There is a wide range of medications available to treat bipolar disorders, and they work with varying degrees of effectiveness in adults. Perhaps the biggest problem that people with bipolar disorder have with medications is refusing to take them. Noncompliance isn't entirely the patient's fault. Some doctors, especially those who don't have a lot of experience in treating bipolar disorders, don't research medications very carefully. They forget to check for interactions with other medicine a patient might be taking for asthma or the flu. They start medications at doses that are far too high, causing side effects that the patient naturally refuses to tolerate. They don't explain enough about recognizing and preventing side effects.

Such is the state of medicine. It's a lucky patient who gets full information about a medication in the doctor's office and reliable follow-up while he continues to take it. The rest of us have to research and monitor efficiency and side effects on our own. Acting carefully increases compliance, and that can be crucial for your child's health.

Dosage details

When it comes to children, there is one dosage rule that should almost always be followed: start low, and go slow. If a patient is given too high a starting dose, or if medications are increased to the full therapeutic dose over just a few days, difficult side effects are far more likely to occur. Gradual titration (increase in dosage) over a period of weeks can make all the difference, even though patients are less likely to see dramatic, positive effects right away.

If possible, only one medication should be started, added, or increased in dose at a time. You shouldn't make major dietary changes or start taking an herbal remedy, vitamin, or supplement at the same time as starting a new medication. Otherwise, it's hard to tell what the culprit is, should a side effect occur.

Nathan has taken Zyprexa and Remeron, and both caused extreme weight gain. He has been on lithium, Tenex, and risperidone at once, which was no help; Depakote and Dexedrine, no help; and clonidine, Prozac, Zyprexa, Dexedrine, Ambien ( for sleeping ) all at one time, which caused severe mania. --Cindy, mother of 16-year-old Nathan (diagnosed bipolar disorder, OCD, ADHD, post-traumatic stress disorder, chemical dependency, bulimia)

It doesn't help that drugs often come in one size only. Even the least powerful pill may be too much for some patients to start with. Surprisingly, many doctors are unaware of options that can help. These include:

• A number of psychiatric medications, including Prozac, Haldol, and Risperdol, are available in liquid form. Liquids can be measured out in tiny doses and increased very gradually. Incidentally, liquid medications can be easily administered to children who refuse pills. You may even be able to mix them with food or drinks (check with your pharmacist first).

• Some medications can be broken into fractions. Pill splitters are available at most pharmacies for just this purpose. Make sure that it's okay to split a medication before you go this route, however: time-release medications and some pills with special coatings will not work properly when broken. Generally speaking, if the pill is scored down the middle, you can split it. If it isn't, ask your pharmacist or call the manufacturer's customer hotline.

• Some pills that are too small or oddly shaped to split can be crushed and divided into equal parts. Again, ask your pharmacist before doing this, as it's difficult to get precise doses with crushed pills. Tiny mortar and pestle sets can be found at health food or cooking shops. You can buy empty gel caps to put the powder in, or you may be able to mix it into food or drink.

Compounding pharmacies make medications to order in their own lab. For example, they can make a liquid version of a prescription normally available in tablet form only. These pharmacies are especially helpful to individuals with allergy problems. Many pills and syrups contain common allergens, including eggs, soy, corn, and dyes. If a hypoallergenic version isn't available from the manufacturer, seek out a compounding pharmacy. If there isn't one where you live, several allow patients with valid prescriptions to order over the Internet. Just use a search engine like AltaVista, http://www.altavista.com/ or Lycos, http://www.lycos.com/ to search for the term "compounding pharmacy." As always with Internet-based or mail-order businesses, check references before you pay for goods or services.

Follow any instructions about eating or drinking before, with, or after your medication. Also, avoid taking medications with grapefruit juice--it may sound nutty, but grapefruit juice can prevent the breakdown of certain medications.

Keep an eye out for unusual symptoms, and let your physician know about your concerns right away. Most people remember to do this when they first start taking a drug, but forget about it after they've had the same prescription for a long time. Vigilance is especially important when using newer medications. The FDA and similar government bodies in Canada and Europe require studies showing new medications are effective and safe in the short term. Long-term studies are expensive, and because they're not required, they are rarely done. In other words, with any medication introduced in the past ten or twenty years, real-life patients are the long-term study subjects.

Prescription notes

• AC: take before meals (ante cibum)

• BID: take twice a day (bis in die)

• gtt: drops (guttae)

• PC: take after meals (post cibum)

• PO: take by mouth (per os)

• PRN: take as needed (pro re nata)

• QD: take once a day (quaque die)

• QH: take every hour (quaque hora)

• QID: take four times a day (quarter in die)

• Q(number)H: take every (number) of hours

• TID: take three times a day (ter in die)

• ut dict: take as directed (ut dictum)

Discontinuing medication

Ask your doctor if there are any symptoms you might expect during the withdrawal period. She might be able to recommend over-the-counter or dietary remedies for likely problems, such as diarrhea or nausea. Decide in advance on non-medication strategies for dealing with problem behaviors and bipolar symptoms that may occur as drugs are tapered off.

Gradually tapering off to a lower dose and then to none is almost always the best approach. Patients should be carefully monitored for signs of trouble. In some cases (such as for discontinuing benzodiazepine tranquilizer use after several years), medication withdrawal may need to take place in a hospital setting or under extra-careful home supervision.

Blood tests and EKGs

These tests return a number indicating how much of the medication is found in the blood. Your doctor compares this level to a chart of therapeutic blood levels: amounts of the medication that have been found to be effective in patients of various sizes and ages. Be sure to find out where your child's therapeutic blood level and current blood level are. Often some other tests of body function are run at the same time as the lithium level is taken, such as thyroid function tests. A physician's assistant or nurse can help you understand what all of these test results mean. Try to learn how to read and understand these figures yourself--many times observant parents have caught mistakes that could have been dangerous. Typical problems include blood assessed with the wrong blood test, misinterpreted levels, and getting someone else's paperwork.

In order to be really successful at living with the illness and the lithium, I've had to really become aware of my internal body. I always know roughly how much lithium is in me at any given time. I used to play a game and predict my level before getting a blood draw. I was almost always right, and knew when I was at .5, .7, or .9. If I want to I can actually tweak my meds a little bit and get the number I want to. --Troy, age 30 (diagnosed bipolar I disorder)

Good phlebotomists (blood-draw specialists) do not cause bruising or more than a twinge of pain when they do their job, unless the patient bruises very easily or has a low pain threshold. If this is the case, let the phlebotomist know--she may have a better way to obtain the sample. Numbing ointments can help.

Patients who do not have regular access to quality lab facilities, such as those living in remote areas, may have a very difficult time keeping up with this testing schedule. Talk to your healthcare provider about alternative ways to handle the need for monthly testing, such as having a visiting home-health nurse do the blood draw in your home and then mail the vial to a lab for testing.

In some cases, liver or heart function should be tested before your child starts taking a particular drug. Liver function is assessed with a blood test that checks the level of certain enzymes, while heart function is usually assayed with a regular blood-pressure test, a physical exam, and an electrocardiogram (EKG).