The Problem With Bipolar Meds

As you are aware, I am in the midst of a massive website overhaul. The last week has involved scrapping most of the articles in the Treatment section of mcmanweb and writing new ones (some of them based on recent blog posts here at Knowledge is Necessity). Thus far, I have 11 new articles, with more to follow, that I look forward to uploading two or three says from now. Following is a sneak peak at one of them, slightly chopped ...

The best data we have is from the NIMH-underwritten STEP-BD trials conducted over the mid-2000s. The study followed "real world" patients over two years, on a variety of meds. Of those who entered the study in a symptomatic state, 58 percent achieved recovery (nearly symptom-free for eight weeks). Of these, nearly half (48 percent) relapsed over two years, mostly into depression.

The math says it all: 1,469 symptomatic patients at study entry, a mere 422 (one in three) who managed to get well and stay well over two years. In classic understatement, the authors of STEP-BD concluded that:

The finding that nearly half of the study participants nonetheless suffered at least one recurrence during follow-up highlights the need for development of new interventions in bipolar disorder.

Cycling vs Episodic

The term, mood stabilizer, suggests that we are not merely treating episodes of an illness. Rather, we are looking to treat the cycle that drives these episodes. Accordingly, it is more helpful to think of bipolar (and recurrent depression) as a cycling illness rather than an episodic one.

Treating an episode for a patient who cycles is highly problematic - just ask any bipolar patient who has ever been prescribed an antidepressant to treat her depression. Too often, the patient flips into mania. Another result is the cycle may be speeded up, ironically resulting in more depression episodes.

An antimanic agent may not yield such a spectacular mirror effect, but the same principle is in play. As I heard it explained at an International Society of Bipolar Disorder conference I attended in 2006 (sorry, the name of the presenter escapes me), clinicians who treat a manic episode need to be aware of the next phase of the cycle, as well. In other words, being saddled with the sedating effects of an antimanic agent on top of a debilitating depression is the equivalent of pushing two rocks uphill.

So - in a perfect world, we would have a perfect mood stabilizer, one that brought the cycle under control and thus obviated the need for any other agents. Alas, our mood stabilizers (lithium, plus a range of antiepileptic agents pressed into service as bipolar meds) fall well short of even pretty good. This forces clinicians into an episode mindset, of devising pharmaceutical blockades to box in mania on one pole and coming up with entirely different blockades to keep depression at bay on the other.

In effect, our doctors are stepping on the bulges of an air mattress rather than regulating the flow beneath. Meanwhile, side effects pile up on top of side effects.

More to come ...