Bipolar disorder (manic-depressive illness) is characterized by cycling mood changes: severe highs (mania) and lows (depression). Cycles may be predominantly manic or depressive with normal mood between cycles. Mood swings may follow each other very closely, within hours or days, or may be separated by months to years. These “highs” and “lows” may vary in intensity and severity.
When someone is in a manic “high,” he may be overactive, overtalkative, and have a great deal of energy. He will switch quickly from one topic to another, as if he cannot get his thoughts out fast enough; his attention span is often short, and he can easily be distracted. Sometimes, the “high” person is irritable or angry and has false or inflated ideas about his position or importance in the world. He may be very elated, full of grand schemes which might range from business deals to romantic sprees. Often, he shows poor judgment in these ventures. Mania, untreated, may worsen to a psychotic state.
Depression will show in a “low” mood, lack of energy, changes in eating and sleeping patterns, feelings of hopelessness, helplessness, sadness, worthlessness, and guilt, and sometimes thoughts of suicide.
The medication used most often to combat a manic “high” is lithium. It is unusual to find mania without a subsequent or preceding period of depression. Lithium evens out mood swings in both directions, so that it is used not just for acute manic attacks or flareups of the illness, but also as an ongoing treatment of bipolar disorder.
Lithium will diminish severe manic symptoms in about five to 14 days, but it may be anywhere from days to several months until the condition is fully controlled. Antipsychotic medications are sometimes used in the first several days of treatment to control manic symptoms until the lithium begins to take effect. Likewise, antidepressants may be needed in addition to lithium during the depressive phase of bipolar disorder.
Someone may have one episode of bipolar disorder and never have another, or be free of illness for several years. However, for those who have more than one episode, continuing (maintenance) treatment on lithium is usually given serious consideration.
Some people respond well to maintenance treatment and have no further episodes, while others may have moderate mood swings that lessen as treatment continues. Some people may continue to have episodes that are diminished in frequency and severity. Unfortunately, some bipolar patients may not be helped at all. Response to treatment with lithium varies, and it cannot be determined beforehand who will or will not respond to treatment.
Regular blood tests are an important part of treatment with lithium. A lithium level must be checked periodically to measure the amount of the drug in the body. If too little is taken, lithium will not be effective. If too much is taken, a variety of side effects may occur. The range between an effective dose and a toxic one is small.
A lithium level is routinely checked at the beginning of treatment to determine the best lithium dosage for the patient. Once a person is stable and on maintenance dosage, a lithium level should be checked every few months. How much lithium a person needs to take may vary over time, depending on how ill he is, his body chemistry, and his physical condition.
Anything that lowers the level of sodium (table salt is sodium chloride) in the body may cause a lithium buildup and lead to toxicity. Reduced salt intake, heavy sweating, fever, vomiting, or diarrhea may do this.
An unusual amount of exercise or a switch to a low-salt diet are examples. It’s important to be aware of conditions that lower sodium and to share this information with the doctor. The lithium dosage may have to be adjusted.
When a person first takes lithium, he may experience side effects, such as drowsiness, weakness, nausea, vomiting, fatigue, hand tremor, or increased thirst and urination. These usually disappear or subside quickly, although hand tremor may persist. Weight gain may also occur. Dieting will help, but crash diets should be avoided because they may affect the lithium level. Drinking low-calorie or no-calorie beverages will help keep weight down.
Kidney changes, accompanied by increased thirst and urination, may develop during treatment. These conditions that may occur are generally manageable and are reduced by lowering the dosage.
Because lithium may cause the thyroid gland to become underactive (hypothyroidism) or sometimes enlarged (goiter), thyroid function monitoring is a part of the therapy. To restore normal thyroid function, thyroid hormone is given along with lithium.
Because of possible complications, lithium may either not be recommended or may be given with caution when a person has existing thyroid, kidney, or heart disorders, epilepsy or brain damage.
Women of childbearing age should be aware that lithium increases the risk of congenital malformations in babies born to women taking lithium. Special caution should be taken during the first three months of pregnancy.
Lithium, when combined with certain other medications, can have unwanted effects. Some diuretics (substances that remove water from the body) increase the level of lithium and can cause toxicity. Other diuretics, like coffee and tea, can lower the level of lithium.
Signs of lithium toxicity may include nausea, vomiting, drowsiness, mental dullness, slurred speech, confusion, dizziness, muscle twitching, irregular heartbeat and blurred vision. A serious lithium overdose can be life-threatening. Someone who is taking lithium should tell all the doctors, including dentists, he sees about all other medications he is taking.
With regular monitoring, lithium is a safe and effective drug that enables many people who otherwise would suffer from incapacitating mood swings to lead normal lives.
Not all patients with symptoms of mania benefit from lithium. Some have been found to respond to another type of medication, the anticonvulsant medications that are usually used to treat epilepsy.
Carbamazepine (Tegretol) is the anticonvulsant that has been most widely used. Bipolar patients who cycle rapidly that is, they change from mania to depression and back again over the course of hours or days, rather than months seem to respond particularly well to carbamazepine.
Early side effects of carbamazepine, although generally mild, include drowsiness, dizziness, confusion, disturbed vision, perceptual distortions, memory impairment, and nausea. They are usually transient and often respond to temporary dosage reduction.
Another common but generally mild adverse effect is the lowering of the white blood cell count, which requires periodic blood tests to monitor against the rare possibility of more serious, even life-threatening, bone marrow depression.
Also serious are the skin rashes that can occur in 15 to 20 percent of patients. These rashes are sometimes severe enough to require discontinuation of the medication.
In 1995, the anticonvulsant divalproex sodium (Depakote) was approved by the Food and Drug Administration for bipolar disorder. Clinical trials have shown it to have an effectiveness in controlling manic symptoms equivalent to that of lithium; it is effective in both rapid-cycling and nonrapid-cycling bipolar.
Though divalproex can cause gastrointestinal side effects, the incidence is low. Other adverse effects occasionally reported are headache, double vision, dizziness, anxiety, or confusion. Because in some cases divalproex has caused liver dysfunction, liver function tests should be performed prior to therapy and at frequent intervals thereafter, particularly during the first six months of therapy.