From the Guidelines
Lamotrigine (Lamictal) is often considered the best mood stabilizer for Bipolar 2 disorder due to its effectiveness in preventing depressive episodes, which are more common in Bipolar 2 than manic episodes. The typical dosage starts at 25mg daily and gradually increases over 4-6 weeks to a target dose of 100-200mg daily to minimize the risk of serious rash 1. Other effective options include:
- Lithium (600-1200mg daily), which works well for both depression and hypomania, and valproate (750-1500mg daily)
- Quetiapine (300-600mg daily) is also effective, particularly for acute bipolar depression Treatment should be individualized based on symptom pattern, side effect profile, and medical history, as noted in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. Medication should be taken consistently, even during stable periods, and regular blood tests may be needed to monitor medication levels and organ function, with consideration of the potential side effects and monitoring requirements for each medication 1. These medications work by regulating neurotransmitters and stabilizing neural pathways involved in mood regulation, helping to prevent the cycling between depressive and hypomanic states characteristic of Bipolar 2. The World Health Organization recommends lithium or valproate for the maintenance treatment of bipolar disorder, with treatment continuing for at least 2 years after the last episode 1. Antidepressant medicines, always in combination with a mood stabilizer (lithium or valproate), may be considered in the treatment of moderate or severe depressive episodes of bipolar disorder, with selective serotonin reuptake inhibitors (SSRI) preferred to tricyclic antidepressants (TCA) 1.
From the FDA Drug Label
Quetiapine fumarate tablet is indicated as monotherapy for the acute treatment of depressive episodes associated with bipolar disorder. Efficacy was established in two 8-week monotherapy trials in adult patients with bipolar I and bipolar II disorder
The best mood stabilizer for bipolar 2 is quetiapine, as it has been established to be effective in the acute treatment of depressive episodes associated with bipolar II disorder 2.
From the Research
Mood Stabilizers for Bipolar 2
- The most effective mood stabilizers for bipolar 2 disorder are still being researched and debated 3, 4, 5, 6, 7.
- Quetiapine has been shown to be effective in treating bipolar depression, including bipolar 2, with minimal risk of switching into mania 3.
- Lamotrigine is also effective in preventing depressive episodes in bipolar disorder, particularly in bipolar 2 with rapid phase change 4.
- Combination therapy, such as lithium or valproate with an atypical antipsychotic, may be more effective than monotherapy in preventing manic relapses 5.
- First-line therapy for bipolar disorder includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine 6.
Comparison of Mood Stabilizers
- Quetiapine and lamotrigine have been shown to be effective in treating bipolar depression, but head-to-head studies are needed to compare their efficacy 3, 4.
- Lithium and valproate are commonly used mood stabilizers, but their efficacy in preventing depressive episodes is modest at best 3, 5.
- Combination therapy, such as lithium or valproate with an atypical antipsychotic, may be more effective than monotherapy in preventing manic relapses, but the efficacy and safety of such combinations have not been systematically compared with monotherapy 5.
Clinical Practice
- In clinical practice, quetiapine is often prescribed for bipolar depression, including bipolar 2, due to its efficacy and minimal risk of switching into mania 7.
- Lamotrigine is also commonly used in clinical practice, particularly in patients with a history of rapid cycling or treatment-emergent affective shifts 4.
- Combination therapy, such as lithium or valproate with an atypical antipsychotic, is often used in clinical practice, but the choice of therapy depends on the individual patient's needs and response to treatment 5, 6, 7.