CarbamazepineCarbamazepine (Tegretol) is similar to valproate in that it was developed to treat seizures. It is also used to treat the mania of bipolar disorder, although it is not as effective as lithium or valproate. Carbamazepine is sometimes helpful when lithium or valproate have not worked. Carbamazepine is not usually used alone. It is most often combined with other mood stabilizers, antidepressants and/or antipsychotic drugs. Types And Doses Side Effects Warnings
Types And Doses The starting dose of carbamazepine is generally 200 to 600 milligrams per day, given in three or four doses. The dose is determined by measuring your response and side effects and by checking the level of the drug in your blood. It can take several weeks or more to establish a stable, therapeutic dose for this drug. Your doctor will periodically order blood tests to check your blood level of the drug, your complete blood counts and liver function. If your results stabilize over time, the need for testing becomes less frequent. Side Effects Side effects usually are not dangerous, but they can be uncomfortable. Some are more common as you start treatment, but then go away: If you notice these or any other changes, talk to your doctor. Warnings Life-threatening reactions are rare but can occur. Carbamazepine can cause liver toxicity, inflammation of the pancreas, and suppression of blood counts. It can also cause a rare, severe inflammation of the skin. Tell your doctor if you have any of these symptoms: These severe reactions usually occur in the first three to six months of treatment. People with liver disease or diseases of the blood are at greater risk. An overdose of carbamazepine can be fatal. Signs of toxicity are dizziness, poor balance, sedation and double vision. People can also become very irritable or lapse into a coma. There may be trouble breathing, a rapid or irregular heartbeat or a drop in blood pressure. Drug interactions. Carbamazepine can interact with many other drugs. It can cause the liver to break down some drugs more efficiently, meaning it decreases levels of other drugs in your blood, including antidepressants, antipsychotics, antianxiety drugs and other antiseizure drugs. It can also change levels of birth-control pills and thyroid-hormone pills. Other commonly prescribed drugs can drive up carbamazepine levels, including erythromycin, some blood-pressure drugs and antidepressants known as selective serotonin reuptake inhibitors, which include Prozac and others.
Lamotrigine Because the antiseizure drugs valproate and carbamazepine have worked for bipolar disorder, researchers are studying other antiseizure drugs to see if they will work on bipolar disorder, too. Of the newer antiseizure drugs, lamotrigine (Lamictal) is so far the most promising, particularly for treating and preventing episodes of depression. (Lamotrigine does not appear to work on mania.) Doses Lamotrigine's dose is adjusted carefully to reduce the risk of a major side effect (see Warning below). The guidelines for use are to start with a low dose and increase slowly: 25 milligrams per day for 2 weeks, then increasing the daily dose to 50 milligrams. Once at a 50-milligram dose, the dose can be increased in 50-milligram increments every 2 weeks. The usual therapeutic dose is between 200 and 400 milligrams per day. Side Effects Side effects usually are not dangerous, but can be uncomfortable. Most common are: Some side effects improve once your body becomes accustomed to the medication. Warning: Stevens-Johnson Syndrome The major drawback of lamotrigine is the risk of Stevens-Johnson syndrome. While rare, this potentially fatal allergic reaction involves the skin and mucous membranes. One of the first signs is a rash, so report any rashes to your doctor right away. In most cases, you should stop taking the drug until your doctor has a chance to evaluate your situation. If you experience other symptoms along with the rash — discomfort around the eyes and mouth, urinary symptoms, fever or swollen glands — it may be a medical emergency. Get evaluated immediately. Except for this major risk, lamotrigine appears to be well tolerated. It doesn't seem to cause much sleepiness, fatigue, intellectual impairment, sexual problems or weight gain. The most common side effect is headache, and that often goes away after a stable dose is reached.Drug interactions. The blood level of lamotrigine may change if you take other drugs at the same time. Valproate, for example, pushes the blood level up and carbamazepine pushes it down. So your doctor needs to move your lamotrigine dose down or up to compensate.
PsychotherapyTalk therapy (psychotherapy) is important in bipolar disorder as it provides education and support and helps a person come to terms with the illness. Recent research has shown that for mania, psychotherapy helps people recognize mood symptoms early and helps them follow a course of treatment more closely. For depression, psychotherapy can help people develop coping strategies. Family education helps family members communicate and solve problems. When families are kept involved, patients adjust more easily, are more likely to make good decisions about their treatment and have a better quality of life. They have fewer episodes of illness, fewer days with symptoms and fewer admissions to the hospital.Psychotherapy helps a person deal with painful consequences, practical difficulties, losses or embarrassment stemming from manic behavior. A number of psychotherapy techniques may be helpful depending on the nature of the person's problems. Cognitive behavioral therapy helps a person recognize patterns of thinking that may keep him or her from managing the illness well. Psychodynamic, insight-oriented or interpersonal psychotherapy can help to sort out conflicts in important relationships or explore the history that has contributed to current problems. When to Call a ProfessionalA manic episode is a serious problem requiring immediate treatment. However, a person in a manic episode may not be aware that he or she is sick. Some people with this illness may have to be brought to a hospital, even when they don't want to go. Many patients are grateful later when they learn that they avoided a loss or embarrassment and were pushed to get the treatment they needed.If you observe manic symptoms in a person who is unaware of his or her condition, arrange a consultation with a health care provider. Treatment can prevent symptoms from accelerating, and can improve a person's progress and functioning over time.Given the elevated risk of suicide in bipolar disorder, any person with known bipolar disorder who exhibits symptoms of worsening depression should promptly seek help.
Additional InfoAmerican Foundation for Suicide Prevention
120 Wall St.
New York, NY 10005
http://www.afsp.org American Psychological Association
750 First St., NE
Washington, DC 20002-4242
http://www.apa.org/ National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd.
Arlington, VA 22201-3042
http://www.nami.org/ Depression and Bipolar Support Alliance (DBSA)
730 N. Franklin St.
Chicago, IL 60610-7224
http://www.ndmda.org/ Mental Health America
2000 N. Beauregard St., 6th Floor
Alexandria, VA 22311