Mood Stabilizer

Photo courtesy of Ark Behavioral HealthOpens in new window Mood stabilizers are medications used in the treatment of bipolar disorder (formerly called manic depressive disorder). The term mood stabilizer (which is not officially recognized by the U.S. Food and Drug Administration, or FDA) is used interchangeably with the terms bipolor medications and antimanic.

Bipolar disorderOpens in new window is a condition characterized by alternating episodes of mania (e.g., elevated mood, high energy, inflated self-esteem, grandiosity, risk-taking behavior), depression, and periods of normal mood and energy (also known as euthymia).

Depending on the type of bipolar disorder, an individual may experience a combination of episode types: manic, depressive, or mixed (features of both mania and depression in the same episode).

Some medications are more effective for treating manic symptoms, others are used primarily to treat depressive symptoms, and some medications are effective on multiple symptoms.

Since individuals respond differently to medications, treatment regimens must be individually tailored and closely monitored for effectiveness, treatment of target symptoms, and any side effects.

Lithium, reported by Australian psychiatrist John Cade in 1949 and approved by the FDA in 1970, was the first effective treatment for bipolar disorder (Patterson, 2006). The anticonvulsants carbamazepine and valproic acid have also been used effectively as mood stabilizers for many years.

Current treatment of bipolar disorder may include multiple mood stabilizers, antidepressants, antipsychotics, and benzodiazepines (Patterson, O’Neal, & Talaga, 2008). While all these medications are used to treat the symptoms of bipolar disorder, mood stabilizers typically refer to lithium, anticonvulsants, and any medications that help prevent switching into a manic or depressive episode. Antimanic more often refers to those medications that treat symptoms or prevent occurrences of mania.

Lithium is a relatively safe treatment and is effective in the treatment of acute mania and prevention of manic and depressive episodes in 60 to 80 percent of cases (Preston et al., 2008).

Lithium has a narrow therapeutic window — the difference between a therapeutically effective dose and a toxic one is very small — and therefore frequent monitoring of blood level lithium concentrations is necessary (Preston et al., 2008).

After initiating lithium treatment, it may take from five days to two weeks before experiencing therapeutic benefits. Side effects of lithium may include gastrointestinal effects (nausea, vomiting, diarrhea), headache, lethargy, muscle weakness, hand tremors, rash, acne, and weight gain.

Some side effects, such as confusion, stupor, slurred speech, or worsening tremor or gastrointestinal symptoms, may be signs of lithium toxicity, which can cause seizures, coma, or death.

Lithium can casue some hormonal changes, so periodic monitoring of thyroid function is recommended. Since lithium depends on the kidneys for excretion, it is important for individuals taking lithium to stay well hydrated (Preston et al., 2008).

Lithium should not be taken during pregnancy. The mechanism of action for lithium is not clearly understood. It may work through its ability to stabilizer cell membranes; its effects on the neurotransmitters (chemical messengers) dopamine, norepinephrine, and serotonin; or its neuroprotective properties (protecting against destructive consequences of certain biochemical processes in the brain; Preston et al., 2008).

The anticonvulsants carbamazepine (Tegretol Equetro), vulproic acid (divalproex, Depakore), and lamotrigine (Lamictal) are all effective mood stabilizers. Other anticonvulsants used as mood stabilizers include gabapentrin (Neurontin), topiramate (Topamax), triagabine (Gabatril), oxcarbazepine (Trileptal), and pregabilin (Lyrica).

The mechanisms of action for the anticonvulsants have not been conclusively identified. Some anticonvulsants have demonstrated neuroprotective properties. Anticonvulsants are believed to affect the activity of certain neurotransmitters (chemical messengers), increasing the activity of gamma-aminobutyric acid (GABA) or inhibiting the activity of glutamate (Preston et al., 2008).

Side effects vary by anticonvulsant but may include sedation, dizziness, drowsiness, blurred vision, incoordination, gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain), rash, or hives. Blood levels should be monitored frequently to identify potential toxicity (Preston et al., 2008).

Some anticonvulsants (e.g., Topamax) can cause confusion or memory loss (Dulcan, 2007). Use of some anticonvulsants (e.g., Depakore) during pregnancy has been associated with neural tube defects; risk cannot be ruled out for other effects (e.g., Tegretol; Preston et al., 2008).

Atypical antipsychotics used (alone or in conjunction with other medications) to treat mania, depression, and for relapse prevention include olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), aripiprazole (Abilify), quetiapine (Seroquel), and clozapine (Clozaril).

Treatment may also include benzodiazepines (e.g., Ativan, Klonopin) or antidepressants (Patterson, 2006; Preston et al., 2008). There are concerns that antidepressants (both selective serotonin reuptake inhibitors and other antidepressants) may trigger a switch to a manic episode, so antidepressants are generally used together with a mood stabilizer (Patterson, 2006).

Omega-3 fatty acids, found in seafood, flax seeds, and eggs, have been studied for the treatment of bipolar disorder. Some studies support the effectiveness of omega-3 fatty acids in treating the depressive symptoms of bipolar disorder.

Studies demonstrated no effect of omega-3 fatty acids on manic symptoms. Research conclusions should be interpreted with caution due to small sample sizes, concerns about study design, and conflicting results (Peet & Strokes, 2005; Ross, Seguin, & Sieswerda, 2007).

St. John’s wortOpens in new window (Hypericum perforatum) has been primarily studied for its effects on depression.

Research does not support the effectiveness of St. John’s wort as a treatment for bipolar disorder, and researchers have studied warnings about harmful interactions between St. John’s wort and bipolar medications (U.S. Food and Drug Administration, 2000) as well as concerns about St. John’s wort triggering manic episodes (Nierenberg, Butt, Mathews, & Weiss, 1999).