Polypharmacy and Bipolar Disorder


How many meds do you use to treat your bipolar disorder?  And your co-morbid afflictions?  Personally, I get off easy and take only four.

In the treatment of bipolar disorder, polypharmacy (the use of multiple meds to treat a disease or disorder) is the norm.  And generally, bipolar I patients take more meds than their bipolar II brethren.  When I began treating the whole spectrum of the disease (instead of just the depressions), what made me angry was not having bipolar, but having to swallow handfuls of pills several times a day for the rest of my life.

Did you know that prescribing multiple meds for the treatment of bipolar disorder is not an evidence-based practice? And in a recent study of 230 patients who took four or more psychotropic meds, 36% of them were taking medications that affected their behavior and mental state.  A few other studies go on to claim there are no clinical trials that examine which medications can be prescribed together effectively for the treatment of BP.  Which in essence is true; most likely the interaction and efficacy of the combination of meds we swallow each day has never been tested or vetted by an agency like the FDA.

Keeping to the theme of polypharmacy, a study published last May by the International Journal of Bipolar DisordersDrug treatment patterns in bipolar disorder: analysis of long-term self-reported data isn’t a clinical trial of any combination of meds, however the conclusions one can draw after examining data from this study of patient reported data is worthy of note.  Here is an excerpt from the Results and Discussion section:

Four hundred fifty patients returned a total of 99,895 days of data (mean 222.0 days). The most frequently taken drugs were mood stabilizers. Of the 450 patients, 353 (78.4%) took a stable drug combination for ≥50% of days. The majority of patients were taking polypharmacy, including 75% of those with a stable combination. Only a small number of drugs were commonly taken within each medication class, but there were a large number of unique drug combinations: 52 by medication class and 231 by specific drugs. Eighty percent of patients with a stable combination were taking three or less drugs daily. Patients without a stable combination took drugs but made frequent changes. Taking more than one drug within a medication class greatly increased the drug load.

To summarize, (1) patients were more likely to take a mood stabilizer than any other drug; (2) although most patients were taking polypharmacy, there were no predominant drug regimens even among those taking a stable combination; and (3) most patients with a stable combination take a relatively small number of drugs daily. The wide variation in drug regimens and numerous possible drug combinations suggest that more evidence is needed to optimize treatment of bipolar disorder.

[Italics and highlight are mine.]

For those interested, the Background and Medication Classes sections are worth a read as well.

But the meat in this study appears in two tables: Table 4 Most frequent stable combinations by medication class (N = 353), Combinations by class) and Table 5 (Most frequent stable combinations by specific drug (N = 353)).  Note these tables are not the results of actual clinical trials held to demonstrate efficacy of each drug combination. But the mere act of collating this type of data scratches the surface of the problem.  Wouldn’t it be great if researchers could drill down further into this overall concept and launch more granular studies that deal with a better defined set of specifics about polypharmacy and bipolar disorder?

Although this study is moving in the right direction, it was even performed by an international team, I doubt our prayers will be answered for several reasons.  For example, there are a myriad of  psychotropic drugs that would have to be studied.  Even if the 10 meds listed under the Monotherapy category in Table 5 were all that were studied and then only 50% of the the possible permutations were initially examined…I’ll stop there.  Another reason is big pharma would never allow it.  The industry sponsors 90% of clinical trials. Imagine what would happen if ‘competing’ manufacturers were to get into the ring together?  Which they surely would have to do if a true, clinical trial using only one of us were launched.


Because I’ve had an overly stressful week and had to rely on more med than I would have liked, I’m going to add a bonus, concluding paragraph fraught with pessimism and a touch of maudlin.  I don’t think the reigns on a polyparmacy approach to treating bipolar disorder will be pulled in during my lifetime.  First and foremost, it’s a business decision.  We are cash cows to the pharmaceutical companies. No one is going to willingly sponsor a clinical trial that could potentially put them out of business.  And bipolar disorder is not understood well enough yet to justify a treatment approach that will veer away from the rut of polypharmacy.  Strides have been made in the last few years with studies in genetics and brain imaging, but it’s not enough to make a difference to me in the here and now.  And, when I’m in a particularly resentful mood (such as right now, as I swallow a gulp of tea and yet another alprazolam) something my Mother used to say comes shooting back into my almost manic thoughts.   She died of non-small cell lung cancer.  A particularly unpleasant way to go.  She chose chemo and suffered through the treatment to prolong her life for three more years after diagnosis.  She always used to say, “It’s barbaric, the way we treat cancer.  The doctors pump you full of toxins until you’re at the brink of death, then pull you back just enough to keep you alive.”  I don’t have cancer.  I have no clue what she or anyone else who has had any form of the disease goes or has gone through.  But when the idea that polypharmacy to treat bipolar disorder is not evidence-based is printed in black and white in front of me?  I wish my Mother were still around to share my stories with.  Not for the obvious reason that I will miss her every day for the rest of my life, but because she is one of the few people who’s graced my life that would truly understand how I was ‘polypharmacied’ to the edge of my sanity and then brought back just as I was about to break for good.


I made a comment on another site, which discussed this issue, that, without doing studies on the efficacy of polypharmacy, psychiatrists were, in essence, performing their own experiments on their patients. Without our consent, really, if we don’t realize that the med cocktails are not based on actual scientific research in clinical pharmacology. I got a lot of downvotes on my comments, mostly from those who had been helped with the multiple drugs.

I have bpII though, rapid cycling. In 1998, I told my first pdoc that, from what I’d been reading, it was unknown how the psych drugs really work; and if it was unknown how individual drugs work, then it stands to reason that it is unknown how two or more drugs work together. I also told him that, from what I’d read, it was unknown how to treat rapid cycling bipolar disorder. We didn’t get along after that. (hah!) It took a few years, but I finally got a psychiatrist to admit to what I’d posited to my first psychiatrist lo those many years ago.

I’m also not treated with multiple drugs now; a cocktail has never worked for me. So, I’m back to working with my mood swings, using them for good, and not evil. (LOL). I no longer expect the drugs to stabilize me; and I’m fine with that. But I don’t have any choice, I guess. But I really hope that more bipolar patients stand up to their psychiatrists, and refuse to take drugs in rapid succession (I think starting and stopping drugs in quick succession can be incredibly destabilizing) — and insist on a more thoughtful (instead of scattershot) approach. Or, you know, just refuse to be guinea pigs.

Hi, Elizabeth. Yeah, this is a touchy subject with some folks. There are a few people who get downright defensive/angry when you talk about polypharmacy and in my personal experience it’s because they’ve been through hell and back to find a cocktail that somewhat works. I’m not saying it’s a completely bad thing (heck, I’m on four drugs myself) but I agree with you in that we’re pretty much guinea pigs.More power to you for finding one drug that helps!rapid cycling is hard to treat. Cycling through psychiatrists because they just won’t listed to you is just as bad a cycling through moods or drugs in rapid succession. I hope you’re doing well!

I suppose I should have said that I’m “treatment resistant”, that I too went through hell trying to find a drug cocktail that worked, and that I had to cycle through psychiatrists who would not take me off drugs that were causing adverse side-effects. In fact, the side effects of the cocktails I was prescribed got me fired from I think 8 jobs, and these were IT jobs with high salaries. I can’t get a job now because my professional reputation is ruined, so I’m on disability. My personal life was also ruined. Polypharmacy can be brutally destructive, in other words. It can literally destroy lives. I’m so happy for people who have found drug cocktails that have finally worked, who are able to keep their jobs and their personal lives intact. But I want psychiatrists to be more careful in their prescribing; I want them to care about the destructive side-effects from “scattershot” drug combinations. And I want mentally ill patients to understand and to protect themselves from “scattershot” drug combinations, which can result in, I think, loss of self, loss of identity, loss of the essence of “normal”. In other words, I don’t want newly diagnosed patients to go through what I went through, and have to rebuild their lives from an absolute implosion. My social worker says I should advocate for the mentally ill. Unfortunately, the focus in my home state is on getting the mentally ill any kind of help at all. See for instance, this: http://www.startribune.com/politics/statelocal/248040271.html

I’m lucky to even have a psychiatrist at this point, although she is about 20 miles and an hour-and-a-half busride away. Anyway. I have been in contact with state senators, and the article brings up some of the things I talked about with them.

Just wanted to clarify my first comment.

Reblogged this on Art Therapy and Related Topics and commented:
This is a very personal and interesting presentation of the lifelong conflict suffered by those with Bipolar Disorder: needing to take a “poly” med combination daily and having to de with other ramifications of taking a medication “cocktail” daily. The Catch 22- if you don’t take all these pills, you will get sick and have an episode; if you do follow your medication regimen, it may make you feel sick in other ways and damage your organs…

I think we get so desperate we’ll try anything. Even though I’m “treatment resistant” and know that medications don’t work on me, I still found myself considering them this fall when my rapid cycling and mixed states overwhelmed me. Managing this illness is never-ending, and the fantasy of the “magic pill” never quite goes away. But when “right-mind” returns, I know it’s all the other things I do that really keep me functioning—exercise, diet, outside support, self-monitoring, stress reduction. These are things we all have to do whether we take meds or not.

I’m so happy you’re doing well again! You (as always!) bring up a very good point. Exercise, diet, outside support, self-monitoring, stress reduction – these are the cornerstones of getting to the place we’re as good as we can be. I so admire you, Sandy. (I can’t even drag myself to go for a walk every day.) Magic pills don’t exist. Handfuls of magic pills certainly don’t. Hats off to those who’ve found relief. We’re just not in that crowd.

Hey ManicMuses, You haven’t posted for a while, so I hate to intrude.

You explain technical wonderfully, though, so when I ran across an article on The National Journal (also at Defense 1) entitled “The Military is Building Brain Chips to Treat PTSD”, I thought it was something you could look into/research and explain in a broader context. For instance, I think “Brodmann Area 25” might somehow be related to this … but I dunno. The article also doesn’t mention bipolar disorder in particular, but hey. A concentrated study of how the brain works is a good thing, right?, even if carried out by the government to figure out how PTSD is affecting the brains of soldiers … .



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