My medication history

I have a long and arduous history with medications. Sometimes, it takes quite some time to strike the right balance with meds and bipolar disorder. This is my own personal review of each medication I’ve been on. There’s a lot! My reviews won’t necessarily be applicable to other people because each person’s response to a medication is different, but hopefully this provides some sense of just how many trials it can take to find something that works.

Stimulants

Adderall — amphetamine salts, a classic stimulant drug. Adderall XR is an extended-release preparation. For some reason the XR didn’t work well for me. I still take the IR daily.

Ritalin — methylphenidate, a different stimulant drug. It has important differences from Adderall and may work better in some people. Slightly different forms of Ritalin go by other names, such as Focalin.

Vyvanse — basically a different kind of Adderall XR,; it is the same molecule as Adderall with an extra group attached that renders it inert, which is then cleaved in the liver over time to release Adderall. To me it feels less effective than Adderall, doses held equivalent.

Mood Stabilizers / Anticonvulsants

Lithium — I’ve taken doses ranging from low to high (currently I take a high dose). Lithium dose is measured by the concentration of it in your blood; the highest dose varies depending on individual differences. You do get frequent blood tests while the ideal dose is being determined, and less after that. It is incredibly effective for many people. Because I’m on a high dose, it sometimes makes me nauseous or makes me throw up, and my hands tremor quite a bit. The cognitive side effects are the worst, but they get better over time. 

Lamictal — lamotrigine. For some people with bipolar disorder, lamotrigine is a better drug than lithium. It is not strongly anti-manic (unlike lithium), but for some this may not be a problem; however, it may be superior at treating bipolar depression. Rarely, it can cause a horrifying skin reaction when you first start taking it (and for that reason, titration takes forever — for me, I believe it took 5 weeks to reach 200mg). Past that initial window, it is considered to have very few side effects.

Depakote — valproic acid. It’s more anti-manic than lamotrigine. It smells terrible, yet apparently it comes in a form designed to put in a patient’s food which psychiatrists call “Depakote sprinkles”.

Gabapentin — I took it for anxiety, and it did put me in a good mood, so I suppose it worked.

Antipsychotics

Seroquel — quetiapine. People pronounce it in wildly different ways, I say “kweh-tie-ah-peen”. It helped with my mixed episode, but eventually it lost effectiveness and I found myself staying awake all night on 800mg (that’s a lot of Seroquel). Basically, it’s good for putting you the fuck to sleep, or at least it should be.

Zyprexa — olanzapine. It made me gain a lot of weight. It was fairly effective, but I had to discontinue it due to problems with my liver and its effect on my metabolism. It’s also pretty good at putting you to sleep. I preferred the sublingual form during my inpatient stays (it’s vaguely citrus flavored) because it made me feel better really quickly when I was agitated.

Abilify — aripiprazole. This drug actually helped me for a long time, and it still seems to have some effectiveness but I developed a facial dyskinesia while taking it. That’s an involuntary muscle movement, in my case of my lower left face. This was thought to be uncommon at first, but it turns out with long-term Abilify use (4 years for me), it’s quite possible. I can’t take any drugs related to Abilify anymore — these include Vraylar (cariprazine) and Rexulti (brexpiprazole). Abilify is not usually good at putting you to sleep, but when I started taking it I was on a dose that was too high for me at the time and I was very somnolent most of the time. 

Geodon — ziprasidone. I felt well but it made me throw up a lot. I discontinued it and got some Zofran from the ER. You have to take it multiple times per day, so you hope it doesn’t put you to sleep. I usually did have to take a mid-day nap.

Latuda — lurasidone. You have to be sure to take it with food. It wasn’t very effective for me. 

Saphris — asenapine. Warning, it only comes in a sublingual form and it’s cherry flavored. Nope. I only took it once and I had nightmares about cherry flavor afterwards.

Clozapine — I didn’t actually take this one, but it was on the table. I chose Haldol instead. It is probably considered the most powerful antipsychotic because it has been shown to break through where other antipsychotics have failed, and it was the first “second-generation” or “atypical” antipsychotic. However, it is quite possibly the single most dangerous drug in psychiatry — the potential side effects include a catastrophic loss of white blood cells, among other serious effects. It’s a “drug of last resort”.

Haldol — haloperidol. Haldol is an older drug, one of the “first generation” or “typical” antipsychotics and it is the most potent among those, also with the highest likelihood to cause dyskinesias (including tardive dyskinesia, which is permanent). These side effects have led to the popularity of the “atypical” drugs listed above, which are less likely to cause dyskinesia. Haldol is very effective for me, and I don’t find it sedating at all (which is a blessing and a curse). Having taken most of the atypicals available in the US (except for clozapine, paliperidone, risperidone, and a couple others that are much more rare), I was surprised at how not sedating it is.

Thorazine — I haven’t taken this one either, but it’s been on the table because of its more favorable side effect profile. It is the original antipsychotic drug, from which tricyclic antidepressants were also derived. It has more action on the histamine receptors than Haldol, making it much more sedating. However, this also makes it less prone to cause troubling dyskinesias — for example, antihistamines are actually a treatment for dyskinesia.

Antidepressants

Prozac — fluoxetine. It’s pretty much the basic SSRI. It didn’t do much for my mood at the time. It’s often used in combination with olanzapine/Zyprexa.

Lexapro — escitalopram. It’s an SSRI, and it has high selectivity to affect serotonin reuptake and not norepinephrine reuptake, in contrast to Prozac (which is not very selective). I took it for anxiety and OCD symptoms; I wasn’t convinced it was effective. It also changed my sexual functioning for the worse. 

Wellbutrin — bupropion. It’s an atypical antidepressant that affects norepinephrine and dopamine uptake. I took it to help with smoking cessation. It did make cigarettes taste bad, but I continued smoking them and within short order the drug made me manic.

Trazodone — an atypical antidepressant and an oldie but goodie. This one puts me to sleep (most of the time), and thank God for that.

Remeron — mirtazapine. Another atypical antidepressant. Usually a sleep drug, sometimes used for straight depression, also a great anti-emetic (anti-nausea drug).

Benzodiazepines

Xanax — the only time I took Xanax was recreationally, but I didn’t feel very enamored with the experience. Xanax is highly addictive, I suppose some people find it euphoric in a way. 

Ativan — it’s like toned-down Xanax, it is quite effective but it’s not as euphoric. It has helped me in ways other drugs couldn’t, although whether I would recommend them would be situational due to the addictive potential.

Valium — I’ve only gotten it in the ER, but it lasts longer than Ativan.

Others

Propranolol — a beta blocker, it helps me with akathisia (a side effect of antipsychotics).

Cogentin — benztropine. An antichonlinergic drug used to treat the side effects of antipsychotics. I didn’t take it for very long.


Best books for people diagnosed with bipolar disorder

When I was first diagnosed with bipolar disorder, my therapist gave me a book that changed my life. Books can influence how you understand your own bipolar disorder, and yourself in relation to it. I haven’t read every single book out there, but here are a few that I have read.

Welcome to the Jungle by Hilary Smith

Technically, this is a self-help book. It contains a lot of good information, tips, and recommendations. The thing I like about this book in particular is its humorous and lighthearted style. I read the original edition of this book, and I no longer have it because I gave it to someone else, but I still remember some of the bipolar jokes! I recommend this book to anyone who has just been diagnosed with bipolar disorder but doesn’t know much about it, and needs a source of information.

Manic by Terri Cheney

Manic is a memoir. Memoir can be so helpful, in my opinion, because it allows us to have insight into the lives of people who have faced similar struggles as us. This book describes itself as “visceral” — focused on the experience of mania and depression from a very subjective viewpoint. Cheney herself said the focus is “on what bipolar disorder felt like inside my own body”. Paradoxically, it becomes very relatable by just how idiosyncratic it is. I recommend this book to anyone who feels alone in their struggles with bipolar disorder.

An Unquiet Mind by Kay Redfield Jamison

This is the book that changed my life. As a freshman in college, it single-handedly inspired me to pursue a career in research, and specifically bipolar disorder — which is now my career. Jamison is an authority on bipolar disorder, but this book is not a textbook — it’s a memoir. In a display of great vulnerability (at the time, nobody could know if this book would end her career) Jamison tells the story of her life, from childhood to a breakdown shortly after completing graduate school, mania, psychosis, depression, and a serious suicide attempt. Throughout it all, Jamison interjects wisdom and knowledge. This book simultaneously provides both deep information about bipolar disorder and a revealing look into the life of somebody who lives with it. I would recommend it to anyone who with a curious mindset, who wants to know more about the science of bipolar disorder and the culture of academic psychiatry, as well as the personal experience of living with bipolar disorder from the perspective of an expert.

Have you read any good books about bipolar disorder? Feel free to leave a comment!


Should I be afraid to take lithium?

Lithium has a reputation. When I was first prescribed it, I felt a sense of fear and also — somehow — a sense of achievement, like I had won the lottery for crazy. When you hear about lithium, it’s often to stress that it is only for those top shelf mental illnesses; and it is good for that, however, it’s not necessarily true that you’re on the top shelf just because you’re starting lithium. A lot of people take lithium. On some occasions it might be the first medication tried. There are a few things to know about lithium in order to make truly informed choices about what you’re getting into.

It’s highly effective

Lithium is one of the most effective medications for bipolar disorder. Which medication is the best varies by person, and a lot of people have success with anticonvulsants like Lamictal. But for many people, the most effective medication is lithium, and its effectiveness has been well-documented for many years (it was first used in psychiatry in 1949). According to one study, about 30% of people who try lithium witness a complete recovery, while 60% see some improvement.

Unlike some other medications, lithium isn’t just a treatment for symptoms of mania; it actually prevents future mood episodes. Relapses become less frequent and shorter. There is some evidence that lithium has a protective effect in the brain.

Lithium has a decent chance of working for any type of bipolar disorder, but there are some people in particular who are very likely to be lithium responders. Those people tend to have:

  • Fewer hospitalizations prior to starting lithium
  • Later age of onset
  • An episodic course (moods cycle and then resolve for a while, as opposed to chronic cycling)
    • About 44% of people with an episodic course have complete remission on lithium, compared to 15% of people with a non-episodic (chronic) course.
    • In one study, 90% of lithium responders who experienced full recovery had complete remission of mood symptoms in between episodes before starting lithium.
  • Mania occurs before depression (mood cycling starts with mania)
  • Strong family history of bipolar disorder and/or a family history of lithium responsiveness
    • One study found that 35% of patients without a family history of lithium response had a complete recovery (similar to other studies mentioned), but among those with a family history of lithium response, that number jumped up to 67% full recovery.

Yes, you’ll get blood drawn

The dosage of lithium is based on how much lithium is in your blood, not how many milligrams are in the pill. The therapeutic window (the space in between the effective dose and the toxic dose) for lithium is much more narrow than most other drugs, so you’ll have to get blood tests frequently, especially when you’re still trying to figure out what dose is best for you.

If you’re afraid of needles, you will probably overcome that fear.

Because lithium blood levels are the most important factor in dosage, it’s probably pointless to try comparing doses with any bipolar friends. Their minimum and maximum dose is probably different than your minimum and maximum dose, so you’re working with two different scales. The middle of their dose range isn’t the middle of your dose range.

Side effects

No doubt, lithium has side effects. The good news is that if you find a low dose is effective for you, you might experience few or no side effects. If you’re on a high dose, it’s more likely that you’ll experience some side effects. These could include:

  • Hand tremors. This can make your handwriting different, and makes it very hard to put Jello in the fridge.
  • Nausea and vomiting. This tends to happen at quite high doses, and it may be a sign that your dose is too high; however, switching to the extended release version of lithium may help.
    • It’s worth noting that your dose can get too high for a variety of reasons, including dehydration; taking ibuprofren or other NSAIDs (you should probably switch to using acetominophen); or climbing a mountain and reaching a very high altitude. That last one hasn’t happened to me personally.
    • If you do actually vomit, it might be very aggressive vomiting and it always seems to come on suddenly.
  • Brain fog. Attention and memory problems come naturally to bipolar disorder, but lithium makes them worse. You may feel that your brain is just working really slowly, and it’s hard to concentrate or read. (Some people also have visual distortions on lithium that make reading even more difficult. I find it easier to read large print.)

In conclusion

Many people are afraid to take lithium, but some experts argue that it’s actually under-used today due to the public perception of it. So, in my opinion, it’s certainly worth trying. Most people won’t experience too many problems; if you’re on a high dose, you might experience some weird stuff, but to me it’s worth it for reducing my mood symptoms, and all of the weird stuff is manageable if you make some small adjustments to your life.

References

Tighe, S. K., Mahon, P. B., & Potash, J. B. (2011). Predictors of lithium response in bipolar disorder. Therapeutic advances in chronic disease2(3), 209–226. https://doi.org/10.1177/2040622311399173


What’s it like to be in a psychiatric hospital?

I’ve been hospitalized 17 times. At this point, it seems perfectly routine. I pack my carry-on suitcase, grab my Pikachu stuffie, and I’m on my way. I know what to expect. However, whenever I’m in the “psych corner” of the ER, there’s always someone being admitted for the first time, and they’re usually crying. I cried during my first admission, too — my therapist told the police to wait until I stopped to put me in the car. I’d read about the hospital online, but still, I didn’t know what to expect and I was very scared.

So, if you’re ever hospitalized, here’s what to expect.

Limited Choices

Where you can go, what you can do, and even what you can eat are very limited when you’re in the hospital. Psychiatric units vary in size and structure, but it will likely be smaller than you would like. Everyday choices are made manageable for people with acute psychosis or severe mood disturbance, which means there are not very many choices.

Here are some activities which are generally allowed, and which I personally recommend:

  • Reading books. The choices of books on the unit are likely to be very slim, so I recommend bringing your own books. Easy to read books may be for the best, as medications can make reading challenging; I enjoy middle grade and young adult fiction.
  • Talking on the phone with friends and family. There is always a phone. I have been in really outdated units where the phones were actual pay phones that required quarters… but in my experience, this is very rare. Phones are usually made unavailable during groups and meal times.
  • Talking to other patients. The other patients in the hospital are likely to be interesting. Some of them will seem “normal” and some of them won’t; a few may be very agitated or aggressive. Don’t be afraid of them, they don’t mean you harm and if things get out of hand the staff will know what to do. It’s a good opportunity to get to know other people with mental illness, and I’ve had many interactions which I’ve remembered for years.
  • Card games. Sometimes there are board games, which may or may not be in playable condition, but there is almost always a deck of cards. Playing cards is a great way to pass time and interact with other patients at a level that isn’t very demanding. I learned to play Rummy 500 in a psychiatric hospital!
  • Take a shower. It’s easy to forget that you need to shower when everyone is wearing pajamas and look like they’ve been in bed for a year, but showering is something that can affect how the psychiatrists see your level of functioning. It’s also a way to pass time in itself. Sometimes you can bring your own shower products and deodorant, which I do recommend because it will make it seem like you’re doing your whole routine.
  • Go to groups. There will likely be a few groups throughout the day, particularly on weekdays. They are likely to be somewhat simple and plain, which makes it so everyone can participate as much as possible. Going to the groups is probably the single biggest action you can take to expedite your discharge. It’s not the only factor and it won’t make a miracle, but it’s worth a try.
  • Go outside. There will be some kind of small outside area. Sometimes it’s on the roof, sometimes it’s a courtyard or a fenced-in patio. You can usually go outside at designated times during the day, weather permitting.

What to bring and what not to bring

Hospitals do vary in their policies and if possible, you can look up their website or call in advance to see what they allow. But this often isn’t possible because when you go to an ER for psychiatric reasons, you could be (and often are) sent to a completely different hospital. Therefore, use your best judgement and pack what you can. I pack a small roller suitcase so that I can fit everything I want.

  • Don’t bring electronics. Cell phones will not be allowed, nor laptops or tablets, or anything that has the ability to take photos, record videos or audio, or access the internet through a browser. However, there are a few exceptions which may be made at some hospitals — UCLA has allowed me to bring old Game Boy consoles, which aren’t capable of anything except playing the inserted cartridge; a basic Kindle e-reader; and an MP3 player with Bluetooth headphones, no wires and nothing with any of the aforementioned capabilities. Bring chargers for your phone and any of these items if you bring them, but be aware you won’t be allowed to charge in your room and staff will supervise your items while charging. (P.S. I’ve heard that electronics are allowed in the UK, so I can only speak for the US.)
  • Bring a light jacket. If you live in a cold climate, you can also bring an outside jacket, but you will want a light jacket for inside the hospital because it’s usually a little bit cold in hospitals. If you bring a hoodie, make sure it does NOT have strings; the same goes for sweatpants and shorts. Strings will probably not be allowed.
  • Bring clothes that make you feel normal. Some people will specifically say to bring comfortable, casual clothing. That is a good idea, but I think the most important thing is to bring clothes that make you feel like yourself, because it’s very easy to feel disrupted when you’re in such a different environment than your usual life. Don’t wear a tuxedo or a $500 designer item, because you’re probably gonna spill cranberry juice on it and you know they wash everything on hot, but wear whatever you want — as long as it doesn’t have strings.
  • Bring slip-on shoes. Some hospitals will not allow you to wear shoes at all. The fancy hospital socks with treads on the bottom are very real, and you’ll get some in the ER. If shoes are allowed on the unit, you’ll have to take the laces out, so bring shoes without laces. Definitely don’t bring boots or anything with a heavy sole, as those will probably not be allowed.
  • Bring books.
  • Bring shower supplies and deodorant. It’s not essential, so if you don’t have space, don’t bring them. But I like them.
  • Bring a comfort item. I always bring my jumbo Pikachu stuffie. Something small would work, but I’m excessive.

Things to be aware of

  • Quiet room. That’s a euphemism, for sure. Most hospitals have one although I think at UCLA they just move you to a different unit if you’re in that place. Basically, this is where they put people who need to calm down. Injectable medications (seems like Zyprexa or Haldol, usually) are often involved, as are restraints. It might actually have padded walls like you see on TV. But if you’re worried about going there, in my experience, you’re probably not going there.
  • Furniture. You won’t notice this until you’ve been in a few hospitals, but they all have a similar physical design with very similar furniture. That’s because they’re designed so you can’t tie anything onto them, if you were to have strings. All safe furniture looks pretty much the same, and it’s very 70s for some reason.
  • Smoking. There are a minority of hospitals that still allow you to smoke cigarettes at designated times. Feel free to bring your preferred kind if you do smoke, but don’t load up; in hospitals I’ve been where smoking is allowed, there are usually house cigarettes available. They are very cheap and seem to be made with cigar tobacco, but trust me, it’s better than nothing.
  • Voluntary status. Not to scare you, but even “voluntary patients” are not 100% free to leave whenever you want. It is better to be admitted voluntarily than involuntarily, but if you do try to leave on a voluntary basis and your treatment team feels strongly that you’re not ready, your status can be changed. At least, mine has been in the past. So it is kind of a catch-22 situation. Some hospitals are more mindful about this than others. It also seems to vary by state.

I hope this overview has been helpful. And if you’re ever hospitalized, don’t worry; it is an adjustment, but most people get used to it very quickly. It’s designed that way. Meals, groups, outside breaks, and pretty much everything will occur at the same time every day. It’s weird how you start to feel hungry for dinner at exactly 5 PM. But it happens quickly!


Who gets bipolar disorder?

People of all ages, all around the world get bipolar disorder. It doesn’t seem to discriminate in regards to gender or ethnicity. But there are some factors that make some people more likely to get a diagnosis of bipolar disorder.

People with a Family History

Bipolar disorder is genetic. In fact, the evidence suggests it is the most strongly genetic disorder in the DSM — its genetic component is larger than schizophrenia or autism, which themselves are thought to be very heritable. Accordingly, the best predictor of bipolar disorder is a family history of bipolar disorder. And the more people in your family who have it, the more your risk increases.

Psychiatrists typically always elicit a family history if possible, and a positive family history is very suggestive of a bipolar diagnosis.

Young Adults

Bipolar disorder usually appears early in adult life (although, more rarely, children can have it). Traditionally, the average age of onset is estimated between 20 and 25 years old. Some research now suggests that the actual “age of onset” — the age that symptoms first appear — is actually between 15 and 19 years old, but there is an average delay of 6 years between symptom onset and diagnosis.

I got my symptoms early (around 10 years old) and received my diagnosis at 17. People with an early age of onset tend to have more depression, but not more mania, than people with a later age of onset. They also experience more mood instability, rapid cycling, and on average they have a greater number of suicide attempts.

These differences might appear because, if you compare two people of the same age — one of them with early onset, and one of them with later onset — the early onset individual has had bipolar disorder longer. Another explanation is genetic anticipation; basically, if you have more people in previous generations of your family with bipolar disorder, the genes that cause it accumulate in the later generations. This produces both an earlier age of onset and more severe symptoms.

People with Depression

It may seem intuitive, since depression is part of bipolar disorder, but many people have depression before they have mania (a little over 50%). In that case, at first it may appear that they simply have depression. It can be hard to tell the difference.

There are a few factors that tip the scales in the favor of bipolar disorder, though: a family history; a tendency to oversleep when depressed; depression that occurs in recurring bouts. Also, many bipolar people experience mania or rapid cycling as a response to antidepressant medications (such as SSRIs). For some, this is the first clue that they have underlying bipolar disorder.