Today’s episode discusses the complexities and reality of mood stabilizers for the treatment of bipolar disorder. Though mood stabilizers can significantly aid in shifting mood, they are not perfect and come with various side effects, some of which may require regular blood monitoring and can affect daily life differently for each individual. You can work with healthcare professionals to manage side effects, and sometimes, you can even find the positives in the challenges of treatment.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

He is also the host of Healthline Media’s Inside Mental Health podcast available on your favorite podcast player. To learn more about Gabe, or book him for your next event, please visit his website,

Dr. Nicole Washington
Dr. Nicole Washington

Dr. Nicole Washington is a native of Baton Rouge, Louisiana, where she attended Southern University and A&M College. After receiving her BS degree, she moved to Tulsa, Oklahoma to enroll in the Oklahoma State University College of Osteopathic Medicine. She completed a residency in psychiatry at the University of Oklahoma in Tulsa. Since completing her residency training, Washington has spent most of her career caring for and being an advocate for those who are not typically consumers of mental health services, namely underserved communities, those with severe mental health conditions, and high performing professionals. Through her private practice, podcast, speaking, and writing, she seeks to provide education to decrease the stigma associated with psychiatric conditions.

Find out more at

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Bipolar, a Healthline Media Podcast, where we tackle bipolar disorder using real-world examples and the latest research.

Gabe: Welcome to the show everyone! My name is Gabe Howard and I live with bipolar disorder.

Dr. Nicole: And I’m Dr. Nicole Washington, a board-certified psychiatrist.

Gabe: One of the things that allows me to operate at all, on any level is the fact that my moods are stable, my emotions are in check. And that’s just I’m not alluding to any medical treatment or medication or anything, I’m just saying. But before I had treatment, my moods were all over the place. One day I thought I was a god and the next minute I thought I was garbage. And it’s really hard to manage life with that kind of instability. So obviously getting my mood stable have been the secret to long term recovery with bipolar disorder. And here is this going to be the shortest show ever? There is a pill that you can take. It’s called a mood stabilizer. You take the pill, your mood is stable, and this whole thing is over for you. And I have just been really excited to talk about this class of medications called mood stabilizers because it they’re, they’re perfect. Dr. Nicole, tell me how I’m right.

Dr. Nicole: [Laughter] You could not be more wrong. They are.

Gabe: Aww.

Dr. Nicole: They’re great. I mean, they’re great. They do. They do a good job of helping, like you said, helping people achieve a level of stability they didn’t think they would ever reach. They do a fantastic job. But they’re not perfect. They have icky, unsexy side effect profiles. And you know, I mean, they have their downsides. So I’m not going to say they’re perfect. I think they’re great. I think they’ve been a game changer for a lot of people. But perfect is a hard sell.

Gabe: Obviously when I was a patient, when I was just trying to get better, I didn’t really think about how these things were named, you know, antidepressants, antipsychotics, mood stabilizers. Right. I was just trying to get better. I was just fighting to get well. But now that I’m on the other side, I. I look at the names of these medications, mood stabilizer and, and it seems, at least to me, like it’s saying, hey, is your mood unstable? We’ve got a class of medications that will fix it. And it and the commercials even are. You always say the side effects don’t sound sexy, but you know what does sound sexy?

Dr. Nicole: [Laughter]

Gabe: The commercial.

Dr. Nicole: The voice.

Gabe: The commercial

Dr. Nicole: The voice.

Gabe: Eh, oh. That voice is so sexy. Everybody

Dr. Nicole: Yeah.

Gabe: Goes hiking in the mountains. It doesn’t matter where you live. You hike up to a cliff. You’re at the beginning of the commercial. Your dog is depressed, but at the end of the commercial, your dog is happy.

Dr. Nicole: Yeah.

Gabe: It’s.

Dr. Nicole: And that person saying you could get liver failure, sexual dysfunction, a rash, abnormal, involuntary movements that you can’t control, like those kinds of things. Right. Like they make it sound good. Yeah.

Gabe: They got to put the sexy commercial with the with the not so sexy side effects.

Dr. Nicole: Yeah, yeah, yeah.

Gabe: It. Oh my God, the commercial is bipolar.

Dr. Nicole: [Laughter]

Gabe: But on to the topic of the episode is the. I know that the medication is designed to stabilize our moods, but is the actual term mood stabilizer? Is it a more marketing than doctoring?

Dr. Nicole: Of course, of course, of course. Even if you think about the names of some of the drugs and that that’s a that’s a fun conversation for a different day. But if you think of some of the names and how when you break them down, you’re like, is that is that what they were trying to accomplish by giving it that name? It’s very interesting from a marketing standpoint, but yeah, absolutely. Right. That’s marketing for sure. But we are trying to stabilize your mood. So we like the I mean, we like the idea as doctors of being able to say we have mood stabilizing medications because even on your end it sounds like, oh my, my mood is going to be stable. Like even in hearing the name of it, it gives people a sense of that’s exactly what I’m looking for. I’m looking for a stable mood. Give me one of those mood stabilizers. I mean, it would be less helpful to us if it was called kind of stabilizing. You know, we don’t want to give you kind of stabilizers. We want you to have mood stabilizers. We want it to be firm. So, yeah, I mean, it’s marketing, but it’s beneficial.

Gabe: I only want to point this out because I don’t think a conversation about things you didn’t know about taking mood stabilizers would be complete. If we left you with the idea that we just need to find, or Dr. Nicole needs to find, the right mood stabilizer for you, and you’ll be perfect. Many of us are familiar with the, quote, bipolar medication, cocktail unquote, or the bipolar cocktail, or the medication cocktail, or the horrible handful of pills that we have to take twice a day. Your, your mileage may vary on what you call it, but I want to hit that right out of the way so that if anybody’s been prescribed a mood stabilizer and it didn’t work, they don’t think, well, I tried that and it didn’t work. Mood stabilizers are partially branding. They’re partially a class of medication. And not only are there many different types of mood stabilizers, but again, they often work in conjunction with other medications. And again, even in a single mood stabilizer, the dosage that you need may need to change to reach efficacy levels. And that leads me to my first point about things that often people don’t realize about taking mood stabilizers. And not that there’s a there’s a blood test. Dr. Nicole, they came at me with needles. They sent needles after me.

Dr. Nicole: Okay, that that feels so dramatic. So very dramatic. They sent needles after me?

Gabe: As somebody who is afraid of needles. It was dramatic. It was dramatic.

Dr. Nicole: Okay, I’ll give you that.

Gabe: I did not know.

Dr. Nicole: I’ll give you.

Gabe: I did not know.

Dr. Nicole: I’ll. I’ll give, okay. That’s fine. I’ll give you that. But before we talk about that, I definitely want to touch base on the whole cocktail regimen versus one pill, because that is something that a lot of people are frustrated about. They say, I came to you and y’all just keep giving me all these pills. Bipolar disorder is a is a very it’s a, it’s a very sensitive delicate disorder and not delicate like a flower. Delicate like a bomb. Right. Like it’s delicate.

Gabe: [Laughter]

Dr. Nicole: Delicate

Gabe: I’m excited to see where this goes.

Dr. Nicole: Delicate like a bomb. It’s delicate. You have to handle it with care. You have to be. You have to kind of be specific and strategic in how you handle it. But we know that if you don’t handle it well, it can blow up, right? Like it can. So it sometimes requires more than one medication. It’s a unique disorder. We’re trying to prevent you from going too high. We’re trying to prevent you from being too low. We’re trying to keep you in this middle zone with as little fluctuation as possible away from that middle line. It’s, it’s delicate. So it may require more than one thing. So yes, off the bat, if you’re new in this and you think, oh, I’m on this one pill, if that one doesn’t do it, and if your doctor says, hey, you might need a second mood stabilizing medication, they are not just throwing things at you that that sometimes and honestly, very often it’s what it calls for. I don’t have a lot of people with bipolar disorder who are managed with one medication. So I just want to get that out, out of out of the gate. You know, it’s not a your doctor is just throwing stuff at you, guessing it’s a very delicate disorder. Now, these needles that people came,

Gabe: Now back to the needle thing. Get to the needle thing

Dr. Nicole: These needles.

Gabe: That that’s that, that’s what the people want to know about that.

Dr. Nicole: They want to know?

Gabe: That other thing was like the part of the commercial,

Gabe: Right? The part of the commercial

Dr. Nicole: Yes.

Gabe: Where it’s like

Dr. Nicole: Yes.

Gabe: And you’ll have the following

Dr. Nicole: Right.

Gabe: Side effects. It’s really important that you understand and

Dr. Nicole: Yeah.

Gabe: That you know that you can remember that. Right?

Dr. Nicole: Yes.

Gabe: Right, right. That’s the unsexy part.

Dr. Nicole: Yeah. Now let’s talk about.

Gabe: Now get to the needles.

Dr. Nicole: The doctor coming at you with a needle.

Gabe: Right. It’s not the doctor. The doctors don’t do their own dirty work.

Dr. Nicole: [Laughter]

Gabe: They send a phlebotomist after you.

Dr. Nicole: That’s true. And plus, I’ll be honest with you, I haven’t drawn blood since I was a third-year medical student. And you? Let me tell you who you don’t want. Drawing blood from you, Dr. Nicole. You. You don’t want. If I’m coming at you and I’m your best option for a blood draw, we are all in a whole lot of trouble. So yes, some of them, they do require blood work, but this is a very. I’m. I’m gonna branch off. I’m gonna pull a Gabe. I’m gonna. I’m gonna branch off for a second. [Laughter]

Gabe: You’re stealing my shtick. All right, all right, that’s.

Dr. Nicole: Mood stabilizers. Yes. There are a certain category of medications that are that are, I guess, categorically referred to as mood stabilizing medications, mood stabilizers. And then there are your antipsychotics, as Gabe talked about. But sometimes we will use those groups interchangeably. So if I say a mood stabilizer, sometimes I could be talking about one of the traditional mood stabilizers, or I could be talking about the antipsychotics. I’m just talking in general about meds that stabilize your mood. So. For the purpose of this episode, we are talking about those traditional mood stabilizers, I think. I think that’s our focus today is the traditional mood stabilizing medication. So. Traditional mood stabilizing meds. Things like lithium, very popular valproic acid. It’s also known as Depakote. Depakene drugs like carbamazepine, also known as Tegretol. Those are some of your more traditional lamotrigine, also known as Lamictal. Those are some of your more. When we think of mood stabilizers, that’s kind of what people are talking about. Lithium kind of falls in its own category by itself. It’s its own thing. It’s very unique in what it does, how it works, its action very unique. The other three are actually seizure medications. And we talk a lot about how sometimes we find things out accidentally. So you have these medications that are created for seizures. And here we found out that they helped to stabilize moods in people that have bipolar disorder.

Dr. Nicole: So here we are using these medications. So all of them need to be monitored. You will have a doctor tell you if you’re taking valproic acid, if you’re taking carbamazepine if you’re taking lithium we have to get those blood draws. And the reason is not because we’re mean. And we know you don’t like needles and we just want to stick you. It is because we have to check those levels to make sure that one, you’re in a therapeutic range. So we want to make sure that you’re at the right level. This is one of the few times in psychiatry that we can say we have a lab value. We have a number, a range we’re trying to fall in to be able to tell us if you’re in the right range for a particular drug. So we know those ranges, we know what those numbers are, and we try to keep you within those numbers. So when you first start one of those medications, we’re going to have to check to see where we are. How will we know what your number is if we don’t check. So we have to check in the beginning for sure. Usually within that first week or so, it takes that long for whatever dose you’re on to get to the right level, a level, a stable level.

Dr. Nicole: And then we check. But guess what? We’re also going to have to check. If you come in and you say, I’m not sure I’m tolerating this mad, well, we’re going to have to check because we need to know, do you have too much? Do you not have enough? Like what’s going on? If you come in and your symptoms aren’t under good control and you say, I’m depressed or my mood is not stable, and we say, oh, you know what, we may have room to increase your fill in the blank, whatever it is. But before we do that, we may want to check a level because we want to see where you are before we just start ramping up doses. Once we make the change, if we make it, we got to check a level again. And once you’re stable on it for a while and we feel good about it, we still have to check periodically to make sure that you’re still in the stable place. So while all that feels like a whole lot of poking on our part, it’s all about safety. Everything I named was just. It was all about safety and making sure that we’re doing the right thing by you and treating you with this medication.

Gabe: One of my favorite things that you said, Dr. Nicole, is that we finally have a value. We finally have a blood test. And y’all complaining about that? You said it nicer, but. But I could tell that that behind your words was what can we do here? You said y’all wanted a blood test. We came up with one, and now you’re unhappy. And I’ll be the first to admit that that was my experience. I didn’t have to do blood draws for other medications. I was on to help with bipolar disorder, but I had to get something called a lithium level or a Tegretol level or a mood stabilizer level. And all of a sudden I’m like, well, I don’t like this. And then I came out later to say, well, I don’t like that there’s not a blood test. I don’t like that you’re all guessing. We found a way not to guess, and you complained about that too.

Dr. Nicole: So make your mind up.

Gabe: I want to own it.

Dr. Nicole: Make your mind up.

Gabe: I do want to own that personally. That that that I cannot make up my mind. I just really, really hate needles. But I do want to say it does take people by surprise. It really, really does. Especially in the treatment of bipolar disorder. We are primed that it’s observational. It’s self-reporting. We’ve talked a lot about on this show why it’s important to, you know, bring a trusted family member. While it’s important to keep a journal, while it’s important to make sure that you’re talking about the last three months, not just today because observation, observation, observation. And then one day somebody brings needles into the conversation. But you are 100% right, and I’m glad. I’m glad that you shared that this really is important for all of us.

Dr. Nicole: And it’s important to remember that your body changes, things change. So we do have to check them periodically. So even once a person gets stable, they become very frustrated when I say, okay, every three months or every six months we need to we need to check this level to make sure we’re still good. And people are like, well, my dose hadn’t changed. Why? Why do you need this lab work? Like, why is that necessary? Well, it’s necessary because things change. We mentioned a medication like lithium. Your kidney function plays a huge role in how your body eliminates lithium. Lithium is a medication that will not leave your body unless you are urinating. So if your kidneys take a hit and your ability to produce urine and how all that works takes a hit, then your levels may be affected. Sometimes you might get started on a medicine by another doctor that can affect your lithium levels, and you don’t know that. And maybe that other doctor didn’t even know you were taking lithium. And then here we go. I check in and find out something’s off, and then I can do some research and figure out what’s what medications can affect the way each other metabolizing your body, like how they leave, how they’re processed. Your liver function for most medications is so important. So we may be wanting to also, in addition to just checking those levels, we may want to check your liver functioning. We may want to look at your blood counts and see what those are looking like for the lithium. We’re going to check your thyroid level because lithium can affect the thyroid negatively. So we stay on top of it. We want to check your kidney functions to make sure nothing has changed. There are lots of reasons that we order these things, and it’s just important for you to remember in all your frustration and fear of needles, that this really is all about your safety and making sure that we can keep you as stable as we have you.

Gabe: Before moving on to other symptoms of mood stabilizers that I want you to be aware of. I do want to give you a pro tip. Our bodies change, as Dr. Nicole said, and testing things like liver function and how our bodies are doing on a lifetime of medication. Ask your doctor to do those panels. Check your vitamin levels. Check. There’s I just ask for the entire workup if they’re going to take the blood anyways, and you’ve got to go through the needle, get as much done as you can. I really do think it pays dividends, especially for for my over 40 crowd. I really learned a lot of things by getting those panels done. And I wouldn’t have known them if I wouldn’t have submitted to regular blood tests that I know for a fact I personally wouldn’t have agreed to. If a doctor just said, oh, we’re going to do it as part of your physical, I’d have been, nah, I’m fine.

Dr. Nicole: Ugh, Gabe.

Gabe: I know myself, I know myself.

Dr. Nicole: Gabe. Gabe, sometimes I don’t even know what to say to you. I, I don’t I don’t even know. But you bring up a good point. If you especially if you’re taking the antipsychotic category for stabilizing your mood, those medications, we do recommend that you have your lipid profiles checked regularly. That we’re checking something that has to do with your glucose, whether that’s a fasting glucose level or what’s called an a-1c. We do recommend that those things get checked regularly when you take those medications, because as a category, a side effect of them is that you can experience changes in those metabolic labs. So your cholesterol, your LDLs, your glucose. So yeah, it’s important to get those things done. And as Gabe said, when you cross that line into middle age. It’s important to check those things because just because we think we’re doing okay doesn’t mean we’re doing okay.

Gabe: I’m going to steal your thing, Dr. Nicole. Stay ready so you don’t have to get ready. I think it is. It is great advice, but I have to credit you because you’re. You’re sitting right there. If you weren’t there, I would just be like, I have this phrase that I use.

Dr. Nicole: You would say, as I

Gabe: Because I’m a deep thinker and remarkable.

Dr. Nicole: As I always say.

Gabe: As I always say,

Dr. Nicole: Hmm.

Gabe: [Laughter] All right, so changing lanes, I want to talk about a side effect that I personally have. You know, other than a deep-seated fear of needles, I have tremors and I develop the tremors after I started taking psychiatric medications. And for the longest time, I just said that the tremors were because of my psychiatric medications. I didn’t really realize which medication was causing it. Now I want to disclose to the audience that the tremors don’t really bother me all that much. It was something that I was willing to live with. I’m not an artist. My handwriting was already terrible, and I’m not an athlete. Me having stable hands wasn’t really important, so I’m okay. Personally with the tremor. The tremor is manageable, but for some people it’s a big, big deal breaker. Now, Dr. Nicole, I know that you work with patients who are on mood stabilizers all the time. Some of them are willing to accept this side effect. Some of them are willing to accept no side effects, and some of them aren’t willing to accept a side effect because it directly impacts their ability to live their best life or make a living. I want to start sort of a little bit at the beginning, though. Why do mood stabilizers cause tremors?

Dr. Nicole: Well,

Gabe: Do we even know?

Dr. Nicole: I was going to say, I mean, this this is a question that I get asked. And my answer is usually, I don’t know.

Gabe: It’s not unfair. We don’t even know how some of these medications work. We just know that they

Dr. Nicole: No. I, I.

Gabe: Do from studies and testing. But the exact mechanism of the positives aren’t well understood.

Dr. Nicole: So, I’m.

Gabe: Just to be fair.

Dr. Nicole: I’m and I and I, I’m kind of joking in the whole. Oh I don’t know why. There are, there are certain meds that we do have an idea why. It’s because of, you know, what neurotransmitters they affect. And if we if we get a little bit too much effect in that area, we can see that. And so we know that I’m not going to get into a pharmacology lesson right now because I think everybody would fall asleep.

Gabe: That’s good, because I wouldn’t understand

Dr. Nicole: Yeah, yeah, it would be.

Gabe: I wouldn’t understand.

Dr. Nicole: Yeah, yeah,

Gabe: Yeah. You’re good, you’re good.

Dr. Nicole: So, for some we do, some we don’t. But I think the, the biggest, really the biggest focus should be then what the heck do we do about it? So you’re here and you have this tremor. And you’re right, tremor is frustrating for a lot of people. And the question always comes, well, did we try something else? That’s always an option. We try different medications, see if it goes away. But that’s not always the answer for some people. Some people say I’ve been on ten different things. This is the one thing I felt decent on, and now I have a tremor that changes how we have to approach it. So your doctor may talk to you about some medication that you can take to help combat the tremor, because maybe for you, going off of that medicine and trying something different is not an option that you’re willing to exercise at that moment. So it really just depends on your history, kind of what you’ve done. But yeah, tremors are common. But talk to your doctor about it if it’s something that’s bugging you. Because there are things that we can do to try to help with that, that can maybe improve that for you, to the point that you can continue to take that medication. And I know I hear somebody out there, I can hear your eyes rolling right now saying, here she is wanting to add another medicine. I said. That a discussion about changing would probably be in order. But if you’re someone who’s done a lot of changes and you haven’t found a lot of things to give you stability, this may be the answer. So I think just have the conversation with your Dr. Nicole, and kind of see how it goes.

Gabe: Now. Now, when you say we don’t know, Dr. Nicole, science doesn’t know. It’s not. It’s not. I mean, Gabe and Dr. Nicole don’t know because nobody understands it.

Dr. Nicole: It’s not just us walking around not knowing. But we.

Gabe: I just don’t want people to think I’m dumb. [Laughter]

Dr. Nicole: No, no, I mean, I say we don’t know and sometimes we don’t know is is a strong blanket answer. The honest to God truth is, there are some medications that we know full well. Very easy to explain. Not going to go into a pharmacology lesson here on this show. You all would be asleep by the time we got to the end. We know that there are certain medications that hit certain neurotransmitters, certain chemicals in your brain. And if we affect those chemicals and those pathways too much, we can cause a tremor. We know that. And then there are some medications that cause a tremor that we don’t have as much ability to explain. Some of them are much more complicated than what I just explained about the neurotransmitters. So we have an idea. But, you know, we don’t know. I don’t know why you take it. And at the same dose and you get a tremor, and I give the same dose or more to somebody else, and they don’t get a tremor. I don’t know that. I don’t know why you specifically are dealing with that. I have no idea. So that that’s where the I don’t know, comes in. So why am I having this? I don’t know, I could have somebody on double your dose who doesn’t have a tremor, and I could have somebody on half of your dose who does have a tremor. I don’t know that part. So when I say I don’t know, there are details of it that we just don’t know.

Gabe: The only other thing that I’m really curious about is, you know, I have a tremor, I have a tremor. I’ve decided that I’m willing to live with it. I take a medication that causes a tremor. What is the long-term effects of this?

Sponsor Break

Dr. Nicole: And we’re back discussing the things you may not know about mood stabilizers and bipolar disorder.

Gabe: I mean, maybe I don’t care when I’m 30. Maybe I don’t care what I’m 40. Maybe I don’t care what I’m 50. Is this one of these things where I’m going to turn 70 and not be able to carry a tray of food? I what are the long-term impacts of this tremor that many people are experiencing for the first time when they’re diagnosed? These prescriptions early in their diagnosis of bipolar disorder.

Dr. Nicole: Yeah, I think this is probably one of the most frustrating parts for the person living with the illness, right? Because we are giving you these medications. They have these side effects. And that’s a question I get asked a lot, like what’s going to happen to me when I’m 80 and I’m, you know, dealing with this tremor? What’s going to happen to me? Is it going to keep getting worse? Is it ever going to go away if I go off this medicine, am I always going to have a tremor? We don’t have any evidence to support that you should not take the medicine because of what’s going to happen to you. You know, when you’re 80, when you’re 90. You know what I do have, though? I have a lot of a lot of data to support me, keeping your mood as stable as possible, because that over time is going to be so much worse to have to manage. If you’ve had all these manic and depression episodes, and we’ve not been able to get control of your mood, that’s going to be worse over time and more difficult to manage. Am I going to tell you that 30 years from now, somebody won’t come back and say lithium causes permanent tremors in the elderly? I don’t know, I don’t know what’s going to happen 30 years from now. I have no idea. But I know that as of today. Our focus is still on you being a stable and having the highest quality of life you can. And if that looks like you taking this medication for the next 2030 years, as long as your body is tolerating it okay, your organs are doing fine. You’re able to maintain adequate levels. You’re not having the bad juju side effects, as I refer to them as, then we recommend that you go ahead and stay with it.

Gabe: One of the things that we talk about on this show a lot is the trade, right? People with bipolar disorder want to be stable. They want to reach recovery. We’re doing it for a really important reason. We want to be a good daughter or son. We want to be a present parent. We want to be a good friend. We want to go back to work. We want to go to Hawaii. We want to enjoy our lives. And when we find a drug like a mood stabilizer that’s working and helping us lead our best life, a tremor is a good trade. And in fact, for mood stabilizers, one of the things that that people talk about a lot is that there’s minimal side effects to them. They’ve been around for a long, long time. They don’t have a lot of side effects. And that makes me wonder, Dr. Nicole, why aren’t you just prescribing these things out, out, out the out the wazoo? I mean, just this this should be your go to for everything. They’re literally known as the psychiatric medication

Gabe: With minimal side effects.

Dr. Nicole: Okay.

Gabe: It should be in the advertising.

Dr. Nicole: Ish. They okay. But minimal compared to what? Like, what are we? I’m asking like what? What minimal compared to what? Like what? What are when you say.

Gabe: Compared to the other from my perspective, compared to the other medications.

Dr. Nicole: Okay. So, other medications being.

Gabe: I mean, for example, weight gain.

Dr. Nicole: Okay.

Gabe: The ones that cause weight gain, the ones that cause lethargy and

Dr. Nicole: Okay.

Gabe: Make you sleep for 24 hours, the ones that you know,

Dr. Nicole: Okay.

Gabe: Cause tardive dyskinesia,

Dr. Nicole: Okay, okay.

Gabe: I mean, yeah.

Dr. Nicole: Okay. Okay, so I usually tell people minimal is relative. Better is relative. When you think about we’ll pick on antipsychotics for a second. The first-generation antipsychotics the old schools right. The Haldols, the Thorazine,

Gabe: Right.

Dr. Nicole: The old school drugs. You know, we knew what those drugs did to people. We know they gave them the tremors and the involuntary movements, the tardive dyskinesia you talked about, like they did that stuff, and then they came out with the second-generation antipsychotics and they said, y’all, this is so much better. This is fantastic. This is amazing. But then we found out that that category was known for metabolic stuff. So people gaining tons of weight, developing diabetes, high cholesterol, those kinds of things. So better is relative. I mean, I can guarantee you that I have patients if I sit down with them. And if we start talking about first versus second generation antipsychotics, I’m going to have half of them say, oh no, I don’t want to gain weight. I’d rather you give me the lowest dose possible, and we just take our chances on the movements. I’d rather have that than to than to gain weight. Right. Because weight is really important to them and the diet and they say, oh, I have a family history. Oh I, I don’t, I can’t afford to gain weight. Oh. And you know, some it could be someone who in like in your case says I had bariatric surgery. Like I had surgery to get this weight off of me. The last thing I want is to gain weight from this medication. For them, the weight gain is a deal breaker.

Dr. Nicole: But they say, well, I’ll deal with the move. Like I’ll take my chances with that. Like that, I’ll take my chances with they would rather deal with that. Then there’s somebody else who says, well, I’m not worried about gaining weight. I can gain 30 pounds, I don’t care, I just don’t want to have these involuntary movements and have my mouth moving and having the shakes. And I don’t want I don’t want that. It’s all relative. It’s all about what you feel like you can handle and what is minimal to you. You mentioned earlier, well, I have a tremor, but I’m a podcaster. I’m not an artist, you know. You’re not an artist. You’re not a surgeon. You’re not doing any of those things that require precision and require you to be steady. So it wouldn’t matter to you. But I can guarantee you, if I was talking to someone who is an artist or a sculptor or someone who is a surgeon, they would say, I don’t want anything that has a high risk of tremor because I don’t I can’t do that. That’s going to impair my functioning too much. So I really don’t like when we say, oh, this category has minimal side effects compared to the other. Minimal is in the eye of the person that is having to take the medicine. So I don’t like to say minimal because I think it just it’s not accurate.

Gabe: I really do understand what you’re saying. I it is not lost on me that I live in Central Ohio, and when I say that I live in a 2500 square foot house, everybody in Ohio is like, well, that’s a modest home. That, that that’s a that’s an average sized home for Central Ohio. Nobody says, I live in a mansion. Nobody says that it’s big. Healthline media is based in New York City, where I spend a lot of time because of this podcast. And when they find out that I have 2500ft², that is like, oh my God, that’s amazing, because 2500ft² on the island of Manhattan would be a multi-million-dollar home. And of course, when they find out I just have a garage for my car, they just it blows their mind.

Dr. Nicole: [Laughter]

Gabe: Plus I have a backyard and a front yard. I just so much, so much wasted space. But that said, I do think that comparing it to other choices is important. So I really do understand that, and I’m not trying to minimize it with what I’m about to say,

Dr. Nicole: Oh, God. [Laughter]

Gabe: But I have to.

Dr. Nicole: Such a dad joke.

Gabe: I’ve reached the age where I have to.

Dr. Nicole: Such a dad joke.

Gabe: I have to. I have to, I have to, but I do have to say, when we look at profiles of medications, the sexual side effects, right? That’s a big one. The weight gain, that’s a big one. How they interact over the long term. That’s a big one. Mood stabilizers. They do well for a reason. They’ve been around for a long, long time. They’ve been tested for a long, long time. And the side effects really, really are well compared to other psychiatric medications, minimal. I recognize that that that your mileage may vary. And what’s good for me might not necessarily be good for you, but I really think this is one of the reasons that a significant number of people with bipolar disorder are stabilized on mood stabilizers, because the side effect panel is, frankly, the sexiest of all the side effect panels.

Dr. Nicole: The sexiest of all. I don’t know that I agree with that 100%. But again, it it’s going to be very individual. It’s going to be a very everyone is going to have a different take on what they’re willing to do and what they’re not. So I just yes, I agree with the fact that sure, minimal whatever, whatever, if that works for you, we’ll keep using minimal. Minimal is fine. We’ll stick with that.

Gabe: I really think the takeaway needs to be keep an open mind and work with your Dr. Nicole and do what you

Dr. Nicole: Yes.

Gabe: Need to do to live your best life now. Now I saved this one specifically for last because frankly, it contains my best joke. But one of the side effects of mood stabilizers is thirst. It makes you really, really, really thirsty. And I know why. I know

Dr. Nicole: Mm-hmm.

Gabe: Why, Dr. Nicole, are you ready?

Dr. Nicole: I’m not, Gabe, but you’re going to tell me anyway, so go right ahead. Go right ahead.

Gabe: It’s because the number one mood stabilizer is lithium and it’s a salt. So you thought there was going to be a joke, didn’t you? A lot of people are stabilized on lithium, which is a salt. It’s actually natural. It comes from the Earth. And it’s fascinating that so many people with bipolar disorder take lithium, which is a naturally occurring substance, and then, of course, want to stop taking it because they want to take a naturally occurring substance that they bought at the gas station. But I digress. We should love lithium in the bipolar community because it’s so natural. But all of that said, the fact that it’s a salt really does contribute to why it makes you so thirsty and interesting sub-fact, why animals will lick you when you sweat. You’re basically a giant salt lick.

Dr. Nicole: Gabe, I don’t. Gabe I. Oh, God. Okay. I don’t I don’t even know what to do with that, but let’s talk about thirst. Let’s just I wish.

Gabe: First, before we get on to thirst. I can see you hemming and hawing. Am I wrong? Is lithium a salt? Let’s start there.

Dr. Nicole: It is. No, it is, it is, it is, it is. And at one point Oh, gosh. At one point one of those stores, one of those, like, granola stores, Whole Foods maybe was selling this water that had small amounts of lithium in it. And I think they marketed it as crazy water is what it was called. Like with a K, I think it was, but if you tasted it, it was salty, like. It was it was a little salty. If you tasted it did not taste good, but it was, it was there. But we do think that. The thirst that comes lithium can cause. Polyuria. Which is just like urinating, more excess urination. And so we think that is the mechanism by which lithium causes people to feel thirsty. So salt, you know, does unique things in your bodies where salt goes, liquid goes. And so if it’s leaving you more liquids, leaving you increased risk of dehydration, bada bing, bada boom, thirst, dry mouth. So yes, lithium is well known to be one of those that people will complain about dry mouth for. But other categories can do it too. So it’s not just lithium like dry mouth is something that you can deal with a variety of psychiatric medications. So not just lithium. So, you know, I wouldn’t avoid lithium specifically because. Oh, I don’t want to have to deal with dry mouth because there’s no guarantee that you might not deal with lithium from some other medication as well. But again, it’s one of those what do we do about it? How do we manage it? How severe is it? And I it’s frustrating because I, I mean, I wouldn’t want to walk around with dry mouth I get that.

Gabe: As I said, I wanted to save this for last because it’s my favorite side effect, because it’s the one that has really benefited me more than any other bipolar side effect. Ever. So because I constantly have dry mouth and I’m constantly thirsty, I’m always carrying a drink. Now. Now remember, I’m of the age that Stanley Cups, Hydro Flask, YETIs, Odwalas. All of that stuff wasn’t popular. In fact, if you wanted to carry a drink on you in the old, you had that green, that green Thermos, right? That that that that your dad. And I’m not even trying to be sexist. Those green thermoses were predominantly carried by men. It had

Dr. Nicole: Yeah.

Gabe: Black coffee in it, and they poured it into the lid.

Dr. Nicole: Yes, yes.

Gabe: I mean, it was yeah. Yeah, it was a time that that’s really all you had. So I was always carrying around a fountain, Diet Coke and I. And I’m now known for it. People are like, hey, it’s the Diet Coke guy. It’s the Diet Coke guy. It’s the Diet Coke guy. Really? Diet Coke should sponsor everything that I do.

Dr. Nicole: [Laughter]

Gabe: Because I always have a Diet Coke. Go back and listen to any podcast, any podcast, and I am drinking a Diet Coke while I’m recording it. And you’re probably thinking, how is this an advantage? Because if you can be remembered for anything, you should take

Dr. Nicole: Okay. Oh, my gosh, Gabe. Okay.

Gabe: It is so difficult to get noticed and I’m known for that. And when I meet people for the very first time, more often than not they will bring me a Diet Coke. And it makes me feel really, really special. And I really, really like it. But all of that came from the fact that my mouth is chronically dry. There’s nothing that I can do to make it not dry. Now I want to save everybody the email. Please do not email me and tell me to drink water. I know, I know, but my mouth would still be dry and then I wouldn’t have Diet Coke. It’s. I only bring this up because it’s really a great example of how I can see the bright side of bipolar disorder, how I can see the forgive me, the positive of this symptom. This is a symptom that is caused me some deal of discomfort and pain and problem. It’s not great. I wish that I could get rid of it. If there was a cure tomorrow, I would in fact make this symptom go away. I’m not trying to keep it, but it is nice that there’s sort of a silver lining that came out of it, which is whenever I meet people and they bring me a Diet Coke, it does make me feel special. And I know the only reason that I’m constantly drinking this is because of a symptom of bipolar disorder. And it’s a nice little moment for me. And I imagine that maybe your symptoms and the way that you manage your symptoms may have resulted in some coping skills for you, and maybe some positives have come out of it. And

Dr. Nicole: Hmmm.

Gabe: I think it’s a good thing to try to find those things rather than just have an entire episode about, hey, here’s all the things that sucks about getting treatment for bipolar disorder.

Dr. Nicole: Well, okay. One I don’t know. I mean, that’s your story. It’s your advantage. I’m not going to take it from you. That’s yours.

Gabe: It’s mine. It’s all I got.

Dr. Nicole: Two, Coke Zero is far superior to Diet Coke, but that’s a that’s a discussion for a different day. But three dry mouth is one of those things that people say, oh, it’s just a little dry mouth. I’ll just drink, I’ll just drink. But I think we have to remember that dry mouth can be a bigger deal. Like dry mouth can cause you problems. So dry mouth is very important to your dentist. Probably more so than your psychiatrist. But I do understand the importance of, you know, moisture in your mouth. Why is it important? There are products out there that some people use. It’s a help. They have a brand of mouthwashes and gums and lozenges and things that you can, you can use to help with moisture in the mouth. But definitely make sure if you’re on a medication that’s causing you to have dry mouth, make sure that you are seeing your dentist twice a year. Make sure you’re going in for those cleanings and those appointments to make sure your dental health is on point. And if it’s a really, really big deal, we need to have a conversation with your, with your dentist. You know, this is another one of those areas where we need to have honest conversations with our health care team, because sometimes your dentist may not get why it’s important that you take this thing and they say, well, you just shouldn’t take that.

Dr. Nicole: Like if that medicine is causing you to have this significant dry mouth, you probably should just take something else. They may not understand that you’ve tried ten different things, and this is the one thing that has allowed you to get out of bed, put one foot in front of the other, not want to kill yourself every day and be able to enjoy your family. So you may have to share that with your dentist. It may not be the conversation you were intending to have, but I think if you tell your dentist, hey, listen, I used to want to die every day and now I don’t. And so dry mouth is bad, I get it. But we got to figure out how to work with this. And despite all the other stuff. And I think that will speak to your dentist to say, okay, well, let’s figure out what we need to do. You know, what can we do? What tips can I give you? So I think this is another one of those moments where we just come back to it’s important to have a team, a whole health care team, your primary care. And now we’re bringing in your dentist. But if you’re having dry mouth on a regular basis, please make sure that you are seeing your dentist twice a year. So go to your dentist, Gabe. Twice a year.

Gabe: First off, you should go to your dentist anyway. I mean, isn’t it sad we got to tell

Dr. Nicole: Yes. Hmm.

Gabe: People that like, hey, go to your dentist. It’s not, it’s not go to your dentist because you have bipolar disorder and you have a symptom of, of of psychiatric medication. Just like go

Dr. Nicole: Yes.

Gabe: To your dentist is like a hard stop moment. But

Gabe: This is a bipolar podcast. So let’s put it in terms of living with bipolar disorder. Dr. Nicole, I was shocked that there is prescription toothpaste. I

Dr. Nicole: Mm-hmm.

Gabe: Absolutely I did not know that this existed. There is also prescription mouthwash. Ask me how I know.

Dr. Nicole: Gabe, how do you know that there’s prescription toothpaste and prescription mouthwash?

Gabe: Because my dentist prescribed it to me and luckily my dental insurance covers it. But even if your dental insurance doesn’t cover it, it is. It’s fairly inexpensive and it’s fairly easy to use. You just brush your teeth once a day and you swap it out. Instead of using regular toothpaste, you swap it out with this special toothpaste once a day, and you use this mouthwash in the morning when you wake up and at night before you go to bed. And I got to tell you, the mouthwash is kind of nice because as you’re falling asleep, it’s minty. I know that’s a that’s a weird thing to say, but yes, this is one of those side effects that does have long term consequences on your teeth. But I want everybody to know my dentist spotted the dry mouth. I didn’t even tell her about it. She’s just like, do you have chronic dry mouth? And I said, yes. And she said, what medications are you on? I told her the medications she goes are. Yes. And then she told me exactly what to do. So obviously you need to work with your dentist. I would really like to believe that there’s not a dentist out there that is going to tell you to stop taking needed medication to save your teeth. Because I, I just it does worry me a little bit, Dr. Nicole that that is a reality that people with bipolar disorder live in. But we do live in that reality. So if you do get any pushback from your dentist, like Dr. Nicole said, explain it to them. Work with your psychiatrist to get the information over that they need. And you can mention, hey, I understand that there might be a prescription toothpaste or a prescription mouthwash that might help with this, and maybe that’ll tap them in the right direction that you need. Obviously, in a worst-case scenario, if anybody tells you to stop taking your medication for any reason, that doesn’t sit well with you it might be time to change providers. But I always hate to fall down that rabbit hole because it’s hard to find providers,

Dr. Nicole: Yeah.

Gabe: Especially providers that we like and in specific areas. But yeah, yeah. Prioritize your whole health, not just your mouth health.

Dr. Nicole: Yeah. No. Your whole dental health is health. No, seriously, it is. It is very important. And I don’t think that a dentist would tell you stop taking your meds. I think more likely somebody might say, well, can you take something else? Do you, do you need to take the, you know, could you try something different? And they just may not know they’re trying something different. It’s not an option for you. It may not be an option for you. It may be. And you decide the dry mouth is bad enough that you want to talk to your doctor about something different. But, you know, that’s when you start making decisions about what’s more important to you, what’s minimal to you, what are those things that you can deal with? What are your deal breakers? That’s why you have a whole team. That’s why you have your psychiatrist and your primary care doctor, and you have your dentist, and you just have a whole team of folks whose job is to keep you together and whole and well.

Gabe: I think it’s a good thing. And also not for nothing, Dr. Nicole, I didn’t want to end the episode on, hey, you know, mood stabilizers, the gold standard for the treatment of bipolar disorder. Here’s all the reasons it sucks. I, I want people to have this information so they can make good decisions. But I did want to be uplifting.

Dr. Nicole: I mean, you know, I love ending on a high note. I would prefer people not walk away from the podcast set so that perfectly fine silver linings, all that stuff. Coke Zero is better than Diet Coke. Let’s just end it right there. Thank you.

Gabe: You are so wrong, Dr. Nicole. Thank you so much, everybody, for tuning in. And we have a couple of favors to ask of you. First off, wherever you downloaded this episode, please follow or subscribe to the show. It is absolutely free and this way you won’t miss anything. And the second favor we have is recommend the show shared in a support group. Share it on social media. Hell, send somebody a text message because by you sharing the show with the people you know is how we’re going to grow. My name is Gabe Howard, and I’m an award-winning public speaker who could be available for your next event. I can also invite Dr. Nicole along if you’d like. I’m also the author of “Mental Illness Is an Asshole and Other Observations,” which you can get on Amazon because everything is on Amazon. However, if you want to get a signed copy with some free show swag or learn more about me, just head over to my website

Dr. Nicole: And I’m Dr. Nicole. You can find me on all social media platforms @DrNicolePsych or at my website, to see all the things I have my hand in at any given moment.

Gabe: And we will see everybody next time on Inside Bipolar.

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