Mood Stabilizers



Excerpt from Cafer's Mood Stabilizers and Antiepileptics



Mood Stabilizers                                            



Mood stabilizers are used to treat bipolar disorder (type I and II). They can also be used off-label for mood swings characteristic of borderline personality disorder, preferably as an adjunct to Dialectical Behavior Therapy (DBT). With the exception of lithium, all mood stabilizers are antiepileptic drugs (AEDs). When stopping any AED, it is important to taper gradually. Abrupt discontinuation of an AED may cause a seizure, even with individuals without epilepsy. 



Mood Stabilizer / monthly cost
Blood levels
Recommended lab work 
Comments 
Lithium                                 
   Lithium IR (ESKALITH)
   Lithium ER (LITHOBID)     
   Lithium Citrate Syrup     


$5
$20
$100
0.6–1.0
for maintenance 


1.0–1.4 
for acute mania
Lithium level
TSH (hypothyroidism)
CMP (renal insufficiency)
EKG if cardiac disease
Pregnancy test (Ebstein’s anomaly)
Most effective medication for prevention of mania recurrence and lowering risk of suicide; Narrow therapeutic index; Risk of renal damage; Neuroprotective
Valproate
   Divalproex DR (DEPAKOTE)   
   Divalproex ER (DEPAKOTE ER)  
   Valproic Acid (DEPAKENE) syrup  


$15
$40
$25
50–100
for maintenance


80–120
for acute mania
Valproic acid (VPA) level
CMP (liver)
CBC (thrombocytopenia)
Ammonia if suspicion of encephalopathy
Pregnancy test (low IQ, neural tube)
Risk of hepatotoxicity; 
Significant tremor is possible (reversible)
Lamotrigine (LAMICTAL)   
   Lamotrigine ER (LAMICTAL XR) 
$10
$50
Not required
(2–20)
None
Few side effects or health risks; Must titrate slowly to avoid SJS, making it useless for acute mania.
Carbamazepine (TEGRETOL)           
   Carbamazepine XR (CARBATROL)
$40
$50
4–12
for seizure disorder


undefined for 
bipolar disorder
Carbamazepine level (optional)
CBC (anemia, neutropenia)
CMP (sodium, liver)
HLA-B*1502 for Asians (SJS)
Pregnancy test (neural tube defects)
“Shredder” inDucer of several CYP enzymes, Decreasing levels of numerous medications; Blood levels required for treatment of epilepsy but not for bipolar maintenance. 
Oxcarbazepine (TRILEPTAL)               
$25
Not required
(15–35)
Metabolic panel (low sodium)
HLA-B*1502 for Asians (SJS)
Off-label for bipolar; Risk of hyponatremia
SJS = Stevens-Johnson Syndrome


Antiepileptics with (possible) weak mood stabilizing properties   


Clinical guidelines generally consider these two medications to be non-mood stabilizing antiepileptics. However, some psychiatrists regard them as adjunctive stabilizers for bipolar disorder. At worst they are unlikely to destabilize mood, which is something that cannot be said of all antiepileptics.

Antiepileptic / monthly cost 
Levels needed
Recommended lab work 
Comments
Gabapentin (NEURONTIN)         
$10
No
None
Off-label for anxiety, neuropathic pain, borderline personality, alcoholism, PTSD nightmares
Topiramate (TOPAMAX)
$10
No
CMP looking for low bicarbonate (CO2) which indicates acidosis
Pregnancy test (hypospadias, oral clefts)
Causes cognitive impairment ≥ 200 mg;
Approved for post-herpetic neuralgia; 
Off-label for weight loss, alcoholism, and  PTSD


Other than lithium, all mood stabilizers are AEDs, but not all AEDs are stabilizers. Bipolar patients on a non-stabilizing antiepileptic should, if possible,  be switched to valproate, lamotrigine, carbamazepine, or oxcarbazepine (in collaboration with the neurologist). 


The following medication monographs include a mechanism of action in the upper right-hand corner. Realize, however, the usual AED has several mechanisms of unclear significance. In general, AEDs enhance GABA activity and/or decrease glutamate activity. GABA is the brain’s principal inhibitory neurotransmitter, while glutamate is the principal excitatory neurotransmitter. Several AEDs block voltage-gated sodium and/or voltage-gated calcium channels of presynaptic neurons. 


Antipsychotics are not considered mood stabilizers, but are used for similar purposes, often in combination with a stabilizer. Antipsychotics work faster than stabilizers to relieve acute mania. For acute mania, it is best to hospitalize the patient and use a stabilizer + antipsychotic + benzodiazepine. To minimize sedatives while treating mania, consider blue-light blocking glasses (as described on page 76) for experimental “virtual darkness therapy”. 

The benzo can be tapered off (or made PRN) while mania is resolving, and it may be possible to taper the antipsychotic within a few months. Keep the stabilizer on board to prevent recurrence of mania or replace it with lamotrigine (Lamictal) for maintenance. Lamotrigine is safer, has fewer side effects, and is effective for prevention of manic and depressive episodes. Antidepressants may be useful for bipolar depression in the short term but may destabilize mood when used long term for individuals with bipolar disorder. 

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