Mood Stabilizers: The What: 5 Things all Clinicians Need to Know about Them

“I feel confident speaking with my patients and clients about antipsychotics. But now, Ron has been asking me lots of questions about his Lithium medication, and I want to help him.”

Lily articulated these words to Dawn, the team psychiatrist, who has been working with the HOPE ACT team, helping them with the tools for client education.  “You and your colleagues have shown confidence and knowledge about antipsychotics; Lithium is a mood stabilizer, and this is a good opportunity to start talking about them,” responded Dawn.

In a series of articles entitled, Basic Knowledge of Antipsychotics, I introduced Lily as the clinician who wanted to learn about antipsychotics, after she had some unfulfilling experiences with some of her patients and clients.  Along with Dawn’s guidance, as the team psychiatrist, Lily and her colleagues dedicated the time and the effort to better understand antipsychotics.  And as Lily puts it, “I now feel confident speaking with my patients and clients about antipsychotics.”

In the first article of that series, I described the five reasons why of basic psychopharmacology for the non-medical staff, like Lily.  I summarized them as:

(1) Improved Adherence;

(2) Minimized Overwhelming Feeling;

(3) Feeling Empowered;

(4) Enhanced Communication; and

(5) Maintained Stability and Decreased Waste.

These five reasons also apply to the basic facts about Mood Stabilizers, as much as they apply to basic knowledge of Antipsychotics.  Just as Dawn promised Lily and her colleagues, below is an overview of the Mood Stabilizers, followed by 5 things that all clinicians ought to know about them.

Mood stabilizers are medications used in the field of psychiatry and neurology to treat conditions that affect the mood. They can help suppress the fluctuations between mania and depression. This type of condition tends to be evident by intense mood changes that go beyond just a simple episode of anger, frustration, or impulsivity. This distinction is very important, because we often hear people say, “He is Bipolar because his mood changes all the time or every now and then.” Mood stabilizers are used in the treatment of Bipolar Type I or Type II and in Schizoaffective Disorder, Bipolar Type. While they are also used in several other conditions, like Borderline Personality Disorder, this is known as a symptomatic treatment, and should be a last resort decision, as you will see below.  Here are the five things all clinicians need to know about mood stabilizers:

They should be used as a last resort in “rapid and short mood changes”

While mood stabilizers are often used for rapid and short mood changes, they should be used as a last resort.  The best way to manage “rapid and short mood changes,” is to address the underlying, responsible factors. In general, their causes may include and are not limited to trauma reactivity, depression, anxiety, substance use, other general medical conditions, externalized anger that comes from unprocessed losses, learned behavior, and the inability to self-regulate, as seen, for example, in Traumatic Brain Injury (TBI), neurodevelopmental disorders, or severe cognitive disorders.

“Rapid and short mood changes” can also be due to pervasive coping mechanisms as seen in several forms of personality disorders, like Borderline, Histrionic, Narcissistic, or Antisocial Personality Disorder.

They are divided into three main categories:

Mood stabilizers are divided into: (A) Minerals (natural substances of crystal structure), (B) Anticonvulsants, and (C) Antipsychotics.

A.     Minerals: Lithium is the first mood stabilizer approved by the Food and Drug Administration (FDA); it is, at times, referred to as the “classic mood stabilizer.”

B.     Anticonvulsants: As the name implies, this is a group of medications used to treat convulsions or seizure disorders.  They are also used as mood stabilizers to treat Bipolar Type I and Type II.  In this case, the term “anticonvulsant mood stabilizers” is used, and this group contains medications like Valproic acid (Depakote), Oxcarbazepine (Trileptal), Carbamazepine (Tegretol), and Lamotrigine (Lamictal).  Topiramate (Topamax) and Gabapentin (Neurontin) are also used, though they have not been found to be any better than placebo.

C.     Antipsychotics: In our series of articles on antipsychotics, I described the atypical antipsychotics and explained that they, too, are used as mood stabilizers, in the treatment of Bipolar Disorder.  The most commonly used are Aripiprazole (Abilify), Risperidone (Risperdal), Quetiapine (Seroquel), and Olanzapine (Zyprexa).  Paliperidone (Invega) and Lurasidone (Latuda) are also used.

Lithium and most of the anticonvulsant mood stabilizers are contraindicated in pregnancy

Those affected by Bipolar Disorder are expected to take medication long term, as is the case, for example, for most of those affected by Diabetes or Hypertension.  Many of the mood stabilizers cited above, notably Lithium and many of the anticonvulsant mood stabilizers cannot be used in pregnancy, though in some cases, it may be a relative contraindication in the case of Lithium. As a result, women of childbearing age taking these types of medications are required to use some form of contraception, especially since the effects of these medications occur very early during pregnancy, often before the patients or clients become aware they are pregnant.  Should a woman with Bipolar Disorder consider becoming pregnant, they should not be on these types of medications; other options should be considered and discussed with their treating physician.  This, however, is beyond the scope of this article.

All mood stabilizers are not created equal

The mechanism of action (how they do what they do) of the mood stabilizers is not homogeneous, as I described already that they belong to a heterogeneous group (the three main categories described above).  Each group has its pros and cons, and while a full description of their similarities and differences is beyond the scope of this article, the following is worth noting and keeping in mind, as you empower yourself with tools to continue providing the most accurate and sound information to your patients and clients, for better informed decisions:

(A) Some of the mood stabilizers do a better job at treating both the manic and depressive symptoms of Bipolar Disorder than others (Lithium is a great example);

(B) Others help better with the depressive symptoms, without worsening any manic symptoms or cycling (episodes of mania and depression) (Lamotrigine or Lamictal is a good example);

(C) Some are better at treating mania and rapid cycling (four or more episodes of mania or depression in one year) (Valproic acid or Depakote is a good example);

(D) Some of them have so high an antidepressant property that the risk for mania may increase (Ziprasidone or Geodon is a good example).  This last point helps illustrate the fact that prescribing is less simple than it seems to be. It requires extensive, contextual, and deep knowledge base of pharmacology, genetics, molecular biology, neuroscience, physiology and anatomy, in addition to knowledge in phenomenology, diagnostic skills, and specialized and clinical expertise.  All this is for us to remind our patients and clients how it is often best to make decisions about their medications in collaboration with their doctors.

Lithium has been shown to be the most effective mood stabilizer

I have described above that all mood stabilizers are not created equal, and I provided some examples. Now, I would like to finalize this article by making sure you know that Lithium has been shown to be the most effective mood stabilizer. If you remember Clozapine (Clozaril) in our article series on antipsychotics, think of Lithium in a similar way in the world of the mood stabilizers, except it is often encouraged as first line treatment, under most circumstances.

“I feel confident speaking with my patients and clients about antipsychotics. But now, Ron has been asking me lots of questions about his Lithium medication, and I want to help him.” Lily articulated these words to Dawn, the team psychiatrist, who has been working with the HOPE ACT team, helping them with tools for client education. “You and your colleagues have shown confidence and knowledge about antipsychotics; Lithium is a mood stabilizer, and this is a good opportunity to start our series of talks on mood stabilizers,” promised Dawn.  And there it went.

After an overview of the mood stabilizers, you have learned that:

(1) They should be used as a last resort in “rapid and short mood changes;”

(2) They are divided into three main categories;

(3) Lithium and most of the anticonvulsant mood stabilizers are contraindicated in pregnancy;

(4) All mood stabilizers are not created equal; and

(5) Lithium has been shown to be the most effective mood stabilizer.

I hope this stimulates your appetite to learn even more about mood stabilizers, as you strive to make a difference in the lives of your patients and clients.

For more in this series of articles, check below!

References:

1. Marmol, F. (2008). “Lithium: Bipolar disorder and neurodegenerative diseases Possible cellular mechanisms of the therapeutic effects of lithium”. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 32 (8): 1761–1771.

2. Ghaemi SN, Berv DA, Klugman J, Rosenquist KJ, Hsu DJ (August 2003). “Oxcarbazepine treatment of bipolar disorder”. J Clin Psychiatry. 64 (8): 943–5.

3. Gao, K.; Calabrese, J. R. (2005). “Newer treatment studies for bipolar depression”. Bipolar Disorders. 7 (s5): 13–23.

4. Geoffroy, P. A.; Etain, B.; Henry, C.; Bellivier, F. (2012). “Combination Therapy for Manic Phases: A Critical Review of a Common Practice”. CNS Neuroscience & Therapeutics. 18 (12): 957–964.

5. Rao JS, Lee HJ, Rapoport SI, Bazinet RP (June 2008). “Mode of action of mood stabilizers: is the arachidonic acid cascade a common target?”. Mol. Psychiatry. 13 (6): 585–96.