Bipolar Disorder: medications and paying cash

Overview

Bipolar disorder causes episodes of mania, or the milder hypomania, and episodes of depression. Mania brings high energy, little need for sleep, racing thoughts and risky decisions; bipolar depression can be severe and is often the longer part of the illness. Treatment ends acute episodes and then continues to prevent new ones, usually for years.

Lithium is a long-established maintenance treatment and reduces suicide risk; it needs blood levels and kidney and thyroid checks. Lamotrigine is particularly good at preventing depressive episodes and needs a slow start to avoid a serious rash. Valproate treats mania but is avoided in women who could become pregnant. Quetiapine, aripiprazole, olanzapine and other antipsychotics treat mania, some treat bipolar depression, and some are used for maintenance, with weight, blood sugar and lipids monitored.

Antidepressants used alone can trigger mania in bipolar disorder, so they are used cautiously, if at all, and only alongside a mood stabilizer. Regular sleep, routine and early warning plans are as much a part of treatment as medicine.

Choosing between the options when you pay cash

Lithium, lamotrigine immediate-release, valproate delayed-release, quetiapine, aripiprazole and olanzapine are available as generics, and ninety-day fills are possible because none is a controlled substance. The alternative forms, extended-release lamotrigine, lamotrigine starter kits and dissolving tablets, extended-release quetiapine and extended-release valproate, are separate products from the plain tablets, so a quote applies only to the form on the prescription.

Newer brand-only antipsychotics approved for bipolar depression, and the long-acting injections, usually go through insurance or manufacturer programs. Blood tests for lithium and valproate are a recurring cost outside the pharmacy.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Lithium
  Capsules (generic), Tablets (generic), Extended-release tablets (Lithobid and generic)
  Generic: Yes · Two to four times a day
• Lamotrigine
  Tablets (Lamictal and generic), Tablets for oral suspension, also called chewable dispersible tablets (Lamictal CD and generic), Orally disintegrating tablets (Lamictal ODT and generic)
  Generic: Yes · Once or twice a day
• Quetiapine
  Tablets (Seroquel and generic), Extended-release tablets (Seroquel XR and generic)
  Generic: Yes · Twice a day, or once a day extended-release
• Aripiprazole
  Tablets (Abilify and generic), Orally disintegrating tablets (generic), Oral solution (generic)
  Generic: Yes · Once a day
• Valproic Acid
  Valproic acid capsules and oral solution (generic), Divalproex delayed-release tablets (Depakote and generic), Divalproex extended-release tablets (Depakote ER and generic)
  Generic: Yes · Once a day
• Olanzapine
  Tablets, Orally disintegrating tablets, Short-acting intramuscular injection
  Generic: Yes · Once a day
• Carbamazepine
  Tablets, Chewable tablets, Extended-release tablets (Tegretol XR)
  Generic: Yes · Two to four times a day
• Lurasidone
  Tablets
  Generic: Yes · Once a day
• Cariprazine
  Capsules
  Generic: No · Once a day
• Lumateperone
  Capsules
  Generic: No · Once a day
• Ziprasidone
  Capsules, Injection (powder for injection into a muscle, given by a health professional)
  Generic: Yes · Twice a day
• Risperidone
  Tablets (Risperdal and generic), Oral solution (Risperdal and generic), Orally disintegrating tablets (generic)
  Generic: Yes · Once or twice a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Which medicine is for treating the current episode and which for preventing the next?
• What monitoring do I need, and how often?
• Is the plain tablet suitable instead of an extended-release form?
• What early warning signs should I and my family watch for?
• What should I know about pregnancy and contraception with these medicines?

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