Bipolar Disorder Treatments and Drugs

Bipolar Disorder Treatment Options

The good news is that treatment for Bipolar Disorder helps many people-even those with the most severe forms of bipolar disorder, to gain better control of their mood swings and other bipolar symptoms. A typical, effective, plan for treatment includes a combination of psychotherapy (also called “talk therapy”), and some type of medication.

No Quick Fixes

Bipolar disorder is a lifelong illness. Unfortunately, episodes of depression and mania often return over time. However, typically, many people with bipolar disorder are free of mood changes between episodes. Some people may have lingering symptoms. In the long-term, most people with bipolar disorder need continuous treatment to help to control any symptoms that arise.


Use of Medications for Bipolar Disorder

Bipolar Disorder Treatments and Drugs

Different types of medications are available that can help control symptoms of bipolar disorder. Oftentimes, those with Bipolar Disorder may need to try several different medications before finding ones that work best for them.

Medications generally used to treat bipolar disorder include:
  • Mood stabilizers
  • Atypical antipsychotics
  • Antidepressants


Those taking these medications should:

Make sure they take the time to talk with their pharmacist or doctor so they can understand the benefits and risks of the medication.

Do not suddenly stop taking a medication without first  talking to your doctor, because doing so may lead to “rebound” or worsening of the symptoms of bipolar disorder, and other uncomfortable or potentially dangerous withdrawal effects.

Immediately report any side effects or concerns to their doctor. The doctor may want to try a different medication, or adjust the dosage of the medication.


When done in combination with medication, psychotherapy (also known as “talk therapy”) can be an effective treatment for Bipolar Disorder. A professional therapist trained in helping people with Bipolar Disorder can offer support, education, and guidance to people with Bipolar Disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

  • Cognitive behavioral therapy (CBT)
  • Family-focused therapy
  • Interpersonal and social rhythm therapy
  • Psychoeducation

Other Treatment Options

Electroconvulsive Therapy (ECT)

This form of treatment has been proven to provide relief for people with severe bipolar disorder who have not been able to recover with other treatments. Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make taking medications too risky. Some short-term side effects can be seen with ECT such as confusion, disorientation, and memory loss. We recommend you discuss with your doctor the possible benefits and risks of using ECT.


Sleep Medications

Those with bipolar disorder who have trouble sleeping typically find that treatment is helpful. And in the case where sleeplessness does not improve, your medical provider may suggest a change in medications. If the problem continues, the doctor may prescribe sedatives or other sleep medications.



We do not recommend the use of supplements as there is not enough research done on natural or herbal supplements and their effect on bipolar disorder.

If you are taking any supplements we recommend that you let your primary care doctor or psychiatrist know about these and any over-the-counter medications because certain supplements taken together with medications may cause drug interactions that can be dangerous.


Getting Help For Bipolar Disorder

Your primary care physician or family doctor is the best resource to start so that any medical issues which may be impacting you can be ruled out.

They will typically refer you to a mental health practitioner. Ideally, if you suspect you have symptoms of Bipolar Disorder-you should request any provider you see has this specialization. In addition, to exploring medications through a psychiatrist, as mentioned above, some form of talk therapy have been shown to be helpful through the treatment process.

If you, or a loved one is in crisis- call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is available to anyone and all calls are confidential.

If you would like to make an appointment to see our Integrative Psychiatrist for Bipolar Disorder and learn more about Bipolar Disorder Treatments and Drugs, call us at 713.426.3100.



Is Seasonal Depression Affecting You?

What To Do About The Holiday Blues?

seasonal depression

What are they and how do they affect us?

Many factors can lead to what we describe as the holidays blues: headaches, insomnia or sleeping too much, excessive worrying, difficulties concentrating, decreased interest in things that are normally enjoyable. They are usually transitory but sometimes they can trigger periods of feeling anxious and depressed that needs to be addressed with a therapist or psychiatrist. Many factors can lead to what we describe as the holidays blues: headaches, insomnia or sleeping too much, excessive worrying, difficulties concentrating, decreased interest in things that are normally enjoyable. They are usually transitory but sometimes they can trigger periods of feeling anxious and depressed that needs to be addressed with a therapist or psychiatrist.

Below, are some of the most common causes of these sad or anxious feelings around the holidays that affect what is supposed to be a time of joy and celebration. Below, are some of the most common causes of these sad or anxious feelings around the holidays that affect what is supposed to be a time of joy and celebration.

    1. Anniversaries of losses such as deaths, departures and breakups. Most people who lost the dear ones, either to death, illness, breakups or departures, anticipate the holidays as a time that instead of being happy, reminds them that their loved ones will not be around this time of the year. Family gatherings are vivid reminders of the person who is not present. Especially the first year after the loss, each holiday becomes an acute reliving of the painful feeling of separation and longing.

We recommend to our patients that they use these times to celebrate the life of their loved one, and reflect on the way they positively impacted the people that they left behind. By focusing on celebrating their lives rather than on the sad separation could help make the holiday times more bearable. We recommend to our patients that they use these times to celebrate the life of their loved one, and reflect on the way they positively impacted the people that they left behind. By focusing on celebrating their lives rather than on the sad separation could help make the holiday times more bearable.

    1. Remembering the happy times that are gone from the present is more common with people whose present lives are not ‘as happy’ as in the past with their departed loved one. Economic hardship, changed family dynamics and transitions through later stages of life can make these times difficult.

What we recommend is to try to spend as much time as possible with the remaining loved ones, focusing and cherishing the warmth and benefit of having healthy relationships, and on the positive light and influence in their lives.

    1. Seasonal depression is mostly seen in the parts of the world further away from the Equator. Some people are more sensitive to the diminished light during the winter months, which appears to decrease the internal brain production of serotonin.

We often suggest “light therapy” or phototherapy which is administered through light boxes which give off specific wavelengths of light, and are administered for a prescribed amount of time. Exposure to this light can result in reduced symptoms of decreased energy, increased appetite and drowsiness associated with this form of depression.  Providing light therapy through light boxes can reduce the symptoms of decreased energy, increased appetite and somnolence associated with this form of depression.

    1. Dealing with dysfunctional families. Some people anticipate with almost despair spending time with members of their family that they simply do not like, or have had previous, unhealed conflicts.

What we recommend is to attempt controlling only the things that can be controlled, such as the time and place where the gathering happen, keep any statements made to ‘I’ without assigning blame, and actively listening and avoiding ‘hot’ topics.

    1. Breakdown of routines during the holidays. Most people’s schedules becoming hectic and disorganized during the holidays, and neglect healthy routines such as exercising, eating healthy and allocating time for themselves.

What we recommend is to treat yourself first with a healthy regimen; avoid excessive consumption of alcohol or unhealthy foods, and keep a regular exercise and sleep schedule.

The bottom line is that the holidays do not have to be a time that causes you anxiety and sadness. Although some of this is natural, there are things you can do to lessen the severity.

For some people, taking the above steps is not enough, and there are other options that you can explore which include counseling, medication and other forms of intervention.
If you’d like to get some help in coping-please call us to set up a time to talk at 713.426.3100

Homocysteine and Depression: What You Need To Know

Ask your psychiatrist if Homocysteine could be contributing to your depression…

homocystein and depression

What is HCY?

Homocysteine (HCY) is an amino acid that is destructive to cell integrity and DNA, and is a risk factor for the development of vascular and neuropsychiatric pathologies.

HCY has been linked to cardiovascular diseases, but when it passes the blood-brain barrier, it contributes to other chronic disorders such as depression, dementia, bipolar disorder, schizophrenia, and acute events, like strokes.

Where do these amino acids come from? HCY is not obtained from the diet – it’s not present in a naturally occurring protein. An amino acid found in a normal diet, called methionine, is broken down to either cysteine (a ‘good’) amino acid or homocysteine (the ‘bad’ form).

What causes HCY Toxicity?

The mostly commonly suggested mechanisms are oxidative injury, direct vascular damage, impaired methylation and impaired DNA synthesis. Another possible mechanism is the possibility of a heightened the inflammatory process, which is associated with depression.

Causes for elevated HCY can be genetic, epigenetic, and environmental and lifestyle-related.

The most common causes of elevated HCY:

  • smoking
  • excessive alcohol consumption
  • lack of exercise
  • obesity
  • some medications
  • psychological stress

Exercise helps distribute the HCY more evenly throughout the body, facilitating metabolism.  Poor vitamin intake makes it impossible for the metabolism of homocysteine to a ‘good’ form (cysteine). Decreased magnesium levels also slows down the metabolism of HCY. Lipid lowering medications or anticonvulsants impair the HCY metabolism as well. Genetic predisposition, like a mutation in the MTHFR enzyme can also decrease the ability of the body to metabolize HCY efficiently (TT and CT are the most variants shown to be associated with depression).

Why and how is this important for the treatment of depression?

Based on the theory of impaired metabolism of HCY, the low monoamines levels (serotonin, dopamine, norepinephrine) are related to the lack of important coenzymes that are necessary for the metabolism of HCY and the synthesis of neurotransmitters.

The coenzymes necessary for the HCY reduction are fully metabolized B vitamins. If a patient with depression is genetically predisposed to not be able to metabolize them (such in CT and TT variants of MTHFR) then they will have high levels of HCY, which may cause a higher level of inflammation and neurotoxic effects on the brain.

How can we individualize the treatment of depression?
  1. Check for the MTHFR mutation. Although it is not the only etiological factor, it can suggest a polymorphism contributory to the inflammation and depression.
  2. Supplement treatment with antidepressants by adding metfolate at 15 mg/day. Depression has been associated with reduced metfolate. Supplementing can help the HCY metabolism, reducing its toxic effects on the brain.
  3. Supplement with complex B vitamins and other necessary micronutrients. Maximizing methylation with reduced complex B and micronutrients necessary in the metabolism of HCY. Many patients can benefit from this supplementation even in the presence of HCY and because they are safe, they should be more largely used as a routine addition to the antidepressant treatment.

If you like this article on Homocysteine and Depression, or have questions, schedule your first session by calling us at 713.426.3100.


  1. Homocysteine and Neuropsychiatric Disease: Angela Pana, MD, Psychiatric Ann. 2015;45(9):463-468.
  2. Inadequate Homocysteine Metabolism: A theory of Depression, Andrew Farah, MD. Psychiatr. Ann. 2015;45 (9): 469-472.
  3. Theory into Practice-Addressing the Homocysteine Basis of Depression. Andrew Farah, MD Psychiatr. Ann. 2015;45(9):473-477.


Depression and Inflammation: What You Need To Know

Ask your psychiatrist if inflammation could be contributing to your depression…

depression and inflammation

In the last few years there has been an increased interest in the link between depression and inflammation. More and more research has been done to understand depression better and find other ways to combat it besides using antidepressant medications. Depression is the most widely spread cause of disability in the world, and these medications do not always work for everybody.


Inflammatory Disorders and Depression

One of the many things pointing to the relationship between depression and an inflammatory process is the fact that depression is frequently associated with other inflammatory disorders such as autoimmune diseases, cardiovascular disorders, diabetes and cancer.

Another important finding is that inflammatory markers are associated with major depressive disorder (MDD). One in five persons with cardiovascular diseases experiences MDD. Up to 70% of patients with autoimmune disorders experience MDD. About 15-20 % of cancer patients also have depression. Diabetes doubles up the rate of depression. Many meta-analyses studies show that individuals with MDD have significant increase in inflammatory markers like TNF-alfa and IL-6.


Stress and Inflammation

Since depression can develop in the absence of other inflammatory diseases, one theory is that stress (acute and chronic) is associated with the increased availability of proinflammatory citokines. Psychological stress can activate inflammation; however, depressed patients have difficulty controlling the body’s inflammatory response to stress. When the inflammatory pathway is initiated, a cascade of reactions results that decreases the serotonin level and boosts the glutamatergic response; thus creating depressive symptoms.


How Does This Apply to Depression Treatment?
  1. This medication helps decrease immunotherapy-induced depression, reduce the inflammatory response, and lower the pro-inflammatory factors.
  2. Stress Management. Managing stress effectively and proactively decreases inflammation.
  3. Healthy Diet. A diet rich in vegetables, fruits and Omega 3 is helpful in reducing inflammation.
  4. Exercise. Aerobic exercise has a well-documented impact on reducing inflammation and acts as one of the best destressors.

If you like this article on Depression and Inflammation, or have questions, schedule your first session by calling us at 713.426.3100.

  1. Depression and Inflammation: Examining the link: Maria Almond, MD, MPH Current Psychiatry, vol 12, no 6, 25-32.

Can Exercise Help Depression?

Physical Activity and Lifestyle Changes as Adjunctive Treatment for Mental Illness

exerciseanddepressionWhen it comes to helping people cope with depression, the most commonly recommended treatments for most are usually either therapy alone, or counseling combined with prescription medications. These forms of treatment are often effective in helping people to manage the symptoms.

Research on Depression: What Works?

However, research on depression, anxiety, and exercise shows that the psychological and physical benefits of exercise can also help reduce symptoms of depression and anxiety, and even help people manage other conditions such as diabetes, high blood pressure, and arthritis.

A study by S. Rosenbaum et al. published in the Journal of Clinical Psychiatry (Sept 2014) showed that physical activity reduced depressive symptoms in people with mental illness. Physical activity has been researched more in recent years showing that when incorporated in a holistic approach to the treatment of mental illness it has the result of augmenting the action of the antidepressants, and speeding up the response to treatment.

What I See In My Practice In Patients With Depression

While some studies suggest that exercise can be a substitute to the pharmacological treatment, what I found in my clinic is that only a certain subset of patients with depression respond to physical activity only; those with depression that is milder in severity. However for moderate to severe depression I find that the addition of exercise to the medication regimen and other changes in lifestyle, make the recovery more robust and sustainable.

Physical Activity Defined

Physical activity was defined for the purpose of the above study as ‘any body movement that is produced by the contraction of the skeletal muscles that increases body energy expenditure’ and exercise as ‘a subset of activities that is planned, structured, and deliberate’. The simplest form of regular exercise that could still make a change in the treatment of depression is walking at a brisk pace, for at least 25 minute a day for a minimum of five days per week.

Challenges for People With Depression

People who struggle with depression know that what may seem to be a simple task, taking a walk, or working out, becomes a difficult one. Especially those with moderate to severe depression, due to the fact that some of the common symptoms include: lack of initiative, decreased energy, difficulty making decisions, thoughts of life not being worth living, etc. These symptoms make taking that first step toward regular exercise extremely difficult.

More Challenges Seen In Depression

Another common form of resistance for those with depression is the reluctance to initiate a change, even one that could potentially be helpful. I hear a recurrent complaint of ‘the lack of time’. For the depressed patient in the midst of their depression, it becomes increasingly difficult to attend to the required activities of going to work, attending to the children, cleaning the house, and taking care of themselves. Usually, they are the last ones to take care of themselves, especially if they are feeling mentally tired and physically exhausted.

Ways to Break Through The Challenges of Depression

Get Support and Encouragement


Rather than add exercise as one more task to add to the ‘to do list’, what I find the most helpful is to ask the patient to rely on a friend or a family member to support and encourage them to set a goal and start working towards it.

Schedule Exercise; Start Small And Build

Usually, I recommend people start with just allocating 10 minutes a day in their daily schedule for ‘exercise’. Even for a short distance of 100 yards is enough to start, but keep the mind aligned with a final goal of walking 25 minutes at a brisk pace every morning, if possible. I ask them to start with this small step, dividing the main goal into smaller ones that are more easily attainable. Accomplishing a small task becomes rewarding, and initiating it is less overwhelming. What I found is that when the window of time allocated for exercise exists in one’s schedule, increasing the amount of time or the intensity of the exercise is easy to adjust in a stepwise approach.

Take Time For Yourself

We all know that we can best help others if we take care of ourselves- so it is important that we make the time for ourselves a priority. Walking is really helpful in increasing the sense of planning, and actually doing something for one self which is extremely healing for the depressed patient who perceives him/herself as not worth it, a burden, and contemplating death.

Take Time To Reconnect With Others

Walking can also provide distraction from our negative thoughts- especially when done with a companion. It helps create a sense of connection with people and with our surroundings as well.

Physical Effects of Exercise

When done at a fast pace, exercise increases the heart rate high enough to provide aerobic benefits, including the production of the endorphins that often help you feel happier and more relaxed. When exercising regularly, people also begin feel better about their appearance which can boost confidence and improve self-esteem. And most importantly, exercise improves your chances of living a longer and healthier life.

Holistic Approaches to Treatment; Other Ways to Manage Depression

In addition to exercise, I encourage my patients to consider other lifestyle changes that can help manage depression. These include healthy nutrition practices, getting good sleep, increasing their social support, and practicing stress reduction techniques. I will talk more about these practices in future articles. So to answer the question can exercise help depression, yes it can, but also explore other options to maintain improvement in mood, energy level, and overall health.

Contact us to learn more about can exercise help depression and treatment options by calling us at 713-426-3100.




Major Depression Treatment and TMS

Major Depression and TMS: Stories From The TMS World

SG is a 53 year old woman, very successful professionally who has been treated for depression for many years and had a hard time taking the antidepressants. Some of them made her feel confused and some of them made her gain weight. She felt torn between taking medication to feel better and struggling with the side effects. At one point she was taking more than five medications for what was considered a refractory to treatment depression. Eventually she found that taking only Wellbutrin helped her to feel better, without feeling ‘medicated’. However her mood was never back to how it was prior to those four episodes of the depression that started occurring in her twenties. She had to give away some of her hobbies, because of the lack of pleasure in doing them, her drive was lower, and she was more fearful of trying new things. She felt that sleep was a good way of not thinking about how life used to be, therefore had a difficult time getting out of bed in the morning.

When her daughter brought her in for the TMS (transcranial magnetical stimulation) evaluation, to discuss the procedure, its pros and cons, she was already reluctant to try something new. The depression itself makes people feel like burdens on their families, and the cost of the procedure made her feel guilty about even considering it. Her negative pattern of thinking made her believe that most likely the results will be null, and on top of everything she felt that ‘at her age’ what else can she expect from life. She was also fearful that the TMS might make her depression worse.

Eventually the family convinced her to give TMS a try and she accepted. For the first two and half weeks she didn’t notice any difference and her guilt and doubt about accepting the treatment increased. We reassured her that most people start to see a response around the third week of the treatment.

Towards the end of week three she was still apprehensive about starting the weekend, but Monday she came back and said that the weekend wasn’t bad at all. For the first time in many years she got out of bed and did things without ‘having to push herself to do it’. She didn’t have to convince herself to go and shop for the groceries; she just got out of the house, did the shopping and even enjoyed it. She started cooking for the family and, for the first time she started thinking about gardening again. Not only did she notice an improvement but the family also noticed the change as well. She started waking up earlier in the morning without dragging around the thought of a new day. She started bringing her book and read during her sessions.

At the end of her thirty sessions of TMS the psychometric scales used to track her progress showed marked improvement, to what is considered remission of symptoms. She continued to take Wellbutrin as a maintenance medication, and her mood remained stable at a higher level of functioning than before.



This can be quite a challenge for the treating psychiatrist and we’ll see why this is a more difficult task then in addressing the same psychiatric problems in adults.

When do we suspect depression in children and adolescents?

Depressed adolescents and children may show some of the several symptoms: frequent crying, feelings of hopelessness, low energy, persistent boredom, social withdrawal, increased irritability and anger, poor performance in school major changes in sleeping, extreme sensitivity to rejection and failure, loss of appetite or overeating, suicidal thoughts, self-harming behavior, difficulties concentrating.

A study done by a group of researchers at the University Of Cincinnati College Of Medicine, suggested that having a depressed mood at baseline would predict obesity at a follow ups. Depressed adolescents have an increased risk in developing and maintaining obesity during adolescence.

The most important factor that seem to contribute to that is overeating as a result of the negative emotions. Inactivity, psychomotor retardation, also could contribute to excessive accumulation of fat. Disrupted sleep also appears to be a risk for weight gain. Poor self-image and low self-esteem, the hallmarks of depression seem to contribute to the choice of peers. Studies show that overweight teens were twice as likely to have overweight friends, as non-overweight peers.

Treatment of depression seems to be the preventive way to stop the development of obesity, by recognizing the symptoms of depression early. Once the obesity is developed, the treatment encounters the difficulty of finding an antidepressant that would not cause weight gain.

The issue of noncompliance is very high in children and adolescents, strongly related to their cognitive and psychological development. The sense of invulnerability to sickness or death, and also, sometimes, the delay in the development of the abstract thinking, hinder the acquiring of proper understanding of the process of depression as an illness.

In addition to that, most antidepressants share the side effect of possible weight gain, except Bupropion, that has a weight –loss side effect. It would seem the antidepressant of choice for this group of population, if the depression is not associated with severe anxiety and the patient and their family is made aware of the non FDA use of it in this age group. The other two antidepressants approved for the young ages are Fluoxetine and Escitalopram, both of them having the potential weight gain.

The strategies to offset the risk of weight gain with antidepressant have to focus on the patient education as well as nutrition counseling and the introduction of an early exercise program. The patient and their family have to be encouraged to ask questions about the treatment and the risk involved.

If you like this article on depression in overweight and obese teenagers, or have questions, schedule your first session by calling us at 713.426.3100.

Treating Depression During Pregnancy

How to Treat Depression During Pregnancy

‘Do we use medication to treat depression during pregnancy or no?’ This is the question that every psychiatrist faces even when she or he doesn’t particularly specializes in reproductive psychiatry. The question applies equally for planned and unplanned pregnancies.

There are several scenarios that seem to repeat more commonly in clinical practice, and according to the situation, the psychiatrist might give a different advice. While the following are the most frequent scenarios, potential and present pregnancies should be discussed with the primary care physician, obstetrician and psychiatrist.

1. Patient has been diagnosed with depression, treated to a remission state for more than two years, would like to start planning for a family. The most common question asked is, if she should continue the treatment while conceiving or should stop it during the conception period. The ideal situation would be to conceive while off medication if the remission could be maintained. If the mother would like to be off medication, then the risks of relapse should be discussed as well as a plan to restart the medication if that relapse occurs.

The medications should be tapered off and not instantly stopped. If the patient would like to stay on medication to avoid the risk of relapse, then the regimen should be reviewed, and changes should be made towards less teratogenic alternatives ( i.e. switch from Paxil-category D to Prozac – category C).

Also, Depakote or Tegretol should be avoided as mood stabilizers, or high doses of Folic acid should be added to prevent potential neural tube related malformations (folic acid in doses of 4 mg, instead of the commonly used dose of 1 mg per day, used in pregnant women without mental illness).

2. A patient who has an unplanned pregnancy while on medication for depression is most likely to ask if she needs to change or stop the medication at that point. Usually when the pregnancy is confirmed the fetus is about 4 weeks old and the effect of the medication most likely already has taken place. In that situation the current consensus is to not change to a different medication in order to avoid exposure of the fetus to two antidepressants vs. only one.

3. A patient who is stable during the pregnancy on her antidepressants might ask if she should breastfeed or if she should change medication while breastfeeding. The most commonly researched antidepressant in breastfeeding is Zoloft, therefore this would be the medication of choice if the treatment targets postpartum depression. However, if the pregnancy and delivery went well on a different antidepressant (i.e. Cymbalta or Prozac) the most likely recommendation would be to continue the use of the same drug since the baby had an in utero exposure already.

4. During the pregnancy, the psychiatrist should counsel the mother that an increase in dosing might be necessary to keep symptoms in remission, because of increased volume of distribution, and the dose should be adjusted again before delivery and immediately postnatal. Because of the risk of inducing neonatal hypertension, some psychiatrists would decrease the SSRI dose in the same trimester, to decrease the risk.

While this is just a short review of using antidepressant in pregnancy, one should be aware of other biological treatments available, less invasive, such as TMS (transcranial magnetical stimulation) or light therapy, that could be a safe alternative to medications.