I want to share with you some highlights
about the mood stabilizing medications.
So when you’re treating a patient
who has an unstable mood,
particularly, a bipolar disorder,
including mania or hypomania,
the goal of treatment is actually going
to be remission versus stabilization.
Mood stabilizers are known
as antimanic medications,
and they’re used to treat acute mania and
also prevent relapses of manic episodes.
And they can also be useful
in treatment of hypomania
and rapid cycling
and mixed episodes.
So they’re indicated for
various bipolar disorders.
They can also be great
to antidepressants and antipsychotics.
They can actually be used to enhance
abstinence in the treatment of alcoholism.
And they can also treat the
aggression and impulsivity
that comes along with other disorders,
things like dementia, intoxication,
mental retardation, personality disorders,
and other general medical conditions.
Some examples of mood
stabilizers include lithium,
acid, and lamotrigine.
We’ll talk a little bit about these today.
So the mood stabilizer lithium
is very important to know about.
It’s the drug of choice
in treating acute mania,
and also, it serves as prophylaxis against
further manic and depressive
episodes in bipolar disorder.
Lithium is the gold standard for mania.
The lithium levels are increased
by a number of medications.
Now, this is an
important point because
lithium is managed through a
very narrow therapeutic window.
And if a patient has too little, the
medicine is not going to be very effective.
If they have too much lithium in
their system, it can be deadly.
So these are medications that can
actually interact with lithium
causing the level to become so high
that the patient becomes toxic.
So for example, NSAIDs, tetracyclines,
metronidazole, ACE inhibitors, diuretics,
diuretics, and acetazolamide
can all increase the levels
of lithium in the system.
So be very careful when
you see these medicines
used in conjunction with
this mood stabilizer.
Well, how does lithium work?
Well, it alters neuronal
It’s actually metabolized in the kidney.
So this is very important to note.
Majority of medications are
metabolized in the liver,
but lithium actually goes through
the kidney and the renal system.
And blood levels, again,
really correlate with efficacy
So you want to keep your patient in this
narrow therapeutic range of 0.7 to 1.2.
Anything less is too little,
and a level over 2 could actually be
toxic and lethal for your patients.
So lithium toxicity presents
in a number of ways.
A patient may be noted to have a course
tremor, ataxia, or slurred speech.
It can progress to dizziness,
weakness, nystagmus, stomach upset.
And it can eventually lead
to stupor/coma and death
after causing seizure, arrhythmia,
or any other problems.
So, how would you manage
Because it’s deadly, this likes
to be questioned on board exams.
Well, mild toxicity can be managed by
taking care of electrolyte disturbances,
giving the patient IV hydration,
of course, stopping the lithium.
And if the level though is
above 3 millimoles per liter,
you’re likely going to need to do
hemodialysis for your patient.
So, this is very important, and because
it’s going through the kidneys,
you want to make sure those
kidneys are still functioning
and that they don’t shut down.
That’s why hemodialysis can
be important in toxicity.
Now, for pregnant women, they should
absolutely not be taking lithium.
It’s very rare to find that the
benefit can outweigh the risk,
and the risk is that there’s
a serious teratogenic effect
that can happen with
lithium during pregnancy.
That’s Ebstein’s anomaly, which
is a cardiac defect in the baby.
Now, if you have a
patient on lithium,
it’s likely that even without being toxic,
they’re going to experience
some side effects.
So let’s go through the potential side
effects you might see in your patient:
a fine tremor, sedation, ataxia,
thirst or metallic taste in their mouth,
polyuria, edema, and weight gain.
They also might have GI problems, benign
leukocytosis, thyroid enlargement.
So it’s very important before
starting a patient on lithium
that you check
baseline blood work.
Make sure their kidneys
are functioning properly,
and make sure their
thyroid looks okay.
They may get nephrogenic
and of course, toxic levels
are going to cause that
coarse tremor and
altered mental status.
When a patient is taking lithium, you
really need to routinely check their level,
as well as their kidney function
and their thyroid hormone.
Other mood stabilizers can include
is one example.
It’s an anticonvulsant that’s useful
in treating mixed episodes of bipolar,
as well as rapid cycling.
Another little pearl is that it
can treat trigeminal neuralgia.
So it has some anti-pain properties.
However, there can be fetal anomalies
associated with carbamazepine,
and also, valproic acid.
Do you know what that is?
Well, it’s spina bifida.
Carbamazine works by blocking sodium
channels and inhibiting action potentials.
It usually can take
about a week to work.
So you need to be a bit patient
when you actually start your
patient on this medication.
Some other notable side effects
are skin rash, drowsiness,
ataxia, slurred speech,
leukopenia, and hyponatremia.
It can also cause an aplastic anemia,
agranulocytosis, elevated liver enzymes,
and therefore, pretreatment, you need to
check a complete blood count and LFTs.
You also want to look out for
thrombocytopenia in these patients.
Now, valproic acid is an
anticonvulsant useful in treating
mixed manic episodes and rapid
cycling bipolar disorder.
Its mechanism of action,
it’s not completely known
but it’s been shown to increase central
nervous system levels of GABA.
Now, there are some side effects here
too, things like weight gain, alopecia,
and the teratogenic effect as well
during pregnancy of spina bifida.
So very important to note that,
and if you have a patient who’s a
woman, always do a pregnancy test.
Also, of course, check a baseline
CBC, as well as liver function.
Now, before moving on, I want to
mention another anticonvulsant
that’s sometimes used for
the treatment of bipolar.
It’s called the lamotrigine.
It’s specifically indicated, actually,
for the treatment of bipolar depression.
So it really helps to stabilize mood
and prevent those really low lows that people
experience during times of depression.
A notable side effect of lamotrigine
that you’ll need to know for your exam
is that it can cause a deadly rash
called Stevens-Johnson Syndrome.
So you want to warn your
patients about that
and really beyond to look out for
that rash throughout their treatment.
A way to protect your patient against
having this potentially deadly side effect
is to start lamotrigine
at a very low dose
and then wait two weeks before making
very small and incremental
increases to the dose.
So this is the best way to
help monitor your patient
and make sure that they stay safe.
and also electroconvulsive therapy
can be helpful in the treatment
of mood disorder including
So the goal of treatment
again is remission,
and this is defined as the
resolution of mood symptoms
or improvement to the point that maybe
only one or two symptoms mildly persist.
If psychotic features are ever
associated with a manic episode,
then by definition, you want to
treat that psychosis first, okay?
Resolution of psychosis is very important
because that can be a really
dangerous side effect.
Now, some patients won’t
achieve absolute remission.
In these cases, you’re looking
for a reasonable response.
So again, improvement in
the number, frequency,
of their symptoms.
And because with bipolar disorder,
mania can be a very serious problem
where people’s judgment is not good,
they are making impulsive risky choices
that can really put their health at risk,
it’s considered a
Likewise, people who
have bipolar depression
who are gripped with
the depressed phase
and maybe experiencing suicidal
thoughts are also going to qualify
as meeting criteria for a
And you need to determine
what level of care
is most appropriate for these patients.
So you may be thinking about inpatient
versus an outpatient level of care.
Well, when it comes to
an inpatient setting,
what you’re considering is whether
or not your patient is safe.
Are they an immediate harm
to themselves or to others?
Are they able to care for
their basic needs of life?
If the answer is no to any of those things
or know that they are not safe
for themselves or others,
you may be considering an
Now, you might also think about
a partial hospital program,
where the patient has
some support at home.
So they go home at night to sleep,
but they spend the
daytime in the hospital
engaging with doctors, nurses,
and therapists to get better.
Or perhaps, your patient has
very good insight and judgment
despite their symptoms, and they also
have a great support network at home.
So that patient may be appropriate
to be treated on an outpatient basis
That’s a summary of
the mood stabilizers.
We hit the highlights of them, an important
topic to know about for your exams.