms such as anxiety, hyperactivity, insomnia and psychosis. For example, Xanax (alprazolam), a fast-acting benzodiazepine, typically is taken for two weeks before mood-stabilizing medication starts to work. Antidepressants might be prescribed for patients who are in a depressive phase, but research suggests they aren’t effective, can trigger mania and exacerbate episodes long term.

Psychotherapy

Psychotherapy is a crucial component of long-term bipolar disorder management. Even when your mood swings are under control, it’s still important to stay in treatment.

Several different psychotherapeutic methods have proved to be effective in treating bipolar disorder.

• Cognitive behavioral therapy (CBT) helps individuals develop strategies to cope with their symptoms, change negative thinking and behavior, monitor their moods and predict their mood to try to prevent a relapse.
• Interpersonal and social rhythm therapy is a combination of interpersonal therapy and CBT. This newer treatment focuses on circadian rhythms to help clients establish and maintain routines and build healthier relationships.
• Psychoeducation teaches individuals about their disorder and treatment and gives them the tools to manage it and anticipate mood swings. Psychoeducation also is valuable for family members.

How Else Can I Manage Bipolar Disorder?

• Take your medication.
• See a therapist regularly.
• Learn more about bipolar disorder and its treatment
• Participate in online communities or in-person support groups
• Adopt healthy habits, including exercising, practicing stress management techniques, eating healthy, avoiding alcohol and drugs, getting seven to eight hours of sleep and avoiding any potential triggers.

What Do I Do Next?

By starting to learn about bipolar disorder, you’ve already taken a significant first step. If you’d like to learn more, check out our detailed guide here.

If you think you or a loved one has bipolar disorder, it’s important to be evaluated by a trained mental health professional. To find a therapist in your area, use a search engine such as this one, or check with your primary care physician or community mental health clinic for referrals.

Further Reading

The Numbers Count: Mental Disorders in America

National Institutes on Mental Health

University of Maryland Medical Center

National Alliance on Mental Health (NAMI)

Depression and Bipolar Support Alliance (DBSA)