LITHIUM:
Lithium is considered the gold standard for the treatment of bipolar disorder in adults, and an estimated 70-80 percent of patients have a positive therapeutic response to it. But there has long been an idea that rapid-cyclers may not do as well on lithium as they do on the anticonvulsant drugs--Tegretol or Depakote and so on.

But is this true for adults and/or children who have such ultra-rapid cycles? Not necessarily. Some children have an excellent response to the drug or to its use in combination with another mood stabilizer.

Very important, there is newly emerging evidence from the research literature that lithium has a strong and possibly unique effect against suicidal behavior in people with bipolar disorder. And this is not true of the other mood stabilizers as far as we know. According to Ross J. Baldessarini, M.D. of Harvard Medical School "If the antisuicidal side effects are not shared with other mood-altering agents, this may be due to the cerebral serotonin-enhancing properties of lithium, properties that are not known to be associated with anticonvulsants.

Testing Before Treatment

*Complete medical history
*Blood tests that include kidney function studies and thyroid-function studies
*Urinalysis

Range of Effective Levels

Acute episodes may require levels of 0.6 to 1.5 mEq
Maintenance treatment levels in children typically range from 0.6 to 0.85 mEq/liter.

TEGRETOL:
Tegretol (carbamazepine) has acute antimanic effects and also acts to prevent future episodes of illness in bipolar disorder. Some studies have reported that Tegretol has antiagressive properties, something that might make it particularly useful for children with frequent rage attacks.

Testing Before Treatment:

*Complete medical evaluation
*Blood tests to evaluate liver function, blood cell and platelet counts and iron concentration

Dosing:

Younger children between the ages of six to twelve might be started on a dose of 100 mg daily (or 50 mg two times a day if the liquid is used). The dose is typically increased weekly by increments of 100 mg with an initial target dose of 500-600 mg/ml. At this point, the blood level is obtained five to six days after reaching the initial target dose. Further increases would depend on evidence of clinical response, side effects, and achieving a therapeutic level.

Adolescents older than twelve usually start treatment with doses of 200 mg twice a day and the dose is increased weekly by increments of 200 mg. The usual daily maintenance dose is 800 to 1200 mg.

Because Tegretol activates certain enzymes in the liver, and this causes Tegretol itself and many others medications to be metabolized faster, the serum Tegretol level may drop somewhat after the first month of treatment, requiring increased doses based on blood levels. Blood tests are needed more frequently in the beginning of treatment and every three months or so afterward.

Note: the generic form of Tegretol--carbamazepine--seems to be less well formulated than the brand name drug. It seems that some of the generic versions are less well formulated and the tablets tend to fall apart and to be less well absorbed. If a young woman is on oral contraceptives, Tegretol will reduce the effectiveness of the pill.

Do not store Tegretol in the bathroom cabinet or in any humid area because humidity may cause Tegretol tablets to harden, become less soluable and lose one-third or more of its effectiveness. They should be stored in moisture-proof containers.

Range of Effective Levels:
6 to 12 mg/ml

DEPAKOTE:
Many children are prescribed Depakote (divalproex sodium) but all too often we receive med charts from parents or emails reporting that the Depakote dosage was 250-500 mg a day and "it didn't work." Most children will require far higher doses to achieve therapeutic blood levels, and while all children will reach different blood levels at different dosages, it's important to get the right levels and wait a few weeks before making any judgment about the effectiveness of the drug.

Testing Before Treatment

*Medical exam to gauge liver function, blood cell and platelet counts, and serum iron concentrations.

Dosing:

Children are often started on a test dose of 125 mg and adolescents on 250 mg, and the doses are gradually increased to obtain a daily target dose of of between 1,000-1,200 mg. Some children will require 1,500-2,000 mg a day to maintain an effective Depakote level. Like Tegretol, Depakote increases its own breakdown and the levels will need to be examined after a month on the medication to see if the level has dropped.

Range of Effective Levels
Many children respond best at levels between 80-90 mg/ml, but some require levels of 100 to 125 mg/ml to achieve adequate symptom relief.

NEURONTIN:
Neurontin (gabapentin) is an anti-seizure medication that seems to have few side effects except for its potential to cause sedation. It does not cause weight gain. Neurontin can also be used safely with other medications needed by a child or adolescent with bipolar disorder. There are no blood levels to be determined. However, it has a short half-life and must be administered three times a day.

Although only limited studies have been mounted, the initial results are not impressive. Several highly respected clinicians we know find it does not work well as a mood stabilizer when given as a monotherapy (when it is the only mood stabilizer). One study reported by Atul C. Pande, M.D. at the Third international Conference on Bipolar Disorder in Pittsburgh last June examined the use of Neurontin as an add-on to lithium or Depakote versus a placebo add-on and found that the patients taking the placebo actually had a better response.

However, it seems to be useful as an anti-anxiety agent and is definitely useful as a sedating agent for individuals who experience evening or late-night activation.

Dosing:

A therapeutic dose seems to be between 900 and 1,800 mg a day, and, as we mentioned above, it must be given in divided doses, three times a day.

TOPAMAX:
Topamax (topiramate) is an anticonvulsive drug chemically unrelated to any other anticonvulsant or mood stabilizing medication. It has been reported to control rapid-cycling and mixed bipolar states in patients who have not responded well to Tegretol or Depakote, but its long-term prevention of cycling has not been established.

What makes this drug of particular interest is that it causes no weight gain. In fact, it may reduce the intense food cravings that may occur with other commonly used psychiatric drugs such as Depakote, Risperdal, and Zyprexa. It can also be used as a sedating agent.

Dosing:

An initial dose of 25 mg is given once or twice a day and increased by 25 to 50 mg every week. When Topamax is prescribed as an add-on drug with other anticonvulsants, a target dose of 150 to 200 mg is often often enough for mood stabilization, but some children will require higher doses, even up to 400 mg a day. When Topamax is used as a monotherapy--alone--as it is starting to be used-- a target dose of upwards of 200 mg seems to provide mood stabilization.

The blood levels of Topamax can be lowered by Depakote and especially Tegretol, and Topamax may decrease the effectiveness of birth control pills.

LAMICTAL:
Lamictal (lamotrigine) is an anti-seizure medication that may have a significant place in the treatment of bipolar disorder. What sets it apart from most the other mood stabilizers is that it seems to have a significant effect on the depressive symptoms of bipolar disorder. The other mood stabilizers work to act to prevent future episodes of depression and mania, but do not work as well on acute depression. This medication might allow doctors to treat the depressive symptoms of bipolar disorder without antidepressants which tend to cause increased cycling or to flip patients into mixed or manic states. However, Lamictal seems to have weaker antimanic effects, and at higher doses--above 175 mg--it can be activating.

There are no blood levels to be taken, and the side effect profile is mild: But as with all things in life, there is no free lunch. As with the sulfa drugs and penicillin--and even some other antiseizure medications-- Lamictal can produce an allergic response that manifests as a rash and, on rare occasions, the rash can be a serious one that signals a life-threatening condition known as Stevens-Johson Syndrome.

In most cases, the rash is mild, similar to a sunburn and usually clears up after the drug is stopped (many people can resume the drug later and no rash will occur). But lets take a look at some of the newest research concerning Lamictal and serious rash.

A rash is most likely to develop when the dosing schedule starts too high or is increased too rapidly (start low and go slow is the pertinent phrase here). We spoke with Dr. Andrew Stoll of Harvard Medical School who has quite a bit of experience with the drug and he said that he often takes three months to reach the target dose.

Other cases of rash occurred when Lamictal was given with Depakote--the Depakote doubled the Lamictal levels. Typically the rash occurs in the first eight weeks of treatment.

A study reported in October 1999 in The Annals of Pharmacotherapy reported on 1,050 patients given Lamictal. The article was a retrospective case record survey at five epilepsy centers in the UK. When reserachers examined the cases of patients who started Lamictal at higher doses, the incidence of serious rash was 1.1 percent and of non-serious rash, 7 percent. In 1994, however, the manufacturer of Lamictal issued a recommendation for a lowered starting dose. When the researchers looked at patients case records which revealed this lower starting dose, there was a significant reduction in the incidence of serious rash: (0 out of 245 patients).

Dosing:

Lamictal should be started at 25 mg for 10 days to two weeks and then increased by 12.5 mg every ten days to two weeks until a target dose of 100-150 is reached.

TRILEPTAL:

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RITALIN - METHYLPHENIDATE:
Comes in Tablet form; 5 mg, 10 mg, and 20 mg. Usually start with a morning dose of 5 mg/day and increase up to 0.3-0.7 mg/kg of body weight. 2.5-60 mg/day. Duration of the med lasts 3-4 hours.

Common Side Effects:

Insomnia, decreased appetite, weight loss, headache, irritability, stomachache.

Benefits:

Works quickly(within 30-60 minutes): effective in 70% of patients; good safety record.

Precautions:

Use cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome.

DEXADRINE - DEXTROAMPHETAMINE:
Comes in a 5 mg tablet and Spansules; 5 mg, 10 mg and 15 mg. Start with a morning dose of 5 mg and increase up to 0.3-0.7 mg/kg of body weight. Give in divided doses2-3 times per day. 2.5-40 mg/day. Duration about 3-5 hours (tablet) and about 7-10 hours (spansule).

Common Side Effects:

Insomnia, decreased appetite, weight loss, headache, irritability, stomachache.

Benefits:

Works quickly (within 30-60 minutes); may avoid noontime dose in spansule form; good safety record.

Precautions:

Use cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome.

ADDERALL:
Comes in tablet form, 10 and 20 mgs. Start with a morning dose of 2.5 mg for 3-5 year olds. For 6 years and older start with 5 mg once or twice daily. Duration of the med is 3-6 hours.

Common Side Effects:

Insomnia, decreased appetite, weight loss, headache, irritability, stomachache.

Benefits:

Works quickly (within 30-60 minutes); may last somewhat longer than other standard stimulants.

Precautions:

Use cautiously in patients with marked anxiety, motor tics or with family history of Tourette syndrome.

CELEXA (citalopram hydrobromide):
Was introduced in the United States in July of 1998. This medication takes approximately two to three weeks to exhibit therapeutic benefits, but may take a shorter or longer time to exhibit effects due to dosage, symptoms, etc.

Side Effects:

Most common side effect: nausea, dry mouth, sleepiness, increase in sweating, low blood pressure, decrease in weight/increased weight, increased appetite, impaired concentration.
Infrequent side effects: high blood pressure, hot flashes, dry eyes, arthritis, muscle weakness.
Rare side effects/Risks: hyponatremia (low concentration of sodium in blood that often occurs in dehydration), sexual difficulties (decreased libido, ejaculation disorder, and impotence).

DESYREL (trazodone):
This medication works by increasing the availability of serotonin, a neurotransmitter, in the brain and thereby relieving the symptoms of depression. You should start feeling the effects of Desyrel within two to four weeks. It may take longer to experience the full effects of Desyrel, which depends on dosage and varies from person to person. Alcohol should be avoided completely; serious, even fatal interactions, have occurred when Desyrel and alcohol have been taken. Desyrel can cause irregular heart rhythms in individuals with heart disease. Consult your doctor if you possess any cardiovascular problems.

Side Effects:

Most common side effects: drowsiness, weight gain, dizziness, dry mouth, constipation, fatigue, nervousness, headache.
Infrequent side effects: nausea, hypotension, blurred vision.
Rare side effects/Risks: priapism, tremors, tinnitus, hypomania, irregular heartbeat, reduction in white blood cell count.

Effexor (venlafaxine):
Is a fairly new antidepressant, introduced in 1993, that is thought to have possess the beneficial effects of SSRIs and TCAs (two types of antidepressants) combined. For some people, Effexor relieves the symptoms of depression better than other medications, perhaps because it increases the levels of both serotonin and norepinephrine (two neurotransmitters thought to cause the symptoms of depression) in the brain. Usually, you should start feeling better within one to four weeks. It may take longer to experience the full effects of Effexor, which depends on dosage and varies from person to person. There seems to be no adverse interaction with alcohol, but due to the possibly adverse effects alcohol may have on a depressed individual, it should be avoided. Talk to your doctor if you have high blood pressure, heart, liver, or kidney disease. Dosage will probably have to be altered in these cases.

Side Effects:

Most common side effects: headache, nausea, weight loss, constipation.
Infrequent side effects: anxiety/nervousness, blurry vision, diarrhea, dizziness, dry mouth, insomnia, sexual difficulties.
Rare side effects/Risks: hypomania, increased blood pressure, seizures.

LUVOX (fluvoxamine):
Fluvoxamine Maleate, or Luvox, was introduced in 1995. It works by balancing the levels of a neurotransmitter, serotonin, and thereby relieving the symptoms of depression. It may take one to two weeks before beginning to feel the effects of Luvox. It may take longer to experience the full effects of Luvox, which depends on dosage and varies from person to person. If nausea and vomiting continue for more than two days after you start taking this medication, call your doctor. A withdrawal syndrome has been reported if this medication is stopped suddenly so do not stop taking this drug without first talking to your doctor.

Side Effects:

Most common side effects: dry mouth, constipation, anorexia, nausea, insomnia, drowsiness.
Infrequent side effects: dizziness, headache, agitation, sleep disorders, delayed or absent orgasm, diarrhea, weakness/loss of strength.
Rare side effects/Risks: hypomania, liver toxicity.

NARDIL (phenelzine sulfate):
Nardil works by increasing the concentration of neurotransmittersepinephrine, norepinephrine, and serotonin, thereby relieving the symptoms of depression. Usually, you should start feeling better within seven to ten days. It may take up to four to eight weeks to experience the full effects of Nardil. The effects of this medication persist up to ten days after therapy is stopped. The onset and duration of the medication depends on the prescribed dosage, and varies from person to person. If you are taking Nardil, you will need to know about some important dietary restrictions. Disregarding the dietary restrictions may lead to hypertensive crisis, which includes headaches, stiff neck, sweating, nausea, vomiting or much worse.

Side Effects:

Most common side effects: dizziness, drowsiness, headache, insomnia, nausea, weakness, constipation, dry mouth, weight gain, fatigue, twitching, sexual dysfunction, hypertension.
Infrequent side effects/Risks: jitteriness, euphoria, urinary retention, blurred vision, skin rash, sweating.
Rare side effects/Risks: shock-like coma, toxic delirium, hypomania, acute anxiety reactions.

PARNATE (tranylcypromine sulfate):
Parnate works by increasing the concentration of the neurotransmitters epinephrine, norepinephrine, and serotonin, thereby relieving the symptoms of depression. Usually, it takes a person taking Parnate within 48 hours to three weeks in order to achieve the full beneficial effects. The medication may take longer to produce full effects depending on the prescribed dosage and varies from person to person. If you are taking Parnate, you will need to know about some important dietary restrictions. Disregarding the dietary restrictions may lead to hypertensive crisis, which includes headaches, stiff neck, sweating, nausea, vomiting or much worse. Do not stop taking Parnate suddenly as there can be complications involved with abrupt withdrawal.

Side Effects:

Most common side effects: dizziness, hypotension, anorexia,nausea, drowsiness, high blood pressure(hypertension).
Infrequent side effects: weakness, headache, blurred vision, sexual problems, skin problems, tremors, dry mouth, tinnitus, constipation, diarrhea, abdominal pain, rash, chills, edema.
Rare side effects/Risks: agranulocytosis (an acute deficit of certain blood cells), thrombocytopenia (a reduction in the number of platelets in the blood, which results in the bleeding into the skin).

PAXIL (paroxetine):
Paxil is a SSRI that works by restoring levels of the neurotransmitter serotonin, thereby relieving depression symptoms. Usually, you should start feeling better within one to four weeks. It may take longer to experience the full effects of Paxil, which depends on dosage and varies from person to person. Inform your doctor if you have impaired liver or kidney function, if you take diuretics or typically drink little water, or have a history of mania or seizure disorders before taking this medication. Paxil may cause excessive sweating, thus patients should replace lost fluids when taking this medication.

Side Effects:

Most common side effects:owered blood pressure and fainting upon standing (postural hypotension), sweating, dry mouth, nausea, headache, drowsiness.
Infrequent side effects:nervousness, insomnia, constipation, loss of appetite, dizziness, blurred vision, abnormal ejaculation, impotence, sexual dysfunction, diarrhea.
Rare side effects/Risks:hypomania, seizures.

PROZAC (fluoxetine):
Was introduced in 1978. Prozac is a SSRI that works by restoring levels of the neurotransmitter serotonin, thereby relieving depression symptoms. Usually, you should start feeling better within one to four weeks. It may take longer to experience the full effects of Prozac, which depends on dosage and varies from person to person. Inform your doctor if you have impaired liver or kidney function, have Parkinson's Disease, had a history of psychosis, have a seizure disorder, or are pregnant or plan to be pregnant while taking Prozac. Avoid grapefruit juice when taking Prozac due to the increased blood levels.

Side Effects:

Most common side effects: decreased appetite, weight loss, nausea, altered taste, insomnia, headache.
Infrequent side effects: blurred vision, anxiety, nervousness, drowsiness, dizziness, excessive sweating, anorexia, impaired erection.
Rare side effects/Risks: hypomania, seizures, tremor.

REMERON (mirtazapine):
It was introduced in the United States since June 1996. This medication works by increasing the availability of serotonin, a neurotransmitter, in the brain and thereby relieving the symptoms of depression. Usually, you should start feeling better within one to four weeks. It may take longer to experience the full effects of Remeron, which depends on dosage and varies from person to person. Remeron is a new medication which may relieve the symptoms of depression better than SSRIs or TCAs. This medication is thought to be particularly useful in reducing anxiety and sleep problems which often accompany depression. However, in clinical studies, 54% of patients have reported drowsiness (Arky, 1998). The cholesterol and/or triglyceride levels of individuals taking Remeron was noticed in clinical trials. Consult your physician if this potential side effect is troublesome. Alcohol is recommended to be avoided when taking this medication due to the enhancing effects Remeron may have on cognitive and motor ability.

Side Effects:

Most common side effects: dizziness, drowsiness, weight gain, increased appetite, weakness, dry mouth, constipation, abnormal dreams and/or thinking, "flu-like" symptoms.
Infrequent side effects: back pain, confusion, frequent urination, nausea, tremors, swelling of ankles or hands, fluid retention, difficult breathing, muscle pain.
Rare side effects/Risks: agranulocytosis (decrease in white blood cells), hypomania.

SERZONE (nefazodone):
Nefazodone, the generic name of Serzone, is a newer antidepressant, introduced in 1994. Usually, you should start feeling better in four to five weeks, if not sooner. However, it may take longer to experience the full effects of Serzone, which depends on dosage and varies from person to person. This medication is sometimes used in patients who were not helped by SSRIs or TCAs. Serzone may improve sleep quality better than other antidepressants, often decreases the troublesome side effect of sexual dysfunction, and possesses fewer cardiovascular side effects than older agents.

Side Effects:

Most common side effects: drowsiness, dry mouth, nausea.
Infrequent side effects: dizziness, blurred vision, weakness, insomnia, agitation, weakness or loss of strength
Rare side effects/Risks: hypomania, seizures.

WELLBUTRIN (bupropion hydrochloride):
This medication works by increasing the levels of the neurotransmitters dopamine and norepinephrine in the brain and thereby relieving the symptoms of depression. Usually, you should start feeling the effects of Wellbutrin within one to four weeks. It may take longer to experience the full effects of Wellbutrin, which depends on dosage and varies from person to person. If you take Wellbutrin, you may be more vulnerable to seizures if your dosage is too high, have suffered brain damage, or have had seizures before. In recent studies, 28% of patients exhibited weight loss of 5 lb. or more (Rybaki & Long, 1998). Caution should be taken if weight loss is a major factor in your depressive illness. Also, many patients experience a period of increased restlessness, especially when first taking the drug. This may take the form of agitation, insomnia, and anxiety.

Side Effects:

Most common side effects: weight loss, insomnia, nervousness.
Infrequent side effects: agitation, constipation, dry mouth, headache, nausea, increased libido, skin problems, tremors, excessive sweating.
Rare side effects/Risks: hypomania, seizures, tinnitus, white blood cell decrease.

ZOLOFT (sertraline):
Zoloft is a SSRI that works by restoring levels of the neurotransmitter serotonin, thereby relieving depression symptoms. Usually, you should start feeling better within two to four weeks. It may take longer to experience the full effects of Zoloft, which depends on dosage and varies from person to person. Inform your doctor if you have impaired liver or kidney function, have Parkinson's Disease, had a recent heart attack, have a seizure disorder, or are pregnant or plan to be pregnant while taking Zoloft.

Side Effects:

Most common side effects: nausea, diarrhea, drowsiness, decreased appetite, weight loss.
Infrequent side effects: dry mouth, vomiting, vagnitis, insomnia.
Rare side effects/Risks: seizures, male sexual dysfunction, increased blood pressure, hypomania.

Tricyclic Antidepressants

CLOZARIL (clozapine):
This medication helps correct an imbalance of nerve impulses that causes schizophrenic thought disorders. Clozaril can help people whose negative or positive symptoms have not improved with treatment, or who experienced severe side effects from taking antipsychotic medications in the past. In fact, clozapine has been found to improve symptoms in 50-60% of people in which standard antipsychotic medications were ineffective. Usually, you should start feeling better within two to four weeks. It may take longer to experience the full effects of Clozaril, which depends on dosage and varies from person to person.

Side Effects:

Most common side effects: rapid heartbeat, low blood pressure, dizziness, fainting, drowsiness, salivation, constipation.
Infrequent side effects: headache, tremor, sleep disturbances, confusion, sweating, dry mouth, high blood pressure, nausea, abdominal discomfort, fever.
Rare side effects/Risks: reduced white-blood-cell count (agranulocytosis).

RISPERDAL (resperidone):
In addition to indications for treatment of psychotic disorders, this drug is indicated for treatment of aggression, agitation, and the age group 2 to 12 years is recommended as an age group where more information is needed. This medication acts to balance two nerve impulses and, by doing so, helps restore more normal thinking and mood. In general, this medication has fewer side effects than standard antipsychotic medication. Risperidone also seems to help improve the negative symptoms of schizophrenia better than the other classes of antipsychotic medications. Usually, you should start feeling the effects of Risperdal within one to two weeks. It may take longer to experience the full effects of Risperdal, which depends on dosage and varies from person to person.

Side Effects:

Most common side effects: sleepiness, agitation, anxiety, uncontrolled movements, headache, and nasal stuffiness and irritation.
Infrequent side effects: dizziness, constipation, nausea, vomiting, upset stomach, abdominal pains, increased saliva, rapid heartbeat, chest pains, fever, skin rash.
Rare side effects/Risks: neuroleptic malignant syndrome (NMS), uncontrolled movements, life-threatening abnormal heart rhythm.

SEROQUEL (quetiapine fumarate):
In general, this medication has less severe motor side effects (such as akathisia and tremor) than standard antipsychotic medications. Seroquel also seems to be effective in the treatment of both positive and negative symptoms of schizophrenia. Seroquel usually starts working in about one and a half hours. The medication may take longer to exhibit beneficial effects in some people due to symptoms and other factors.

Side Effects:

Most common side effects: dizziness, drowsiness, constipation, dry mouth, indigestion, hypotension (abnormally low blood pressure).

ZYPREXA (olanzapine):
In addition to the use for management of the manifestations of psychotic disorders, this drug is recommended for use in treating pervasive developmental disorder in age 6 and older. This medication acts to balance two nerve impulses and, by doing so, helps restore more normal thinking and mood. In general, this medication has fewer side effects than standard antipsychotic medications. Zyprexa also seems to help improve the negative symptoms of schizophrenia better than the other classes of antipsychotic medications. Usually, you should start feeling the effects of Zyprexa within one week. It may take longer to experience the full effects of Zyprexa, which depends on dosage, symptoms, and varies from person to person.

Side Effects:

Most common side effects: drowsiness, agitation, insomnia, dizziness.
Infrequent side effects: skin rash, headache, depression, fast heart rate, constipation, weight gain.
Rare side effects/Risks: abnormal movements, neuroleptic malignant syndrome (NMS), orthostatic hypotension (low heart rate upon standing).

Other Antipsychotic Medications