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< List of Mood Stabilizers | Mood Stabilizer Overview/Topic Index | Antiepileptic Drugs (AEDs) as Mood Stabilizers

1.  Using Antipsychotic Drugs (APs) as Mood Stabilizers

Most atypical/second-generation antipsychotic medications (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 there is far more money to be made in bipolar disorder.

Lithium and some of the older standard / first-generation antipsychotic medications (APs/FGAs) are also approved to treat acute mania. The FGAs other than lithium were the original modern medications to treat bipolar disorder. 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 Communications Interference Hypothesis of psychiatric and neurological conditions or some other reason for the cause of depression and bipolar disorder; APs and antidepressants work in essentially the same way 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.

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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.
  • 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.

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< List of Mood Stabilizers | Mood Stabilizer Overview/Topic Index | Antiepileptic Drugs (AEDs) as Mood Stabilizers

1 And third-generation antipsychotics (TGAs), there just aren't a hell of a lot of those. [[Abilify]] is currently the only one approved on the US market, although some old FGAs may actually be TGAs, because the definition is based on mechanism/method of action (partial agonism at the D2 dopamine receptor), and not when they were created. Most people who classify APs in this way tend to call all AAPs "second generation."

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 It is a novel way to ensure med compliance. Not necessarily a good one, but apparently an effective one.

Antipsychotic Drugs as Mood Stabilizers is copyright 2012 Jerod Poore
Page created by: Jerod Poore. Date created: 26 January 2011 Last edited by: JerodPoore on 2014–06–01

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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 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.

3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.

* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.

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