Weight gain and Bipolar Medication

Amber writes in to say . . .

I am 20 and have just recently been diagnosed with Bipolar Type II. Right away my doctor prescribed me Lamictal, in addition to my Welbutrin…then added lithium. It all just seems too much. I have been taking birth control for years now and I am afraid that all this “medicine” is interfering with my weight. Although it says that Lamictal does not promote weight gain, I fear that the combination of all these drugs is working against me in my efforts to loose weight. Any help?

Feeling like a guinea pig? One of the complicated problems in psychiatric treatment is the frequent need for multiple medications and the need to “experiment” with various combinations to see what works.  Many of the medicines have the same mechanism of action, but people have this odd way of responding to only one specific medicine or only to a specific combination.  There is no way of knowing which medicine or which combination of medicine will work.  Patients don’t like to hear that I’m guessing what will work . . . but often times it is a guess (an educated and experienced guess, mind you!).  You bring up several important issues in your question.  I’m going to start by causing trouble and second guessing your psychiatrist.  Patients who have been on antidepressants and experience agitation, irritability, sleep dysfunction, racing thoughts, self injury, impulsive behavior, etc, often get diagnosed with “bipolar disorder”.  This may or may not be true.  It might be that the person is just very sensitive to the medicine and has the above symptoms as a reaction to the medicine (there is even a hypothetical bipolar-III to describe that type of reaction).  Using Lamictal is a reasonable way to approach this.  Sometimes the Lamictal is added to the antidepressant, sometimes the antidepressant is stopped and the Lamictal is started.  Important in that decision is how fragile and depressed the patient is.  In any case, the big question is . . . do you need a mood stabilizer? If the bipolarishness was brought about by the antidepressant . . . maybe not.  Maybe all you need to do is to get off the antidepressant to have the hypomanic symptoms resolve.  While you give very few details, your story does not clearly indicate to me that you do need to be on a medicine like lithium.  Make sure you talk to your psychiatrist about whether he/she feels that the hypomanic symptoms were brought about by the antidepressant or if they were present before the use of Wellbutrin.  If the symptoms are dependent on the antidepressant, they may resolve (and may not come back) once the antidepressant is removed.  If the symptoms are independent of the antidepressant, then they should be treated independently.  Talk to your psychiatrist. 

Now, your other issue . . . the issue more important than mental stability . . . weight gain.  I only half joke here.  People may SAY that would choose to be happy/stable and fat over sad/crazy and thin . . . but more often than not . . . they don’t really mean it deep down.  Bottom line is that weight gain is unacceptable to people and if the risk of weight gain is not taken into account, my patients will not be compliant with their medicine.  Of the medicines you list above, Wellbutrin and Lamictal are not typically associated with weight gain.  Birth control pills can be associated with weight gain.  Lithium is, as well.  Generally speaking, the weight gain from lithium is not terrible (especially in comparison to some other mood stabilizers) but, sometimes, it is.  Again, going back to that infuriating fact that all of us react to medicine in a distinctly individualized way, a small percentage of people do experience significant weight gain on lithium.  There is just no way to predict.  What you should do is to look back on the start dates for the medicines that you are on and see if the weight gain correlates with any of the medicines.  The other issue to keep in mind is that mood disorders often disrupt diet and exercise routines.  That alone may cause some people to gain weight.  Remember, don’t make any changes on your own.  Consult with your psychiatrist and make sure that your issues are addressed and your questions answered.  There are so many options for medications these days that it is more typical to find a good combination of medicine that will not impact on weight or life-style.

–Dan Hartman, MD