With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. Over the past couple weeks, we covered two commonly used atypical antipsychotics – Zyprexa (olanzapine) and Risperdal (risperidone). Because the Zyprexa post contains a great deal of information that applies to the atypical antipsychotics as a group, we encourage you to read it first.
Like Zyprexa and the other atypical antipsychotics, Seroquel (quetiapine) was developed primarily to treat schizophrenia and psychosis but is approved to treat acute bipolar mania, mixed episodes (mania and depression), and as a maintenance treatment for bipolar. Seroquel can improve symptoms of schizophrenia and psychotic breaks that may occur in bipolar, including the following:
- Hallucinations (audio and visual)
- Disorganized thinking
It may also improve conditions such as social isolation, limited motivation, and reduced speech activity for some people.
Seroquel can also improve symptoms related specifically to mania, including the following:
- Elevated mood
- Racing thoughts
- Inflated self esteem
- Decreased need for sleep
Like other medications in this class, Seroquel can help in the treatment of bipolar in two ways – by treating the mania and by reducing cycling (the switch from baseline mood into either mania or depression).
Seroquel has also received an FDA indication specifically to treat bipolar depression. It appears to have some antidepressant effect that may be quite useful in bipolar disorder because it reduces rather than increases the risk of mania at the same time.
Caution: Especially in child psychiatry, we must carefully weigh the risks of these medications with their potential benefits. The metabolic issues with weight, insulin, and lipid changes can cause significant life problems for individuals on Seroquel. If someone is diagnosed with schizophrenia, they will have to take something in this family and manage the risks. In bipolar disorder, however, other medications may be available that will work as well, but this family of medicine often becomes essential to managing the illness.
Most patients take Seroquel two or three times each day. For bipolar disorder, your prescriber is likely to start you on a low dose (perhaps as low as 25 to 50 mg twice a day) and then increase your dose by 50 to 100 mg per day until you are taking between 300 and 400 mg daily. (If you have low blood pressure, poor liver function, or are elderly or in a weakened condition, your prescriber may ramp up the dose even more slowly.) Depending on how well it works at these levels, your prescriber may keep this as the maintenance dose or raise it. The maximum dose listed by the manufacturer is 800 mg per day, but prescribers may use more than that in certain situations.. As always, follow your prescriber’s advice and instructions.
In my practice I often choose Seroquel if I am concurrently treating depression and/or anxiety with mania or dysregulation. It appears to have some antidepressant benefits, and many prescribers think of it when trying to reduce severe anxiety that hasn’t fully responded to other interventions. Seroquel is sedating, so it can be used as a sleep aid, but since it is so strong and has so many potential side effects, prescriber and patient should review this decision carefully.
Potential Side Effects
Like other atypical antipsychotics, Seroquel has the potential of producing negative side effects, including the following:
- Seroquel is one of the more sedating of the atypicals – fatigue and dizziness are not uncommon when someone first takes Seroquel.
- Weight gain is the most prominent and unpleasant side effect.
- Increased risk of developing metabolic syndrome (pre-diabetes) and diabetes and problems with sugar metabolism.
- Increased cholesterol and other changes in fat and lipid metabolism.
- Movement problems like Parkinson’s disease (tremors and stiffness), although the risk is lower than with other atypical antipsychotics and older antipsychotics.
- Irreversible uncontrolled movements called tardive dyskinesia – facial twitches or uncontrolled movements of the tongue, lips, arms, or other body parts (lower risk than older medications).
- Changes in cardiac rhythms.
Unlike most other atypical antipsychotics, Seroquel does not increase levels of the reproductive hormone Prolactin. Many other atypical agents do increase this hormone, which can affect menstrual cycles.
You may have seen Seroquel and AstraZeneca (the pharmaceutical company that manufactures it) in the news over the past several months. On May 14, 2008, AstraZeneca announced that the FDA had approved Seroquel for maintenance treatment in bipolar disorder. On July 1, 2008, the company announced a summary judgment granted for Seroquel patent litigation. And it announced on October 10, 2008 that the FDA had approved Seroquel XR (extended release) for the treatment of bipolar depression and mania. For more about Seroquel, visit AstraZeneca’s Seroquel Page.
If you’ve taken any form of Seroquel for bipolar disorder or are a doctor who has prescribed it, please share your experiences, insights, and observations.