Topamax before and after


Topiramate (Topamax) for Migraine Prevention

Migraine and epilepsy share many biologic features, and so not surprisingly certain of the newer antiepileptic drugs have proven to be effective for the prevention of migraine attacks as well as seizures. One of these drugs is topiramate (Topamax), and its successful performance in carefully conducted national studies has led to topiramate receiving the Federal Drug Administration indication for use in migraine prevention.

Precisely how topiramate prevents migraine is unclear, but, generally speaking, it appears to reduce the genetically derived brain hyperexcitability that provokes migraine attacks in susceptible individuals.

As a potent, “brain-active” medication, topiramate is not without potential side effects. Early in therapy topiramate may cause nausea or other gastrointestinal distresses. It also commonly produces an odd “pins and needles” sensation that may involve the hands, feet, or even the face; this side effect is benign, causes no neurologic injury, and is usually transient. More concerning is the drug’s potential for causing cognitive disturbance, typically manifested by impairment of recent memory, impaired concentration, or word finding difficulties; while these cognitive side effects occur in a minority of patients and may be minimized by beginning with a low dose and gradually increasing the dosage each week, the “start low/go slow” technique does not totally eliminate the risk. In rare instances, during the first 1 to 2 months of therapy the drug may cause impaired vision by increasing intraocular pressure (“glaucoma”). Topiramate not uncommonly causes weight loss, and the degree of weight reduction tends to correlate with dose and duration of therapy. Finally, the drug may cause carbonated beverages to taste “flat.”

Usual dosing instructions for topiramate are as follows:

TABLE: Week Morning (mg) Bedtime (mg) 1 0 25∗ 2 25 25 3 25 50 4 50 50 ∗1 tablet = 25 mg.

Fifty milligrams twice daily was the dose proven to be the most effective and best tolerated in the clinical research trials conducted. In the individual patient, however, a lower or higher dose may be more appropriate.

Warning:The primary use of Topiramate, and the only use for which it has regulatory approval, is to treat seizures. Some people use Topiramate to treat other conditions, which may include PTSD, Axis II mood disorders, and eating disorders. However, no peer-reviewed studies have established that Topiramate is safe and effective for those conditions, and therefore these uses have not been approved by the FDA. There is limited evidence supporting these uses that comes from small-scale case studies, but as yet there have been no large studies that researchers have published.

What is Topiramate?

Topiramate is often sold under the brand name Topamax. It is an anti-convulsive drug that stands apart from all other drugs used to treat convulsions or mood disorders because it does not share the same chemical composition. Medical researchers currently do not know how Topiramate works.

When did the FDA approve this drug for marketing in the US, and what uses of the drug are approved?

The FDA gave final approval for the drug on December 24, 1996. As stated above, the only approved use to date is the treatment of convulsions.

Does Topiramate have a generic version?

The manufacturer of Topiramate still holds patent protection over the drug, so there is no generic version available yet.

How is Topiramate different from other mood stabilizers?

There are two things that set Topiramate apart from other drugs in this class. First of all, physicians and psychiatrists sometimes prescribe it when other mood-stabilizing drugs fail to be effective for a patient. Secondly, the set of side effects that patients may experience is quite different on Topiramate compared to other mood stabilizers.

How is Topiramate different from carbamazepine and valproate?

For rapid cycling or mixed bipolar states, there are some cases where Topiramate is effective when these other two drugs are not.

Which disorders has Topiramate been most successful in controlling so far?

The lack of research about Topiramate makes it hard to tell which disorders will respond best to the drug: to date, there is not enough psychiatric research to make specific recommendations. In the field, practitioners have had success when prescribing Topiramate to individuals with bipolar disorders that have resisted other forms of treatment. The most effective use of Topiramate appears to be the case of patients whose use of lamotrigine has induced mania. Some psychiatrists have reported using Topiramate to help relieve the symptoms of PTSD and the side effects related to eating that other psychiatric drugs can create.

Can Topiramate treat episodes of depression, mania, and mixed states? Can it prevent these episodes?

While Topiramate’s first use was for the treatment of mania, depression, or mixed states that were resistant to other drugs, its effectiveness for preventing those states has not yet been tested. There have been no research studies that placed patients on Topiramate for an extended time and evaluated whether it decreased their likelihood of these episodes.

What lab tests are necessary before a patient can be prescribed Topiramate?

It is important to test for any of several conditions that can interact with mood disorders. The necessary tests include blood and urine tests, because these conditions could be the cause of a mood disorder.

What dosage is appropriate for starting a course of Topiramate?

The initial dose for Topiramate should be either 12.5 or 25 milligrams taken either once or twice a day. This dose increases by 12.5 or 12 milligrams each week until it reaches the final level, which depends on the use of the drug and how the patient is responding. A typical final dosage is between 100 and 200 mg per day, although some patients benefit from no more than 50 mg. The case of PTSD entails a final dose of approximately 175 mg per day and generally not exceeding 500 mg per day.

Are there any special problems prescribing Topiramate for
people taking lithium, carbamazepine (Tegretol), or valproate (Depakene, Depakote)?

There are no known interactions between Topiramate and lithium. However, carbamazepine can lower the blood-plasma level of Topiramate by 50 percent and valproate can lower it by 15 percent. Topiramate itself can lower the blood-plasma level of valproate by 10 percent. Thus far, there are no known interactions for patients taking Topiramate and either lamotrigine or gabapentin.

What final doses of Topiramate are typical and what doses are appropriate for different disorders?

The final doses of Topiramate vary widely based on the targeted disorder, the patient, and whether or not the patient is taking any other drugs at the same time. The most common doses fall between 50 and 200 mg a day for most therapies, but this can be lower for PTSD. Higher final doses may be required if Topiramate is being taken alone, up to 500 mg a day. Some patients experience relief with only 25 mg a day.

How long until the patient feels the effects of Topiramate?

This also varies significantly depending on the individual. Some feel the effects within days, while others need up to a month before they feel any difference.

What is the side effect profile of Topiramate?

Topiramate’s side effects appear most strongly just after an increase in dosage. A research study that compared 711 participants taking Topiramate and 419 taking a placebo observed the following sets of side effects in both groups:
Common Adverse Reactions (%)

(Topiramate = 200 mg/day)
Adverse Reaction Topiramate Placebo

Somnolence 30% versus 10% Placebo

Dizziness 28% versus 14% Placebo

Vision problems 28% versus 9% Placebo

Unsteadiness 21% versus 7% Placebo

Speech problems 17% versus 3% Placebo

Psychomotor slowing 17% versus 2% Placebo

Pins and needles 15% versus 3% Placebo

Nervousness 16% versus 8% Placebo

Nausea 12% versus 6% Placebo

Memory problems 12% versus 3% Placebo

Tremor 11% versus 6% Placebo

Confusion 10% versus 6% Placebo

Which of these side effects are the strongest?

The five side effects that were most likely to cause people to discontinue use of Topiramate were psychomotor slowing, fatigue, memory problems, confusion, and somnolence. In rare cases, approximately one person of patients develop kidney stones and a very few develop acute glaucoma.

What psychiatric side effects do people who take Topiramate experience?

The list includes sedation, psychomotor slowing, agitation, anxiety, concentration problems, forgetfulness, confusion, depression, and depersonalization. There are also rare cases of psychosis.

How does Topiramate interact with prescription and
over-the-counter medications?

The interactions between Topiramate, valproate, and carbamazepine have already been noted above. In addition to that, Topiramate appears to raise the blood-plasma level of phenytoin, while phenytoin decreases the level of Topiramate by 50 percent. There have been some reports that Topiramate reduces the effectiveness of oral contraceptive pills.

Is it safe to take Topiramate and drink alcohol?

If you drink while taking Topiramate, then you may experience more intense side effects.

Is it safe to take Topiramate if you are pregnant?

The FDA places Topiramate in the “C” category for pregnancy safety. That means the drug is known to affect the human fetus in an adverse way, but there is not much research about the specifics, and that the drugs benefits may outweigh the risks.

Is it safe for children and teens to take Topiramate?

Yes, the FDA has approved the drug for children.

Is it safe for older adults to take Topiramate?

So far, there are no reports about using Topiramate for older adults, although there is no reason to believe that they would have a different response to it.

Is it necessary to wean off Topiramate?

There are no reports of bad reactions to suddenly stopping use of Topiramate, so there is no need to wean off the drug. On the other hand, the entire class of anticonvulsants is known to lead to seizures if you stop taking them suddenly. Therefore, the only thing that should lead to a sudden cessation of Topiramate use is the rise of a dangerous side-effect.

Is it possible to overdose on Topiramate?

There are no reported effects and no deaths from an overdose of Topiramate.

Does Topiramate interact poorly with MAOIs?

There is no danger in taking Topiramate with MAOIs.

Is Topiramate expensive?

When bought in bulk, Topiramate is not particularly expensive. The 25 mg per pill set costs about $1.45 a pill, 100 mg costs $3.75 a pill, and 200 mg costs about $5.75 a pill.

Can Topiramate help people who have not found relief with other psychopharmacologics?

That is precisely the role of Topiramate. It is effective for those who found no useful effect from other mood stabilizers. Potential new uses of the drug include PTSD and reducing alcohol cravings, as well as heading off migraine headaches.

Why use Topiramate?

Topiramate is most useful for people who have bipolar mood disorders that other mood stabilizers have been unable to control. It can relieve symptoms and make taking antidepressants possible for people who ere unable to take them before without experiencing mania or a mixed state. Topiramate has a favorable side effect profile and up to half of all people who take the drug experience weight loss. This is a beneficial counteraction to the weight gain that many antidepressants can cause.

Does Topiramate have downsides?

Because the drug is only about 20 years old, there has not been much study about prolonged use, especially with regards to side effects. There has not been enough time to determine how long the benefits of Topiramate last and if they end or reduce after sufficient time. Likewise, much of the drug’s use as a mood stabilizer and for disorders like PTSD is currently not supported by a large body of research, pending more publications.

If Topiramate has so little evidence supporting its use, why should anyone prescribe it over an older drug that has more research showing its effectiveness?

First of all, Topiramate generally has a better side effect profile than those older drugs. Some patients find that older mood stabilizers have side effects that are too dangerous or impact their lives too much.
Second of all, many patients find that the older drugs do not control their disorders, while Topiramate does. That makes it the only effective known remedy for them.
Lastly, topirmate is so far the only psychopharmacologic agent that appears to have an effect in providing relief for PTSD symptoms. These symptoms can be extremely debilitating.

Is Topiramate prescribed all over the world?

Yes, many nations have approved Topiramate for use and prescribe it.

Last Updated: Nov 18, 2018

Is Topiramate a Mood Stabilizer?

Several anticonvulsants are mood stabilizers. Even a ketogenic diet —long used as an anti- seizure strategy, particularly in children, for whom parents can control carbohydrate intake —has been shown to have a mood-stabilizing effect.1

But several other anticonvulsants are not mood stabilizers: gabapentin, for instance. A multi-center study, sponsored by the manufacturer, showed Neurontin was slightly less effective than placebo. Both treatment groups had a decrease in mania scores from baseline to endpoint, but the decrease was significantly greater in the placebo group.2

Topiramate has one huge advantage over many other psychotropics: it causes weight loss —not gain. While gabapentin caused an average gain of 2.2 kg during randomized trials (nearly as much as olanzapine’s 2.4 kg and worse than quetiapine’s 1.1 kg), topiramate caused an average loss of 3.8 kg.3

But then there is the cognitive impairment associated with topiramate, leading to cruel monikers like “Stupimax” and “Dopimax.” (With far too much bullying in the world lately, there’s little room for more —except upon pharmaceutical company trade names!) How bad is this cognitive impairment? An early investigation noted, “According to subjective reports from our patients, we note that some do not experience any altered cognitive abilities when taking TPM.”4 The investigators had to remark on the few who didn’t have problems with mental slowing, word-finding difficulties, difficulty calculating, dulled thinking, and blunted mental reactions.

Be careful to warn patients about cognitive effects such as mental slowing, difficulty calculating or finding words, dulled thinking, and blunted mental reactions.

The investigators also observed that “some patients are aware of such side effects but prefer to continue to take the drug.”4 Not so surprising, perhaps: where else can one obtain a 10-lb weight loss in 2 or 3 months? In my experience, the only people who want to continue taking topiramate are those who don’t work, don’t go to school, and don’t take care of children; and, cruelly, these are almost entirely women, who are societally under more pressure to lose weight.

Back to the original question: does topiramate deserve to be classed, with other anticonvulsants, as a mood stabilizer? A recent Cochrane review examined this in typically thorough fashion and concluded: “It is not possible to draw any firm conclusions about the use of topiramate in clinical practice from this evidence.”5 Few of the available studies met their quality criteria. Among the few that did were several that found lithium to be more effective than topiramate as monotherapy for acute episodes. Other than that, the door is open.

On the other hand, one can also conclude that none of the available evidence sufficiently confirms topiramate as a mood stabilizer. And with its cognitive effects, one would think that more evidence in favor of its efficacy would be needed —except for that weight effect . . . .

A few readers may remember an open trial (no control group) of topiramate for PTSD, when the drug was new, in which dramatic improvements were seen.6 That study appears to have been one of many in which early open trials suggest benefit not later confirmed in randomized trials. (Thus the cynical aphorism: “when a new drug comes out, use it quick before it stops working.”)

Subsequent meta-analyses have not found topiramate to be better than placebo for PTSD.7 Granted, some patients’ responses to topiramate, for PTSD or mood or anxiety, may be excellent (one study was quite positive, for example.8) Let not my review lead to a deflation of their belief or response. At the same time, the most recent meta-analysis confirms again that treatments with the largest effect sizes in PTSD are psychotherapies. Sertraline outperformed other antidepressants in this setting except for the potential hypertension-and-hypomania inducer, venlafaxine.7

Nevertheless, as an antidote for antipsychotic-induced weight gain, topiramate is effective. In that context, the average weight loss in randomized trials was 2.8 kg (not as much as the 3.8 kg average in patients who did not take antipsychotics, but still negative!).9 And for binge eating, the evidence shows clear benefit.10

Just be careful to warn patients about those cognitive effects, as well as renal stones. One of my patients, a high-powered executive, told me that she nearly lost a multi-million-dollar contract when she was pitching it after recently starting topiramate. Colleagues recognized her impairment, gently moved her aside, and won the deal. And don’t expect it to add to mood stability —unless, as I sometimes do, one proceeds in the desperate hope that effective weight loss might improve things (one trial in depression showed some value11).

This article was originally posted on 10/11/2016 and has since been updated.

(updated 12/2014)

People occasionally write me saying they really like topiramate, why don’t I sound more enthusiastic about it, etc. Please note: the way for the rest of us to judge a medication’s effectiveness is not based on your personal results. If you’re on it and it’s working, that’s great! Don’t consider stopping just because you read here that it has not been shown in “randomized clinical trials” to be more effective than placebo.

Indeed, as you’ll see below, research evidence it does not strongly support use of Topomax has a “mood stabilizer”. However, it seems like about once a month someone writes me and says that it was tremendously helpful for them. You’ll see below that the evidence is not entirely negative. This is a medication where comparing the potential for benefit versus the potential risks is quite tricky. You can find strong opinions on both sides.

Nevertheless, in general the best way to judge a medication’s effectiveness is to compare it to a placebo (randomly assigning people to the medication, or the sugar pill — thus the term “randomized clinical trial” (read more about randomized trials as a superior kind of evidence; that link refers to treatment of panic disorder but it could be any treatment — including in this case topiramate). In January 2006 the Cochrane group, a highly respected team that evaluates the effectiveness of treatment based on randomized trial reslts, concluded there was not sufficient evidence to recommend topiramate as a treatment
for bipolar disorder.Vasudev Even the manufacturer published a paper saying it didn’t work in bipolar disorder (treatment of mania, in this case), and that lithium was better.Kushner

Or rather, that’s where we were until this report — from my December 2005 update: However, now comes a comparison trial of topiramate versus valproate (Depakote) for the treatment of Bipolar I mania, when added to a relatively low dose of an atypical antipsychotic, risperidone.Bahk These data could support a major shift in strategy, away from valproate as a mainstay mood stabilizer, because of the associated weight problems (2.5 kilogram gain in this 6-week study), as they so often are seen in practice); toward a medication whose effectiveness is in serious question but which does not have the weight-gain problem. This would seem foolish — except in light of the results in this study, where the topiramate + risperidone group did as well as the valproate + risperidone group. And the topiramate + risperidone group had no more significant nor serious side effects, while their weight stayed stable (half lost a little, the other half did not). This re-opens the case for consideration of topiramate as a mood stabilizer, in my opinion, but we’ll need more data now.

A reader wrote and complained that I was unfairly negative about topiramate when she had improved tremendously on it:

I have been on Topomax since April of this past year and it RADICALLY CHANGED MY LIFE!!

For 30 + years I was impulsive, negative, moody, depressed, suicidal, hearing voices, too many thoughts to get straight in my mind, quitting jobs, church-hopping, unstable, a MESS!

Finally, when I got diagnosed and the doc wanted to put me on Depakote, I did some research and opted OUT of that idea and decided to try Topomax instead, due to the weight loss properties. Within 30 minutes, it was quiet in my head, I could focus, I was peaceful, happy, signed up to head to college for a career, joined back up with the former church I had left, rekindled all my old relationships that ended due to bad communication with people.

I have had no side-effects from the medicine, other than occasional tingling in my lips.

But she agreed that she made her medication choice not based on evidence for effectiveness, but rather by choosing among side effect risks. Rather than go with Depakote, she chose topiramate because with it frequently causes weight loss, whereas with Depakote often causes weight gain. In my experience with topiramate, she got really lucky as far as effectiveness goes. Can’t hardly argue with her outcome: great benefits, minimal side effects. I wish this happened more often with topiramate; it would be an obvious top choice.

This medication clearly can decrease appetite and lead to weight loss, as is now even more certain following the publication of a large British study comparing it to placebo.Wilding In this study, all patients were part of a weight loss program. Even the patients on placebo lost weight, almost 2% of their body weight, which may not sound like much, but these folks had to be quite overweight to get into this study. But the folks on about 100 mg of topiramate lost 7% of their body weight in a year, and more if they were on higher doses, as shown here:

Dose % of weight lost (1 year) Lbs. lost (if 250 lbs or more to start) Lbs. lost (if 300 pounds or more to start)
placebo 2 5 6
100 mg 7 15 20
200 mg 9 23 27
250 mg 10 25 30

So, there is not much doubt that this stuff helps people lose weight. But there are two problems with it.

First, it does not appear to be a mood stabilizer, except for that new study up there by Bahk. Or perhaps we should put it this way: it does not appear to be an effective anti-manic in Bipolar I (with four research studies showing it was not better than placebo in this roleKushner). That leaves open the possibility that it might do something useful in non-manic versions of bipolar disorder (like Bipolar II, the type most of this website focuses on). And it might have some significant antidepressant action though, as much as Wellbutrin, an antidepressant, in a recent comparison study.McIntyre

Secondly, it has lots of side effects. It can cause depression (listed as such in the PDR); it can cause anxiety, quite frequently in my experience; and about 1/3 of patients get cognitive impairment (not to mention to 1.5% risk of kidney stones, a lower risk of glaucoma, and a rare risk of “metabolic acidosis”, a potentially fatal blood chemistry change).

Revised 9/2007: This medication has some role in appetite management in select cases. A recent study showed that it was better than placebo for weight control when patients were taking olanzapine (Zyprexa), and the benefits continued for over a year.Egger But I do not routinely use it for bipolar symptoms. It’s just too unpredictable and too loaded with really impairing side effect potential. Some new data on naltrexone are hopeful but as of 12/2014 that’s a new strategy, too early to know for sure. More on that in the naltrexone section of my Weight essay.

Treating Addiction with Severe Bipolar Disorder

Extreme fluctuations in mood and energy levels are the hallmark signs of bipolar disorder, a form of mental illness that causes severe psychological instability.

Bipolar disorder involves more than just typical mood swings; it causes dramatic changes in emotional states, cognitive functioning, judgment, and behavior. People with bipolar disorder can veer from a depressed state to a manic high in a matter of weeks or even days, depending on the type of the disorder and the nature of their episodes. The effects of bipolar disorder are wide-ranging, causing relationship conflicts, occupational difficulties, an increased risk of suicide, and an overall decline in quality of life.

The incidence of substance abuse is higher among individuals with bipolar disorder than among the population as a whole. The National Alliance on Mental Illness states that over half of people with bipolar disorder (56 percent) have a history of illicit drug abuse, while 44 percent have abused or are dependent on alcohol. When severe bipolar disorder co-occurs with drug or alcohol addiction, the potential for negative outcomes increases. A combination of therapies — including psychiatric medications, individual and group therapy, and intensive substance abuse treatment — can help these clients achieve a sense of inner balance and create more satisfying, productive lives.

Understanding Bipolar Disorder

According to the Archives of General Psychiatry, approximately 2.6 percent of American adults have experienced bipolar disorder within any given 12-month period, and nearly 83 percent of these cases could be considered severe. Once known as manic depression, bipolar disorder is characterized by episodes of depression followed by elevated emotional states known as mania. The term “bipolar” reflects these opposite states of mind.

The length of time that an individual spends in either state can vary based on the form of the disorder present.

The major variations of this condition include:

  • Bipolar I: Individuals with this form of bipolar experience the most dramatic transitions from mania to depression, and mood swings can be sudden and severe. The National Institute of Mental Health states that depressive periods in bipolar I typically last for at least two weeks. The level of functional impairment is high with this form of the disorder, and many of these individuals must be hospitalized in order to protect their safety.
  • Bipolar II: This type of bipolar is characterized by less severe fluctuations between emotional states. Depressive episodes may last longer and alternate with periods of hypomania, a milder form of mania. While it may be easier to function with this less severe form of the disorder, bipolar II can nevertheless interfere with normal activities and cause functional impairment.
  • Cyclothymia: This mood disorder is marked by milder depressive episodes and periods of hypomania. Episodes of depression are generally not as long or as profound as they are with bipolar I or II.
  • Bipolar with mixed features: In this form of the disorder, individuals may experience symptoms of mania and depression at the same time. For example, the individual may have elevated energy levels, sleeplessness, and appetite loss combined with feelings of despair, low self-worth, and sadness.
  • Rapid-cycling bipolar: This manifestation of the disorder is characterized by multiple, rapidly alternating episodes of mania and depression, usually at last four within a 12-month period. Individuals with other forms of bipolar may go through phases of rapid cycling, in which their moods fluctuate very quickly. During rapid cycling periods, depression may be more severe, and self-destructive behavior and suicide attempts are more common.

JAMA Psychiatry reports that although both depressive and manic episodes are functionally debilitating, depression causes more overall impairment, and the symptoms of depressive episodes are typically more severe. Substance abuse may occur in either state, but depression is likely to cause harmful symptoms such as self-isolation, suicidal ideation, and feelings of hopelessness, all of which increase the risk of alcohol or drug use.

Bipolar disorder can also cause psychotic episodes, in which the mind breaks with reality and the individual experiences delusions or hallucinations. During a manic phase, psychosis might involve delusions of grandeur or wildly unrealistic beliefs about one’s capabilities, such as the belief that one could fly. During a depressive phase, psychosis may express itself as paranoid delusions of persecution or isolation from others. When psychosis occurs, suicide attempts, high-risk behaviors, and hospitalization are common.

Detecting the Signs of Bipolar Disorder

Bipolar disorder can be difficult to identify, especially in people who abuse drugs or alcohol. The extreme mood swings caused by this psychiatric disorder can resemble the highs and lows that individuals experience during periods of intoxication or withdrawal from substances. By the same token, substance abuse can intensify the highs and lows of bipolar disorder, making it hard to know whether these mood swings are chemically or psychologically induced.

The changes caused by bipolar disorder are much more drastic than the mood swings that average adults experience throughout their lives. Although these fluctuations may follow certain patterns, they often strike in unpredictable ways, leaving the individual feeling out of control. Similarly, loved ones, coworkers, or acquaintances may feel helpless when confronted by these dramatic changes in the individual’s personality. The red flags of bipolar disorder can be divided into depressive and manic symptoms:

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  • Feelings of low self-worth
  • A sense of hopelessness and despair
  • Physical fatigue
  • Low energy levels
  • Changes in appetite
  • Difficulty sleeping or sleeping too much
  • Problems with memory and concentration
  • Foggy thinking
  • Self-destructive behavior
  • Suicidal thoughts or suicide attempts

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  • An inflated sense of power or importance (grandiosity)
  • High levels of energy and enthusiasm
  • Rapid speech that jumps quickly from one topic to another
  • Racing thoughts
  • Poor judgment
  • Impulsive behavior, such as excessive shopping, eating, or substance abuse
  • Risk-taking behavior, such as driving too fast or having unsafe sex
  • Loss of appetite
  • Lack of the need to sleep
  • Edginess or irritability
  • Angry outbursts

Some people with bipolar disorder experience a state called hypomania, a less extreme form of mania characterized by elevated energy levels, increased productivity, and more outgoing behavior.

Symptoms of bipolar disorder can vary from one individual to another.

Substance abuse may occur in either a manic or depressive state. When individuals are in a manic phase, they may use stimulants like methamphetamine or cocaine to prolong this high-energy period or depressants like alcohol or tranquilizers to calm down. In a depressive phase, sedatives or depressants may be used to calm feelings of hopelessness, while stimulants may be used to elevate mood.

More on Mental Illness and Substance Abuse

  • Psychotic Disorders
  • Neurodevelopmental Disorders
  • Trauma Stressor-Related Disorders
  • Personality Disorders
  • Sleep-Wake Disorders
  • Dissociative Disorders
  • Anxiety Disorders
  • Attention Deficit Hyperactivity Disorder
  • Depression Disorders

Causes and Risk Factors

Although the origins of bipolar disorder are still unknown, there are several underlying causes and risk factors that increase the likelihood of developing this disorder. Heredity appears to be one of the primary factors involved. According to the Depression and Bipolar Support Alliance, approximately two-thirds of individuals with bipolar disorder have one or more family member who also has a severe mood disorder.

Neurological factors also play a significant role in mood disorders like bipolar disorder. Brain chemicals called neurotransmitters, such as dopamine, norepinephrine, and serotonin, play critical roles in moods and energy levels. In people with bipolar disorder, these chemicals may be deficient or imbalanced, contributing to the severe emotional fluctuations and energy states. Hormonal imbalances and structural changes in the areas of the brain responsible for cognition and mood regulation have also been associated with bipolar disorder, according to Frontiers in Psychiatry. Current research indicates that there is no single neurobiological factor involved in bipolar disorder, but that there are several different pathologies that may trigger bipolar symptoms.

An individual’s environment can be a risk factor for developing bipolar disorder.

Children who grow up in stressful or abusive home environments may have a higher risk of developing mood disorders in adolescence or young adulthood, when the symptoms of bipolar disorder first manifest themselves.

A chaotic or violent living environment can continue to trigger mood fluctuations later in life. Chemical dependence, sleep deprivation, and other lifestyle factors also contribute significantly to bipolar mood swings.

Addiction and Bipolar Disorder

In an attempt to regulate these changes in mood and energy, individuals with bipolar disorder may abuse drugs or alcohol. According to the Journal of Clinical Psychiatry, up to 70 percent of people who meet the criteria for bipolar disorder also have a history of substance abuse — a percentage that far exceeds the general population. Substance abuse affects the outcomes of bipolar disorder in several ways:

  • Intensification of symptoms (mood swings, poor judgment, impulsivity, hostility, and irritability)
  • Longer episodes of emotional instability
  • Increased number of suicide attempts
  • Diminished quality of life

Treating bipolar disorder and substance abuse can be complex, requiring intensive attention to the symptoms of mental illness as well as the behaviors associated with addiction. The results of treatment for individuals with dual diagnoses, or a mental illness co-occurring with a substance use disorder, are generally much better if both conditions are treated at the same time, within the same program. In order to provide the most effective care, staff should be cross-trained in mental health care and substance abuse treatment.

Addressing Addiction and Bipolar

The Centers for Disease Control and Prevention notes that the psychological and physical impairment caused by bipolar disorder make it the most expensive behavioral health diagnosis, both in terms of health care costs and loss of quality of life. Individuals with bipolar disorder may feel misunderstood, stigmatized, or isolated because of their illness. The disorder can have a negative impact on all aspects of a person’s life, from occupational functioning to the quality of relationships. Having the support and concern of a close friend or family member can make a significant difference in the outcome of treatment.

Many people feel uncomfortable about broaching the subjects of mental illness and addiction with a loved one. However, it is important to remember that the course of addiction and bipolar disorder will rarely improve without professional intervention. Expressing concern to a loved one may feel awkward or embarrassing at first, but this conversation could make a significant difference in the outcome of the disease.

Too often, the official diagnosis of bipolar disorder comes years after the individual has first experienced symptoms. The Journal of Clinical Psychiatry states that most people with the disorder do not receive treatment until at least six years after having their first episode. Because of this delay, symptoms tend to be more extreme and relapse is more common in the early stages of treatment. Intervening on behalf of a loved one who is displaying the signs of bipolar disorder and substance abuse could prevent these unnecessary delays and expedite the process of recovery.

Exploring Treatment Options

Bipolar disorder is a complex psychiatric condition, especially when combined with a substance use disorder. Treatment should draw from multiple modalities and disciplines to address the client’s neurological, psychological, physical, and psychosocial needs. In addition to intensive individual therapy, clients with dual diagnoses of bipolar disorder and addiction can benefit from the following research-based interventions:

  • Motivational Interviewing (MI): Motivational Interviewing is a collaborative approach in which the therapist and client become partners in helping the client define sources of motivation and achieve self-defined goals. This positive, client-centered approach is especially useful in treating individuals who are working to recover from the effects of addiction. A study published in Issues in Mental Health Nursing showed that MI can help clients with bipolar disorder overcome ambivalent feelings about taking psychiatric medication.
  • Cognitive Behavioral Therapy (CBT): CBT addresses the learned thought patterns and destructive behaviors that contribute to addiction, depression, and anxiety. Clients learn to identify self-defeating thoughts and actions, and replace them with more positive, self-affirming coping strategies.
  • Solution-Focused Therapy (SFT): This practical, client-centered modality helps individuals with mental illness and addiction set and achieve specific goals. Rather than delving deeply into the origins of mental health issues or substance abuse, SFT focuses on measurable outcomes of therapy.
  • Trauma therapies: A history of trauma, childhood abuse, violence, or chaotic living environments can increase the severity of bipolar disorder. Trauma therapies such as Seeking Safety and Eye Movement Desensitization Reprocessing (EMDR) target the unprocessed memories and internalized fears that can intensify anxiety or depression.

For many individuals with bipolar disorder, medication therapy is highly effective at controlling symptoms. By stabilizing moods and restoring balance to energy levels, psychiatric medications can also help to curb the impulse to abuse alcohol or drugs. Medications must be selected and adjusted carefully, as certain types of drugs can trigger manic episodes or worsen depression. The antidepressants that are used successfully to treat major depression, for example, may not be effective at treating bipolar depression and can actually induce a manic phase in bipolar patients, especially if they are used without other medications. The most common drugs used to treat bipolar disorder fall into the following categories:

  • Mood stabilizers: Lithium is the most widely prescribed mood-stabilizing medication for bipolar disorder. Lithium is most effective at preventing or reducing the severity of manic episodes and may be prescribed in combination with other medications.
  • Anticonvulsant drugs: Anti-seizure medications such as divalproex (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol), and topiramate (Topamax) are also prescribed to prevent mood instability in individuals with bipolar disorder. These drugs are especially useful at reducing the frequency and severity of depressive episodes.
  • Antipsychotic medications: Quetiapine (Seroquel), risperidone (Risperdal), olanzapine (Zyprexa), and aripiprazole (Abilify) are some of the most common antipsychotic medications used to treat the effects of bipolar disorder. These medications help to minimize the delusional thought patterns and erratic moods that characterize manic phases.
  • Additional medications: In addition to psychiatric medications, pharmacologic treatment for bipolar disorder may involve medications that address the physical symptoms that can contribute to bipolar symptoms. These include certain blood pressure medications that slow down the activity of the central nervous system and medications that help to correct hormonal imbalances.

In order to provide comprehensive care for a client with a dual diagnosis, substance abuse treatment should occur at the same time, through the same program.

This integrated approach to treatment represents a departure from older schools of thought, which maintained that substance abuse treatment and mental health were separate, distinct fields. Today, integrated rehabilitation programs incorporate therapy for bipolar disorder and other forms of mental illness with addiction treatment. Addiction treatment services include:

  • Medical detox (inpatient or outpatient)
  • Inpatient treatment
  • Residential services
  • Partial hospitalization programs
  • Outpatient programs

In the early stages of rehab, many clients need the structure and supervision of an inpatient or residential treatment program. After establishing a foundation for recovery and completing the intensive, initial work of rehab, clients may make the transition to outpatient services, which provide more flexibility and autonomy.

Seeking Help

Both bipolar disorder and addiction are complex, multifaceted conditions that affect all aspects of the individual’s life. Like bipolar disorder, addiction is a progressive illness that increases in severity if left untreated. In order to provide comprehensive care and maximize the outcomes of therapy, a rehab program should offer services for both substance abuse and mental health treatment. With a combination of research-based therapeutic modalities, pharmaceutical interventions, and psychosocial services, the outcomes of bipolar disorder and addiction can improve significantly.


Generic Name: Topiramate (toe-PYRE-a-mate)

Drug Class: Antiepileptic, Antiseizure

Table of Contents

  • Overview
  • How to Take It
  • Side Effects
  • Warnings & Precautions
  • Drug Interactions
  • Dosage & Missing a Dose
  • Storage
  • Pregnancy or Nursing
  • More Information


Topamax (topiramate) is an anticonvulsant used to control and prevent seizures (epilepsy). Topiramate is used to treat seizures in adults and children who are at least 2 years old.

It is also used for migraine headache prevention in adults and teenagers who are at least 12 years old. This medicine will only prevent migraine headaches or reduce the number of attacks. It will not treat a headache that has already begun.

It works by helping change certain chemicals in the brain, which professionals refer to as “neurotransmitters.” It is not yet well-understood why changing these neurochemicals results in symptom relief for the conditions this drug is commonly prescribed for.

How to Take It

Topamax may be taken with or without food. Drink plenty of liquids while taking this medication. Take this medicine as directed and do not take more or less of it or more often than prescribed by your doctor. Continue to take this medicine even if you are feeling better.

Side Effects

Side effects that may occur while taking this medicine include:

  • lack of concentration
  • nervousness
  • dizziness
  • speech disturbance
  • anxiety
  • drowsiness
  • confusion
  • diarrhea

Contact your doctor immediately if you experience:

  • eye redness
  • increased eye pressure
  • chills
  • speech or language problems
  • memory impairment
  • rolling eye movements
  • convulsions
  • confusion

Warnings & Precautions

  • Before taking topiramate, tell your physician if you have any allergies to this medication or anything else.
  • If you experience a sudden loss of vision, eye redness or eye pain, or in or fluid in the eye, contact your physician immediately. Topamax can lead to serious eye problems that, if left untreated, could cause permanent vision loss.
  • DO NOT drive or use machinery while taking this medication until you know how it will affect you. Topamax could impair your judgment and make you feel dizzy and drowsy.
  • Let your doctor know your medical history, and if you have the following conditions: lung, kidney or eye problems, long term diarrhea, if your diet includes a lot of fat, or if you have osteoporosis.
  • Topamax might increase your body temperature and decrease your ability to sweat, which can result in a fever. Contact your healthcare provider immediately if this occurs.
  • For an overdose, seek medical attention immediately. For non-emergencies, contact your local or regional poison control center at 1-800-222-1222.

Drug Interactions

Talk with your physician or pharmacist if you are taking other medications. Avoid drinking alcohol.

Dosage & Missed Dose

This medication comes in tablets in 25 mg, 50 mg, 100 mg, and 200 mg. It is also available in extended release oral capsules in 25 mg, 50 mg, 100 mg, 150 mg, 200 mg. It may also be taken as a sprinkle capsule in 15 mg and 25 mg doses, that can be taken orally or sprinkled onto soft food.

Take your next dose as soon as you remember. If it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not double doses or take extra medicine to make up for the missed dose.


Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (preferably not in the bathroom). Throw away any medication that is outdated or no longer needed.


If you are using birth control pills, Topamax could make them less effective. If you plan on becoming pregnant, discuss with your doctor the benefits and risks of using this medicine during pregnancy. It is recommended that you DO NOT breast-feed while taking this medicine.

More Information

For more information, talk to your doctor, pharmacist or health care provider, or you can visit this website, for additional information from the manufacturer of this drug.


If there’s a way to safely drop lbs while relaxing on the couch and watching Real Housewives, that’s definitely something we want to know about.

Welp, some people say Topamax is that magic weight-loss bullet the world has been waiting for.

The drug was designed to treat and prevent seizures and migraines, but people who took it started to notice that they also lost weight on it. In fact, the makers of Topamax specifically list “weight loss” as a common side effect of taking the drug.

Still, this is a drug that’s made to help control seizures and migraines—not weight loss—which definitely raises a red flag if you’re thinking of taking it just to lose weight.

If You Take Topamax For Weight Loss, You’re Going Off-Label

The drug is approved by the Food and Drug Administration as being safe for treating seizures and migraines—but it’s not a drug that weight-loss physicians would usually recommend, says Peter LePort, M.D., a bariatric surgeon and medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in Fountain Valley, Calif. “It’s a serious medication,” he says. “Whether it’s safe to use for dieting is really up in the air right now.”

Worth pointing out: Topamax comes with a bunch of other potential side effects that you really don’t want to mess with. We’re talking an increased risk of suicidal thoughts, vision problems that can lead to blindness, an increase in the level of acid in your blood (which can lead to soft bones and kidney stones), and birth defects if you take it when you’re pregnant.

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People Who Take Topamax Do Lose Weight—But There’s A Huge Catch

A few studies have looked at Topamax and weight loss. One, which was published in the journal Diabetes Research and Clinical Practice, analyzed existing research and found that Topamax led to an average of seven and a half pounds of weight loss in obese patients with type 2 diabetes. But—and this is a big but—it increased the likelihood that a patient would have “serious adverse events” like the side effects we mentioned above.

Another meta-analysis of 10 studies published in the journal Obesity Reviews found that obese patients lost an average of 12 pounds on Topamax, compared to those who took a placebo. Those who took the drug for 28 weeks or longer had more significant weight loss than those who took it for a smaller amount of time. But again, the study conclusion mentions that side effects need to be considered.

“This is not a weight loss that’s going to happen in a week or two.”

And a JAMA meta-analysis and review of several drugs that could cause weight loss found that Topamax led obese patients to lose at least 5 percent of their body weight after taking it for a year.

Worth pointing out: Topamax hasn’t been studied for weight loss in a long-term, double-blind, placebo-controlled trial, which is the gold standard for research. It’s also only been studied in people with obesity, so it’s hard to say how it might impact someone who just wants to drop a little weight. And, again, there are those side effects, which every study seems to warn about.

Another thing you should know: It would take some solid time to lose weight with this drug. “This is not a weight loss that’s going to happen in a week or two,” LePort says.

As for whether this could work for long-term weight loss, LePort says that “nobody really knows.” But, he points this out, “what has mostly been found with weight-loss medications is they may work while they’re being taken—but the idea is not to take them forever. A lot of patients gain the weight back after they stop taking it.”

Would It Be A Horrible Idea To Still Be Interested In Taking It?

Potential side effects are the biggie here. While plenty of people take Topamax for its intended purpose and have no issues, others have pretty major ones. Also, you need a prescription for this, and it’s pretty unlikely your doctor is going to love the idea of prescribing this for weight loss when it’s designed to treat other health conditions.

So…it’s probably best to talk to your doctor about other options.

Korin Miller Korin Miller is a freelance writer specializing in general wellness, sexual health and relationships, and lifestyle trends, with work appearing in Men’s Health, Women’s Health, Self, Glamour, and more.

Advice & Tips: I have been on seizure control meds all my life, this is the first one that actually helped me lose weight instead of gain it. I’m not on very much Topamax, and the rumor I heard/read was that people using it gave it the name Dopamax. I’m a writer and artist. I depend on my brain, needing it to work properly so I can have a happy and functioning life. I take my 3 pills all at once, 75 mg, at night before bed so I can write during the day. It was the only way I could do it. I still feel sleepy at times but I don’t feel dopey… but I’m not on a lot either. The other thing I’d say is to be prepared for an entourage of strange sensory changes and sensitivities. I see in HD, as I like to put it, experience De Javu’ all the time now, see titles on book come off the cover as though I’m wearing 3D glasses all the time, I taste smell and taste certain things at certain times of the day like burning fabric or the smell of metals like iron. I also cough for no reason and I am sneezing all the time now and it’s not allergies… of which I don’t have any. Should you take this med, I’d say take lots of notes, start slow, and keep the communication lines very open with your doctor.

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