Mood Stabilizers

Question 1

Symptoms of Mania
Mnemonic: DIG FAST

Answer 1

D- Distractibility
I- Irritability
G- Grandiosity
F- Flight of Ideas
A- Activity (increased)
S- Sleep (decreased need for)
T- Talkativeness

Per DSM-5, patients must have 3 out of the 7 above symptoms for at least 1 week to be considered a manic episode.

Question 2

What is the goal of treatment when the patient is in the euthymic mode of bipolar?

Answer 2

Euthymic: having a normal, stable, and tranquil mood that is neither excessively euphoric nor depressed.

Goal: preservation of functional capacity and prevention of further episodes.

Question 3

What is the treatment goal for patients in the manic or depressed modes of bipolar?

Answer 3

Goal: reduction of symptoms and a return to functional capacity.

Question 4

Bipolar Disorder Type 1

Answer 4

Characterized by the presence of manic episodes (DIG FAST). These patients very likely have depressive episodes as well.

Question 5

Bipolar Disorder Type 2

Answer 5

These patients experience hypomanic episodes where they have some features of mania, but don’t quite reach the level of functional impairment.

Question 6

Bipolar Mood Disorder (BMD) vs.
Borderline Personality Disorder (BPD)

Answer 6

BMD:
Mood changes over weeks or months.
Mood reactivity often independent of life events.
Frequency is rare (1-3%).
Treatment is primarily medications, but therapy can help.

BPD:
Mood changes over minutes or hours.
Mood reactivity highly dependent on life events.
Frequency is more common (6-10%).
Treatment is primarily therapy (drugs don’t really help).

Question 7

Lithium (Eskalith, Lithobid)
Mood Stabilizer

Answer 7

Mechanism of action unknown.

Single best medication we have for bipolar disorder and is the only one that has an effect on both treating and preventing both mania and depression.

Been shown to reduce rates of suicide.

Harsh side effect profile.
Low therapeutic index: the dose needed for therapeutic effect is uncomfortably close to the dose that can harm or kill.

Target dose: 0.8-1.2 mmol/L
Toxicity: 2.0 mmol/L or higher

Question 8

Lithium Side Effects
Mnemonic: LMNOP

Answer 8

L- Lithium
M- Movement (tremor in hands)
N- Nephrotoxicity (renally metabolized, watch for AKI, can cause CKD and nephrogenic DI)
O- hypOthyroidism (most common with long term use)
P- Pregnancy (teratogen, first 5 weeks especially)

Tremor in hands is earliest sign of toxicity.

Treatment of lithium toxicity is hydration and sometimes hemodialysis in extreme cases.

Lithium exposure in utero can cause Ebstein’s anomaly, which is a downwardly displaced tricuspid valve.
Think: LIThium can cause a Low Implanted Tricuspid.

Question 9

What labs should be checked regularly with lithium?

Answer 9

Lithium level
Creatinine
TSH
Pregnancy test

Question 10

How are anticonvulsants effective at stabilizing mood?

Answer 10

Use of anticonvulsants for
bipolar disorder arose out of an idea that mania may be partly due to neuronal
hyperactivity. Therefore, it would make sense that anticonvulsants, which slow
neuronal firing in the brain, may be helpful, and indeed, studies have shown that
several anticonvulsants (though certainly not all) are effective mood stabilizers.

Question 11

Valproate (Depakote, Depakene)
Anticonvulsant
Mood Stabilizer

Answer 11

1. Inhibits voltage-gated
   sodium channels, which accounts for its anticonvulsant properties.
2. Increasing the amount of GABA, throwing in a bit of a
   benzodiazepine-like sedative effect.

**Valproate is effective at treating and
preventing manic episodes, but not bipolar depression!!

Question 12

Side effects of Valproate

Answer 12

Undesired, but common:
Nausea, drowsiness, skin changes, weight gain, and hair loss (none of which cause lasting harm).

Dangerous side effects:

Valpro ate a folate PLaTe

Folate (linked to neural tube defects)
Pancreatitis
Liver problems
Thrombocytopenia

** interferes with folate metabolism!

Question 13

What labs do you draw to monitor Valproate?

Answer 13

Regular checks of: valproate levels, liver function tests, CBC,
and a pregnancy test.

Question 14

Lamotrigine (Lamictal)
Anticonvulsant
Mood Stabilizer

Answer 14

Uniquely beneficial for bipolar depression and not mania.

Lamotrigine is associated with both benign itchy rashes
as well as the
life-threatening Stevens-Johnson syndrome (skin sloughs off, mortality rate of 5%).

Question 15

Carbamazepine (Tegretol)
Anticonvulsant
Mood Stabilizer

Answer 15

Treats and prevents manic episodes.

1. Inhibits voltage-gated sodium channels.
2. Augments GABA transmission

Carbamazepine is used for bipolar disorder,
epilepsy, and trigeminal neuralgia.

CBZ = Cranial nerve pain, Bipolar disorder , and
seiZures

Question 16

Carbamazepine Side Effects

Answer 16

Messes with liver enzymes, needs frequent dose adjustments.

Neural tube defects
Agranulocytosis

People of Asian descent are at high risk for Stevens-
Johnson syndrome
from carbamazepine and should be genetically
screened prior to starting.

Remember this association by thinking carbamASIApine.

Question 17

What is the “8-12 rule” of mood stabilizers?

Answer 17

Serum levels

Lithium: 0.8-1.2
Carbemazepine: 8-12
Valproate: 80-120

Question 18

Antipsychotics for Bipolar Disorder

Answer 18

Initial treatment of an acute manic episode is with
an antipsychotic.
Mood stabilizers just don’ t work fast enough!

Cariprazine, quetiapine, olanzapine, and
lurasidone help with bipolar depression.

The CQuOL (depressive episode) is never as good as
the original (manic episode):
Cariprazine
Quetiapine
Olanzapine
Lurasidone

Question 19

Antidepressants for Bipolar Disorder

Answer 19

While antidepressants are helpful for unipolar
depression, they haven’t been shown to be nearly as effective for bipolar
depression and are generally not first-line drugs for this purpose.

Question 20

Polypharmacy is the rule, not the exception in Bipolar Disorder.

Answer 20

Successful treatment of bipolar disorder often involves more than one
medication.

Both mood stabilizers and antipsychotics (often in
conjunction) are often required for both acute treatment and long-term
prevention of mood episodes.

Question 21

Choose medications for Bipolar Disorder based on the phase of illness.

Answer 21

in contrast to antidepressants and antipsychotics (where you should choose
based on side effects), your choice of medications should come down to the
phase of the illness that you are trying to treat or prevent.

For mania, use
lithium, valproate, or carbamazepine as mood stabilizers; in addition, any
antipsychotic (either alone or combined with a mood stabilizer) will do.

For depression, use lithium or lamotrigine as mood stabilizers and either cariprazine, quetiapine, olanzapine, or lurasidone as antipsychotics.

After deciding on the phase of illness being treated, then consider the side effect
profile to hone in on the specific drug to be used.

Question 22

Should antidepressants be used for bipolar disorder?

Answer 22

With few exceptions, antidepressants should be avoided for any phase of
bipolar illness due to their lack of efficacy.

If they are to be used, make
sure that they are paired with a mood stabilizer and/or antipsychotic rather than
used as monotherapy.

Question 23

What type of psychotherapy is effective for Bipolar Disorder?

Answer 23

Cognitive behavioral therapy, family-focused therapy, and psychoeducation, have been shown to improve outcomes for patients with bipolar disorder.