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1. Using Antipsychotics (APs) as Mood Stabilizers
Most atypical/second-generation antipsychotics (AAPs/SGAs)1 are approved to treat acute (short-term) bipolar mania, and a few, like Seroquel, have de facto approval or are used off-label as actual mood stabilizers. These days it’s unusual for an SGA or third-generation antipsychotic (TGA) to be approved in the US for schizophrenia alone2. Schizophrenia is profitable, but the real money is in bipolar disorder.
Lithium and some of the older standard / first-generation antipsychotics (APs/FGAs) are also approved to treat acute mania. Carbamazepine and valproic acid weren’t seriously studied for bipolar mania until the 1980s. Lithium wasn’t approved to treat manic-depression (as it was known) until 1970, and while prescribed in the 1960s, it wasn’t all that widely used, so almost all FGAs available were either approved for or prescribed off-label to treat manic-depression. Most of them are no longer available because their adverse effects were just too adverse3.
Although it has fallen out of fashion, lithium is still the best drug available for classic bipolar 1.
2. Advantages of Using Antipsychotics & Atypical / Second & Third Generation Antipsychotics (AAPs) as Mood Stabilizers
Some of these apply to all APs, some apply to AAPs only. While lithium is classified as an antipsychotic, most of these advantages don’t apply to lithium, other than being a true mood stabilizer4 and the only danger you risk if you suddenly stop taking it is sudden rebound of symptoms. One of the great ironies of crazy meds is that lithium, when it comes to being a mood stabilizer, is practically an antiepileptic drug (AED); except that lithium causes seizures5 instead of preventing them.
- Most antipsychotics (not lithium and especially not Clozaril (clozapine)) are a lot easier to prescribe and take than AEDs. When all your insurance coverage is going to pay for is four 15-minute medication-checking appointments a year, that can make a big difference.
- APs have simple titration schedules.
- APs require fewer dosage adjustments than AEDs.
- APs have consistent side effects. They may suck, but at least you know what you’re in for.
- APs are far less likely than AEDs to cause a severe allergic or similar reaction, or really severe side effect in general that will require you to stop taking the med immediately.
- Missing doses, even suddenly stopping the med, isn’t dangerous. It’s not a good idea, but there is little chance that sudden discontinuation will be directly responsible for physical harm.
- Although the sudden rebound of symptoms, which initially could be a lot worse than any you previously experienced, could land you into all sorts of trouble.
- Regardless of how or why you stop taking it, an AP usually works just as well the next time you take it.
- APs work quickly.
- AAPs are more likely to be actual mood stabilizers, in that they treat both mania and depression, so you need to take only one med. The fewer meds the better.
- Doctors know and understand why APs work as anti-manics and AAPs work as mood stabilizers. It doesn’t matter if you subscribe to the chemical imbalance hypothesis or some other popular reason for the cause of depression and bipolar disorder; APs and antidepressants work in essentially the same way6 and in ways that are easy to understand.
- Because they know how they work it’s easier for a doctor to tailor an AAP to your symptoms, and figure out which one would be the best to switch to in case of an allergic reaction or change in your insurance company’s formulary.
3. Disadvantages of Using APs/AAPs as Mood Stabilizers
- The usual long-term side effects of APs, especially AAPs, are a lot more problematic than those of most AEDs - Depakote being the one exception.
- One collection of side effects common to all APs - movement disorders - is almost like an allergy in that if you get any (or all) of those from one AP you may have to stop taking all APs. There are a couple exceptions:
- This doesn’t necessarily apply to lithium. While lithium does have a movement disorder associated with it, the data are conflicting as to whether or not getting bad lithium tremors means you’re more likely to get an AP-induced movement disorder, or vice versa. Plus beta blockers like propranolol are really effective in treating lithium’s tremor, while only barely effective in treating AP-induced movement disorders.
- Two popular movement disorders, extrapyramidal symptoms (EPS) & dyskinesias (especially the tardive form (TD), which happens after you’ve been taking a med that has been working great for over six months) are extremely rare with Zyprexa and clozapine, and rare with Seroquel. If you get EPS and/or TD from any other AP, especially Saphris, Risperdal, and the more potent FGAs, you can still try Zyprexa, clozapine, or Seroquel (if you haven’t already). Of course, if you got EPS and/or TD while taking Zyprexa, clozapine, or Seroquel - and no other AP - you may as well give up on the idea of using an AP to treat bipolar disorder. Or anything else.
- And if you got EPS and/or TD when taking Clozaril (clozapine) your doctor should order a bunch of tests and write you up as a case report.
- Fortunately there are some ways to deal with these side effects. See the page on AP-induced movement disorders for more information.
- Another side effect common to most AAPs is metabolism/metabolic syndrome. That’s the one where they give you diabetes and make your cholesterol levels shoot up even if they don’t make you fat as well.
- Because they are new and shiny - new AEDs are being approved but they aren’t being tested for bipolar disorder that much - doctors are more likely to prescribe the latest AAP, regardless of how appropriate the latest one might be for you.
- The data are still contradictory whether or not APs can help you stop drinking or deal with other substance abuse problems the way AEDs often do.
- Not only that, Drinking while taking some APs can enhance your alcohol experience, as well as make your symptoms worse7.
- Mixing chronic, heavy drinking and AAPs over the long term is a “which sucks less?” proposition. Early death or early dementia? Decisions, decisions.
- AAPs are extremely profitable for drug companies. As such the pharm reps push them like you wouldn’t believe.
- So while a doctor understands the theory behind how AAPs work for bipolar disorder, the latest drug’s mechanism of action isn’t taken into account to see if it fits with your unmedicated symptoms. So it still winds up being a total crap shoot and you may as well open the PDR to a random page and try that med next.
‹ Mood Stabilizer Overview/Topic Index | AEDs as Mood Stabilizers ›
2 E.g. Fanapt (iloperidone). Developed in 1993 by Hoechst Marion Roussel, phase III clinical trials for schizophrenia began in 1998 (Novartis had the license). Iloperidone kept getting shopped around and tested. Eventually Vanda Pharmaceuticals bought it and decided to go old school by getting it approved for schizophrenia first, and then if it made any money go through the process for bipolar.
3 Most anti-psychiatry fearmongering is based upon the adverse effects of drugs no longer available and practices no longer, uh, practiced. Although it's a tough call as to which sucks more, the asylum depicted in One Flew over the Cuckoo's Nest, or being seriously batshit crazy with no choice but to live in a cardboard condo and no hope of ever getting near a tablet of trifluoperazine.
4 Although lithium is approved only to treat the manic phase of bipolar disorder.
5 Lithium is given to rats, mice, and other critters to induce seizures when testing AEDs.
6 Regulating the genetic expression of various bits of your brain involved with various neurotransmitters and enzymes. I.e. it's soup or some other cooking metaphor (chemical imbalance hypothesis), it's fertilizer or some other growth metaphor (various hypotheses regarding brain structure), or it's something else that's still an ingredient. Ingredients are an easy concept to grasp.
7 It is a novel way to ensure med compliance. Not necessarily a good one, but apparently an effective one.
Page created by: Jerod Poore. Date created: 26 January 2011 Last edited by:
Antipsychotics as Mood Stabilizers is copyright 2011 Jerod Poore
Antipsychotics as Mood Stabilizers is copyright 2012 Jerod Poore
Page created by: Jerod Poore. Date created: 31 March 2012 Last edited by:
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Almost all of the material on this site is copyright © 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, and 2012 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and the following disclaimer, I’m usually cool with it.
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Crazy Meds is optimized for the browser you’re not using on the platform you wish you had. Between you and me, it all looks a lot cleaner using Firefox or Safari, which is what a plurality of visitors use. And I’m running Windows XP3. On a computer that sits on top of my desk. With a 23 inch monitor. Hey, at least you can make the text larger or smaller by clicking on the + or - buttons in the upper right hand corner. If you have Java enabled. Like 99% of the websites on the planet, Crazy Meds is hosted on domain running an open source operating system with a variety of open source applications, including the software used to display what you’ve been reading. As such Crazy Meds is not responsible for whatever weird shit your browser does or does not do when you read this site2.
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had the forerunner to QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]
