The medications you should be concerned about can be divided into two broad categories--those that may directly provoke or exacerbate mania and those that interact negatively with medications used to treat bipolar disorder.  In addition to prescription medication, there are over-the-counter medications, street drugs, and herbal remedies that should be avoided and are this being lumped into the category of "medications" here.  Medications that provoke or exacerbate mania can be divided into four subcategories:

• Antidepressants and stimulants used commonly to treat psychiatric and neurological conditions
• Steroids and beta agonists used commonly to treat pulmonary conditions
• Dopamine agonists used commonlyto treat neurological conditions
• Over-the-counter medications and street drugs that are stimulants and hallucinogens

Antidepressants cause the most concern among patients and clinicians alike for two main reasons: they may cause switching to mania and/or they may cause mood to destabilize, leading to worsening depression.  Two recent reviews have focused on the issue of switching from depression into mania.  In the first study reviewing a very complex literature on the subject using very sophisticated statistics, the switch rate appeared to be between 20% to 40%, with tricyclic antidepressants causing higher rates than SSRIs.  The study also suggested that being on a mood stabilizer provided only partial protection against switching.  In another study, however, which looked only at randomized trial data, switch rates on antidepressants were no different than placebo in the short run.  Most agree that switching can definately occur in patients with bipolar I disorder.  The greatest controversy lies in how to properly treat patients with bipolar spectrum disorders, as the vast majority of them are predominately depressed.  Patients who are seen in a bipolar specialty clinic in a tertiary care center are less lekely to be prescribed an antidepressant than if they saw a community psychiatrist.  This may be due to the fact that most patients who are sent to a tertiary care center have already failed multiple medication trials, including antidepressants.  In fact, it appears that one of the indicators of switching is a past history of failed multiple antidepressant trials.  Finally, to complicate matters more, the abrubt withdrawal of antidepressant medications can cause a manic switch, so a slow taper is strongly advised for bipolar patients on them.

With respect to mood destabilization, or an increase in cycle frequency, the available literature seems to support the concept that the addition of anitdepressants can cause patients to cycle much more often than if they were not on an antidepressant.  Furthermore, bipolar disorder often worsens over the years through a process that may be identical to kindling.  Antidepressants may hasten the process, although there is not literature currently to support that.  Unfortunately, no randomized studies have been performed, so the available literature is scant.  Because studies have demonstrated reduced suicidality with patients on either Depakote (valproate) or lithium and no clear benefits with respect to suicidality with bipolar patients on antidepressants, most doctors feel strongly that treating depression with mood stabilizers that have antidepressant effects (Lithium and Lamictal [lamotrigine]) should be the first course of action in bipolar patients, and if antidepressants are necessary they should be discontinued as soon as the depression has resolved.

A long history of research demonstrates a link between hormonal levels and mood disorders.  Hormones are chemicals produced by endocrine glands that are released into the blood stream to carry out functions in other parts of the body.  Hormone-producing endocrine glands include the thyroid, which produces adrenaline or epinephrine, among others; and the reproductinve glands, which produce testosterone and estrogen, among others.  Hormones clearly play a role in various mood disorders such as premenstrual dysphoric disorder, postpartum depression, major depresion and bipolar disorder.  Recently the issue of steroid use among prefessional athletes has been discussed in the press, as there have been a number of cases of suicides in previously mentally healthy young men who used them as performance enhancers.  Steroids are often used to treat a variety of medical conditions that cause inflammation as they reduce the inflammatory process.  But steroids are extremely activating, causing the body to mobilize into the "fight or flight" mode.  The body also generates this mode naturally when very stressful circumstances occur.  It is caused by a part of the involuntary, or autonomic, nervous system known as the sympathetic nervous system.  Its counterpoint, which causes "rest or restoration," is known as the parasympathetic nervous system.  These systems act on both the body and the brain.  The sympathetic system uses the chemical norepinephrine (noradrenalin), which is similar to epinephrine (adrenalin).  Epinephrine is often given to people who have severe allergies to bee stings, foods, or medications.  These allergic reactions cause a condition known as anaphylaxis, making it impossible to breathe.  Epinephrine is life saving in such circumstances.  But the consequences are that the system is activated.  For those with mood disorders, particularly bipolar disorder, this can have a destablizing effect and cause relapse.  Any medication that activates the sympathetic nervous system can to this, not just steroids.  Medications used to treat asthma, emphysema, chronic bronchitis, or other pulmonary conditions that cause wheezing stimulate the sympathetic system to make the airways bigger in order to breathe easier.  These medications are known as beta-agonists as they stimulate beta-receptors of the sympathetic nervous system, causing the airways to dilate.  Such stimulation, however, affects the sympathetic nervous system throughout the body in addition to the airways.

There are also over-the-counter medications that can have a similar effect.  Prior to removal from the market, Ephedra was known for this effect, but any medications that contains phenylpropanolamine has that potential.  Stimulants, too, can potentially do this.  The final common pathway of all these medications, including antidepressants, appears to be their impact on norepinephrine, of which TCAs have more of an impact than SSRIs.  But this includes street drugs that have stimulant properties or hallucinogenic properties (uppers and hallucinogens).  Downers, on the other hand, which include barbiturates and alcohol, can destabilize mood due to their withdrawal effects, which mimic a sympthetic response.  This is one of the reasons why it is critical to avoid alcohol and drugs of abuse.  Finally, because of the popularity of recent herbal remedies, we have listed various herbs with psychotropic effects, with their adverse effects and interactions.  These herbs should be avoided by all individuals with mood disorders.