Medication Treatment for Manic Depressive Illness

Lithium: The first treatment developed for manic depressive illness was lithium carbonate. Lithium is a naturally occurring mineral that was known in the 19th century to have positive effects on mood. In the late 1940's it was evaluated by a psychiatrist in Australia and found to have beneficial effects in manic depressive illness. This research was followed up in the 1950's by Dr. Morgens Schou in Scandinavia. Since that time, lithium has been the mainstay of treatment for manic depressive illness, being effective for both the manic as well as the depressed phases of that illness. Lithium may be taken alone or in conjunction with other medications, depending on the circumstances. Side effects of lithium treatment include weight gain, memory impairment, tremor, acne, and occasionally thyroid disfunction. During treatment with lithium, which is usually over an extended period of time, that patient should be monitored for thyroid function as well as kidney function.

Valproic acid (Depakote): In addition to lithium, there are a number of other agents available for treatment of manic depressive illness. Valproic acid is available in the United States and was approved for treatment of manic depression this past year. Valproic acid is commonly prescribed as Depakote, and is an effective agent for mood stabilization. Current research studies are underway to compare the efficacy of Depakote as compared to lithium. Side effects associated with Depakote include nausea, weight gain, hair loss, and increased bruising.

Carbamazepine (Tegretol): A third commonly used mood stabilizer is Tegretol. This is a medication that was initially developed for facial pain and subsequently found to be useful for certain types of epilepsy. In the past twenty years it has been developed as a mood stabilizer, and it has been found to have anti-manic, antidepressant, and prophylactic efficacy. Tegretol is associated with a relatively low incidence of weight gain, memory loss, and nausea. Skin rash is sometimes found with Tegretol, and there is the possibility of bone marrow suppression, which requires monitoring by blood tests.

New medications: There have been several new medications that are under development for the treatment of manic depressive illness and show some promise. Neurontin, or Gabapentin is an anticonvulsant compound which is being developed as a mood stabilizer. It shows promise and has the benefit of very few interactions with other medications. Another medication under development is Lamictal. This medication is an anticonvulsant, approved in the United States as an anticonvulsant several years ago. It has been found to have antidepressant properties, and may turn out to have mood stabilizing effects as well, although this is currently under investigation. Lamictal carries the risk of rash with it, which at times may be severe.

Antipsyschotic Medications

The final class of medications is the antipsychotic category. This group of medications has usefulness in more severe states of depression and manic depression. This group of medications is very effective in controlling severe agitation, disorganization, as well as psychotic symptoms which sometimes accompany the more severe instances of mood disorders.

Typical antipsychotic medications: The Typical antipsychotic medications include drugs such as Haldol, Trilafon, Stelazine, and Mellaril. They are quite effective in controlling agitation as well as hallucinations and unrealistic thoughts. They are less effective in controlling or treating the apathy, withdrawal, and indifference that sometimes occurs in these conditions. ( Individuals with mood disorders may have an increased potential for developing neurological side effects associated with the use of these medications, specifically a condition referred to as Tardive Dyskinesia. This is a persistent twitching of the fingers or lips. )

Atypical antipsychotic medications: In recent years, a new class of antipsychotics has become available referred to as the "Atypical antipsychotic medications". This includes Clozaril, Zyprexa, and Risperdal. This group of medications represents an advance over the older medications in that they continue to be effective against psychotic symptoms such as agitation and hallucinations, but they are also helpful in treating apathy and indifference which may also occur. These medications seem to have a significantly reduced likelihood of development of neurological side effects as well.

Continuation or Discontinuation of Medications

Depression and manic depression tend to be recurrent problems, and often maintenance medication is recommended. This recommendation should be discussed carefully between the patient and his or her physician.

A final issue in the use of the psychotropic medications is the issue of discontinuation. The timing of discontinuation of psychotropic medications is an important and highly individual decision, which should always be made in conjunction with one's physician. As a general rule, stopping medications in a gradual way is preferable to abrupt discontinuation. Abrupt discontinuation may result in return of original symptoms, or may result in what is referred to as "discontinuation syndrome". Discontinuation syndrome has a variable presentation. Patients often will feel as if they have a severe case of the flu. Abrupt discontinuation of lithium in the context of manic depressive illness carries the risk of a sudden return of manic or depressive symptomatology. In addition, there is a small group of manic depressive patients who, once they discontinue lithium, become refractory to its effectiveness at a later time.

These medications can be highly effective and may significantly alter the course of an individual's life. One must always keep in mind that the choice to take the medication is based on an assessment of the risks and benefits associated with taking medication as well as not taking the medication. Those choices should always be undertaken in the context of an ongoing relationship with the prescribing physician.

Source: National Institute of Mental Health

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