There is nothing like a patient’s request to spur me on to tackle a long delayed project.
Noting that a significant percent of the patients I see have bipolar, one of my patients wondered why I did not have any information on this website that addressed, in an organized way, the considerations that go into selecting a mood stabilizer.
I replied that Jim Phelps’ wonderful Psycheducation.org site provided a host of resources that I could recommend without reservation. But, it got me thinking, and, eventually, working, and I am pleased to report that there are two new webpages in the Treatment Resources section of this website.
One is an overview of various medications thought to be “mood stabilizers” and the other is a page specifically devoted to lithium (inspired in part by the residents in the Bipolar Disorders Clinic at UCSF).
There is still work to be done, in particular I don’t have adequate pages on lamotrigine or carbamazepine, but I am glad to note the progress being made on this website… and to acknowledge my patients, who teach me so much, and inspire me always….
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.
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.
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.
The original mood stabilizer, discovered by happenstance, but with some unique benefits.
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.
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 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 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.
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