In response to the ongoing interest from Dr. Nigila’s TalkBD about Medication and Bipolar, Dr. Nigila is back! In this blog post, Dr. Nigila answers your top 10 questions–including the questions we didn’t get to during the livestream.
If you haven’t already, watch the complete episode below to find answers to more of your medication questions:
1. Why is it the norm to take medication continuously, instead of treating symptoms for episodes as they arise?
The reason it’s best to take medication continuously is that episodes can occur without warning. They can also occur due to triggers like sleep changes, stress, work requirements, lack of routines, change in daily routines, life events, substance use, and a number of other reasons.
When an episode starts in the absence of medication, the episode takes longer to treat and get better. For this reason, it’s safest for someone to take medication all the time.
We also observe that the same doses of medications that had helped in the past may become inadequate in some people and higher doses may become required.
Regularly taking medication can also prevent rapid cycling in those prone to such changes in bipolar disorder.
2. How long should I tolerate a new medication that causes side effects (e.g. sleep) until we decide that this medication does not work for me?
Generally, side effects may be observed in the first few days of starting a new medication. If they are mild and tolerable you can continue the medication and monitor yourself. If side effects persist, worsen or cause new concerns, it’s best to discuss with your doctor. There is no specific time period, but within a week or two of noticing side effects, you may contact your doctor. Make the contact sooner, if the side effects are intolerable and severe.
3. Is it appropriate for psychiatrists to send their patients back to their family physician for ongoing care where they stay on a set amount of medications for long periods without specialist feedback? How often should one see a treating psychiatrist if they have been stable? What do you think about family doctors evaluating use of medications?
The practice of trained family physicians and general practitioners monitoring and continuing to prescribe for patients on long-term medications is available in many areas of the world now. There is usually a system for the primary care doctor to provide and get feedback from the psychiatrists. If there is a need for specialist review, this would be recommended and coordinated too.
4. Are there any new drugs effective for mania?
Some of the newer drugs approved by FDA for use in BD are:
- Caplyta (Lumateperone)
- Vraylar (Cariprazine)
5. Are there any new drugs effective for depression?
Brintillex, Ketamine*, Cariprazine have been tried for depression recently.
*We strongly advise against taking any medication without guidance from a doctor. While ketamine has shown effectiveness for depression, this has been in safe, controlled, medical environments. This is different from how some people use ketamine recreationally. You can find out more in this blog post.
6. Why is it so common that psychiatric medications turn out to be ineffective and have bad side effects? Newly diagnosed people often have to be “tested” on multiple drugs before settling for something. Are the drugs just that poorly understood, and, if so, why should we ever trust them?
It’s not that the medication is ineffective–it’s that it’s not effective for everybody. A medication that works very well for one person may be a poor match for another.
So, similar to any medications in general use, psychiatric medications may be used for the first time in an individual and if the response is not adequate, a change may have to be considered.
Generally, we start someone with low doses to see the response and to watch for side effects before deciding on further dose increases. We do what we can to assess what will work for an individual. We also start with medications that have the best track record for the largest number of people.
Overall, we do understand the drugs fairly well and as prescribers we have our confidence that they work for most of the users.
7. What is the relationship between electroconvulsive therapy (ECT) and medications? I have been lucky to be able to come off medications after a round of ECT, but I also see that ECT is often not as effective for others. I haven’t been able to receive a good explanation except that ECT is like “rolling the dice”.
ECT and medications complement each other. Like medications or any form of treatment, responses vary between individuals. Generally, it is recommended that medications are to be continued after a period of ECT treatment to maintain stability.
8. How do you know when the right time is that I can start tapering off my meds? I have not experienced any episodes in over 2 years.
There is no specific time period, but generally, a period of stability for at least six months may be a good time to consider reviewing medications. Most psychiatrists would prefer maintaining an individual on low doses of medications to prevent relapses and not recommend completely stopping medications.
9. Can you explain how alcohol affects bipolar disorder? How does alcohol interact with medication? And does alcohol have a direct effect on depression or mania?
Alcohol interferes with physical health even in people with no known illness.
The known effects of alcohol pertaining to bipolar disorder may be:
- Increase sedation
- Increase proneness for depression
- Manic episodes may occur following the initial euphoria. This can lead to hyperactivity, disinhibitions, judgment errors and risky behaviours.
Alcohol also competes with many substances, including food consumed by the body as they are also metabolized (broken down) by the liver. This may cause mild to severe interactions between alcohol and drugs. This means alcohol can either lower or increase the effects of medications used for BD.
10. Do you know of any promising use of new technology that could change how medication is used for treatment in the coming years?
There are many ongoing trials and papers on this; to date, my knowledge on this is only at reading level. I do not have any specific recommendations at present.
11. Would you approach prescribing medications in a different way if you know the person regularly uses substances like marijuana or alcohol? How would you know if their bipolar disorder symptoms are drug induced or organic?
There would be cautions exercised in persons using other medications or substances. In addition to interactions, there can be medication dose effects which may be altered due to substances and withdrawal effects. Ideally, close monitoring of the individual would be required when medications are initiated. This can be done in an inpatient setting when feasible or by close outpatient reviews.
A good history and information from the individual and a significant person who knows them well and has known them well would help in establishing whether the substance use could be the cause or has contributed to the mental illness.
Dr. Nigila Ravichandran, MBBS, MMed
Consultant Psychiatrist, Institute of Mental Health (Singapore)
Adjunct Assistant Professor, Lee Kong Chian School of Medicine
Senior Lecturer, Yong Loo Lin School of Medicine
crestbd.ca/nigila / Club2Care
Dr. Nigila Ravichandran is a Consultant Psychiatrist from Singapore with more than 20 years of experience in mental health in clinical, academic, and research fields. She is an Adjunct Assistant Professor in Psychiatry and actively involved in teaching and mentoring junior medical and allied health staff. She has also been in volunteering and community work and is the Vice President of Club2Care, a charity organization geared towards educating the community at large and creating awareness about mental health. She regularly gets invited to give talks and training at community events, speak on television and radio and other media, speaks in webinars both in Singapore and internationally. She has been a Keynote Speaker and presenter in several international conferences.