Mood Stabilizers

mood-stabilizerMood Stabilizers – Overview

Mood stabilizers are medications that reduce mood cycling, whether by reducing depressive episodes, reducing energized or manic episodes, or both.

In creating this page I have relied on many sources (see the end of the article) but in particular I have been helped by the writings of Jim Phelps, an Oregon psychiatrist who has become a nationally recognized expert in the clinical treatment of bipolar disorder. Check out his website, psycheducation.org.

This page uses the traditional scheme for classifying psychotropic medications. For information about the Neuroscience Based Nomenclature, an alternative system that is supported by a number of prestigious organizations click here.

Mood Stabilizers – Types

Broadly speaking, mood stabilizers can be classified into 4 groups:

  • Antipsychotic agents, especially atypical antipsychotics

These are medications that were first developed to treat psychosis, but have since been found to have many other uses, so that a minority of all antipsychotic prescriptions are for people with psychosis.

  • Antiepileptic agents

This is one of the few types of medications for bipolar that is based on a theory of the cause of mood swings. In this case, Dr. Bob Post at the NIMH noted many similarities between epilepsy and mood swings, particularly in terms of the phenomena of “kindling” or the way that episodes can lead to more mood instability in the future, and set out to study anti-seizure medications as possible treatments of bipolar. Many are effective, some are not.

  • Lithium

The original mood stabilizer, discovered by happenstance, but with some unique benefits.

  • Other agents

Many other medications are sometimes used as mood stabilizers, with varying amounts of evidence.

We will go through these groups in more detail below. For now, let’s describe some of the key features of the medications, in terms of benefits and adverse effects.

Antipsychotic agents

The medications most often prescribed from this class include quetiapine (Seroquel), lurasidone (Latuda), olanzapine (Zyprexa), aripiprazole (Abilify)… but there are many other medications depending on the specific therapeutic effects being sought.

Quetiapine (Seroquel) and lurasidone (Latuda) have the best evidence for effectiveness in treating depressive symptoms.

The medications are described in more detail in this page. 

Antiepileptic agents

The antiepileptic agents most often prescribed are lamotrigine (Lamictal), valproate or divalproex (Depakote), and carbamazepine (Tegretol).

One antiepileptic agent has been shown to be harmful in bipolar (gabapentin (Neurontin)) and a similar agent (pregabalin (Lyrica)) has not been adequately studied but should be used with great caution.

Lithium

Lithium is the oldest of these agents to have been shown to have a significant “mood stabilizing” effect on both manic and depressed episodes. It also is one of the rare medications in psychiatry with clear anti-suicide effects. Finally, it has positive effects on grey matter formation and preservation that also distinguish it from most of the alternatives. On the other hand, it has a narrow therapeutic range (the toxic dose is only about double the usual therapeutic dose) and can have adverse effects on kidney function, particularly with long term use. Recent studies suggest that the kidney effects are much less common than previously thought.

Other agents

A number of other agents have been proposed as mood stabilizers. Here we note that omega-3 fish oil supplements are benign nutritional supplements with reasonable evidence for modest effects.

Medications to Consider

It can be overwhelming to think about which medications to consider. These charts may be helpful.

Selecting Medications by Problem

Treats Mania and Depression Treats Depression without Mood Destabilizing Effects Treats Mania and Rapid Cycling Use with Caution
Lithium Lamotrigine Atypical antipsychotics Modafinil – for depression
Quetiapine Fish Oil Valproate Bright light – for depression
Olanzapine Thyroid Carbamazepine Pramipexole – for depression
Carbamazepine Lithium (?) TMS – for depression
ECT

Effectiveness in Preventing Episodes

Medication Preventing Episodes Preventing Mania Preventing Depression
Lithium ***** **** **
Divalproex **** ** ***
Lamotrigine **** ** ***
Olanzapine ****** ***** ***
Aripiprazole **** **** *
Quetiapine ****** ***** ***