When caring for patients with bipolar disorder, one of the greatest concerns that we have is manic episodes. Drug therapy in the form of mood stabilizers are utilized to help prevent manic episodes from happening. As a pharmacist, it is critical to review the medication history of any patient presenting with symptoms of mania. For me, it is easiest to remember some of the drugs that induce mania by recognizing those that may cause insomnia and activation or increase certain CNS neurotransmitters like dopamine, serotonin, or norepinephrine. Here’s a list of common drugs that induce mania and that we should be cautious with in our bipolar patients.
Antidepressants. Antidepressants such as SSRIs (podcast), TCAs (podcast), and others have been associated with inducing mania symptoms. This is critical to recognize in patients newly diagnosed with depression. Patients who experience mania following the initiation of antidepressants may have been misdiagnosed with depression instead of bipolar disorder. Inevitably, you will see the use of antidepressants in patients with depressive symptoms associated with bipolar disorder. This should be done very carefully with the recognition that one could induce mania. This has historically been controversial and still is at the time of writing this article. As a pharmacist, if I know a patient has bipolar disorder and an antidepressant is being initiated, I would try to monitor that patient a little more closely over the initial weeks of therapy if possible. Another consideration that may be helpful to prevent future issues is to document the issue in the allergy/intolerance list if a specific medication induced mania.
Stimulants. The easiest way for me to remember that stimulants can induce mania is to understand what stimulant use looks. Euphoria, overconfidence, and a feeling of invincibility are some of the psychologic effects from stimulant use which mimics mania perfectly.
Dopamine activating agents. Excessive dopamine has been associated with inducing mania so medications like Sinemet and dopamine agonists (i.e. Requip, Mirapex) are considerations when a patient presents with mania symptoms. RLS is probably the most common non-serious issue that these medications might be used for. In a patient with bipolar disorder, it would be ideal to look for other options before considering these agents.
Corticosteroids. Use of corticosteroid bursts are incredibly common for acute pain and inflammatory disorders. They are associated with numerous adverse effects both long and short term. They can also cause patients to experience insomnia and other symptoms of psychiatric disorders. While withholding the steroid may not be possible, the patient should be monitored more closely to ensure that we are not exacerbating their bipolar disorder.
There’s my list of common drugs that induce mania. It is critical to monitor for this risk if any of your bipolar patients are being placed on any of these agents.
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