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Mood Stabilizers

by Helen Farrell, MD
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    00:01 I want to share with you some highlights about the mood stabilizing medications.

    00:06 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.

    00:19 Mood stabilizers are known as antimanic medications, and they’re used to treat acute mania and also prevent relapses of manic episodes.

    00:28 And they can also be useful in treatment of hypomania and rapid cycling and mixed episodes.

    00:34 So they’re indicated for various bipolar disorders.

    00:37 They can also be great adjunctive medications to antidepressants and antipsychotics.

    00:43 They can actually be used to enhance abstinence in the treatment of alcoholism.

    00:48 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.

    01:02 Some examples of mood stabilizers include lithium, carbamazapine, valproic acid, and lamotrigine.

    01:09 We’ll talk a little bit about these today.

    01:11 So the mood stabilizer lithium is very important to know about.

    01:15 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.

    01:25 Lithium is the gold standard for mania.

    01:29 The lithium levels are increased by a number of medications.

    01:33 Now, this is an important point because lithium is managed through a very narrow therapeutic window.

    01:39 And if a patient has too little, the medicine is not going to be very effective.

    01:43 If they have too much lithium in their system, it can be deadly.

    01:47 So these are medications that can actually interact with lithium causing the level to become so high that the patient becomes toxic.

    01:55 So for example, NSAIDs, tetracyclines, metronidazole, ACE inhibitors, diuretics, theophyline, osmotic diuretics, and acetazolamide can all increase the levels of lithium in the system.

    02:10 So be very careful when you see these medicines used in conjunction with this mood stabilizer.

    02:15 Well, how does lithium work? Well, it alters neuronal sodium transport.

    02:20 It’s actually metabolized in the kidney.

    02:23 So this is very important to note.

    02:26 Majority of medications are metabolized in the liver, but lithium actually goes through the kidney and the renal system.

    02:32 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.

    02:42 Anything less is too little, and a level over 2 could actually be toxic and lethal for your patients.

    02:50 So lithium toxicity presents in a number of ways.

    02:53 A patient may be noted to have a course tremor, ataxia, or slurred speech.

    02:59 It can progress to dizziness, weakness, nystagmus, stomach upset.

    03:05 And it can eventually lead to stupor/coma and death after causing seizure, arrhythmia, or any other problems.

    03:13 So, how would you manage lithium toxicity? Because it’s deadly, this likes to be questioned on board exams.

    03:20 Well, mild toxicity can be managed by taking care of electrolyte disturbances, giving the patient IV hydration, of course, stopping the lithium.

    03:30 And if the level though is above 3 millimoles per liter, you’re likely going to need to do hemodialysis for your patient.

    03:41 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.

    03:48 That’s why hemodialysis can be important in toxicity.

    03:52 Now, for pregnant women, they should absolutely not be taking lithium.

    03:57 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.

    04:06 That’s Ebstein’s anomaly, which is a cardiac defect in the baby.

    04:11 Now, if you have a patient on lithium, it’s likely that even without being toxic, they’re going to experience some side effects.

    04:19 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.

    04:33 They also might have GI problems, benign leukocytosis, thyroid enlargement.

    04:39 So it’s very important before starting a patient on lithium that you check baseline blood work.

    04:44 Make sure their kidneys are functioning properly, and make sure their thyroid looks okay.

    04:49 They may get nephrogenic diabetes insipidus, and of course, toxic levels are going to cause that coarse tremor and altered mental status.

    04:58 When a patient is taking lithium, you really need to routinely check their level, as well as their kidney function and their thyroid hormone.

    05:08 Other mood stabilizers can include anticonvulsant medications.

    05:13 So, carbamazepine is one example.

    05:15 It’s an anticonvulsant that’s useful in treating mixed episodes of bipolar, as well as rapid cycling.

    05:22 Another little pearl is that it can treat trigeminal neuralgia.

    05:26 So it has some anti-pain properties.

    05:29 However, there can be fetal anomalies associated with carbamazepine, and also, valproic acid.

    05:35 Do you know what that is? Well, it’s spina bifida.

    05:40 Carbamazine works by blocking sodium channels and inhibiting action potentials.

    05:46 It usually can take about a week to work.

    05:48 So you need to be a bit patient when you actually start your patient on this medication.

    05:54 Some other notable side effects are skin rash, drowsiness, ataxia, slurred speech, leukopenia, and hyponatremia.

    06:03 It can also cause an aplastic anemia, agranulocytosis, elevated liver enzymes, and therefore, pretreatment, you need to check a complete blood count and LFTs.

    06:14 You also want to look out for thrombocytopenia in these patients.

    06:18 Now, valproic acid is an anticonvulsant useful in treating mixed manic episodes and rapid cycling bipolar disorder.

    06:26 Its mechanism of action, it’s not completely known but it’s been shown to increase central nervous system levels of GABA.

    06:36 Now, there are some side effects here too, things like weight gain, alopecia, hemorrhagic pancreatitis, hepatotoxicity, thrombocytopenia, and the teratogenic effect as well during pregnancy of spina bifida.

    06:52 So very important to note that, and if you have a patient who’s a woman, always do a pregnancy test.

    06:57 Also, of course, check a baseline CBC, as well as liver function.

    07:03 Now, before moving on, I want to mention another anticonvulsant that’s sometimes used for the treatment of bipolar.

    07:08 It’s called the lamotrigine.

    07:10 It’s specifically indicated, actually, for the treatment of bipolar depression.

    07:15 So it really helps to stabilize mood and prevent those really low lows that people experience during times of depression.

    07:22 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.

    07:31 So you want to warn your patients about that and really beyond to look out for that rash throughout their treatment.

    07:37 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.

    07:51 So this is the best way to help monitor your patient and make sure that they stay safe.

    07:55 Now, antipsychotic medications, benzodiazepines and also electroconvulsive therapy can be helpful in the treatment of mood disorder including bipolar disorder.

    08:08 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.

    08:20 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.

    08:36 Now, some patients won’t achieve absolute remission.

    08:39 In these cases, you’re looking for a reasonable response.

    08:43 So again, improvement in the number, frequency, duration, intensity of their symptoms.

    08:50 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 medical emergency.

    09:07 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 psychiatric emergency.

    09:19 And you need to determine what level of care is most appropriate for these patients.

    09:25 So you may be thinking about inpatient versus an outpatient level of care.

    09:30 Well, when it comes to an inpatient setting, what you’re considering is whether or not your patient is safe.

    09:36 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 inpatient hospitalization.

    09:52 Now, you might also think about a partial hospital program, where the patient has some support at home.

    09:57 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.

    10:06 Or perhaps, your patient has very good insight and judgment despite their symptoms, and they also have a great support network at home.

    10:14 So that patient may be appropriate to be treated on an outpatient basis That’s a summary of the mood stabilizers.

    10:23 We hit the highlights of them, an important topic to know about for your exams.


    About the Lecture

    The lecture Mood Stabilizers by Helen Farrell, MD is from the course Major Psychiatric Disorders. It contains the following chapters:

    • Mood Stabilizers
    • Lithium
    • Carbemazepine
    • Valproic Acid

    Included Quiz Questions

    1. Treatment of resting tremors.
    2. Potentiation of antidepressants.
    3. Treatment of impulsivity and aggression.
    4. Potentiation of antipsychotics.
    5. Treatment of Bipolar disorder.
    1. There is no correlation between the blood levels and clinical efficacy.
    2. It alters neuronal sodium transport.
    3. Blood levels more than 3mmol require hemodialysis.
    4. The onset of action of Lithium is 5-7 days.
    5. It is secreted by the kidneys.
    1. Nephrogenic Diabetes Insipidus.
    2. Resting tremors
    3. Leukocytopenia
    4. Weight loss
    5. Hyperthyroidism
    1. Carbamazepine
    2. Valproic acid
    3. Phenobarbital
    4. Clonazepam
    5. Diazepam
    1. Steven Johnson's Syndrome.
    2. Diabetes Insipidus.
    3. Fine tremors.
    4. Renal failure.
    5. Leukocytosis
    1. Remission
    2. Stabilization
    3. Augmentation
    4. Response
    5. Sedation

    Author of lecture Mood Stabilizers

     Helen Farrell, MD

    Helen Farrell, MD


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