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To limit side effects, antipsychotics are usually initiated at a low dose and increased slowly with regular monitoring of the blood. Dosages can also be adjusted to minimize side effects. If a patient cannot tolerate atypical antipsychotics, typical antipsychotics are an alternative.

Antidepressants

On October 15, 2004, the U.S. Food and Drug Administration (FDA) issued a Public Health Advisory, asking manufacturers of all antidepressant drugs to revise the labeling for their products to include a boxed warning and expanded warning statements that alert health care providers to an increased risk of suicidality (suicidal thinking and behavior) in children and adolescents being treated with these agents, and additional information about the results of pediatric studies. On May 2, 2007, the FDA expanded the warning regarding suicidality to include young adults between the ages of 18-24. The FDA also informed these manufacturers that it has determined that a Patient Medication Guide (MedGuide), which will be given to patients receiving the drugs to advise them of the risk and precautions that can be taken, is appropriate for these drug products.

The American Psychiatric Association recommends conservative use of antidepressants in the treatment of bipolar disorder for the following reasons:

• They have not been shown to significantly prevent suicide and reduce mortality
• They have not been shown to be more effective than mood stabilizers
• They are less effective than mood stabilizers in preventing relapse of depressive episodes
• They may actually increase the risk of mania and long-term worsening of bipolar disorder

Antidepressants must be used together with mood stabilizers in the treatment of bipolar disorder. They are not used as first-line treatment for bipolar depression; however, if the situation warrants physicians may first consider the use of the following three:

• Bupropion (Wellbutrin)
• Selective serotonin reuptake inhibitors (SSRIs)
• Venlafaxine (Effexor)

Bupropion

Side effects may include:

• Dry mouth
• Headache
• Nausea/vomiting
• Fatigue

Selective Serotonin Reuptake Inhibitors (SSRIs)

Drugs in the category of SSRIs include:

• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

Side effects of SSRIs can include:

• Dizziness
• Tremor
• Fatigue
• Decreased sex drive

Venlafaxine (Effexor)

Side effects may include:

• Sweating
• Nausea
• Dry mouth
• Dizziness
• Tremor

In June 2004, the U.S. Food and Drug Administration (FDA) and Wyeth Pharmaceuticals notified healthcare professionals of revisions to the WARNINGS, PRECAUTIONS, and DOSAGE AND ADMINISTRATION sections of labeling to alert healthcare providers about the following important safety issue:

Neonates exposed to Effexor, other SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), or SSRIs (Selective Serotonin Reuptake Inhibitors), late in the third trimester of pregnancy have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery.

Other antidepressants may be used in the treatment of bipolar depression. They are not preferred, however, because of reduced efficacy and/or potentially more severe side effects. These antidepressants include:

• Mirtazapine (Remeron)
• Monamine oxidase inhibitors - phenelzine (Nardil) and tranylcypromine (Parnate)

Monoamine oxidase inhibitors require special dietary considerations.

• Tricyclic antidepressants:

  • amitriptyline (Elavil)
  • desipramine (Norpramin, Pertofrane)
  • imipramine (Trofranil)
  • nortriptyline (Pamelor)

Tricyclic antidepressants are more likely to have side effects or to cause mania or rapid cycling than other antidepressants.