From the Guidelines
Mood stabilizers such as lithium, valproate, and carbamazepine are primarily indicated for the treatment of bipolar disorder, particularly for managing acute manic episodes and preventing mood episode recurrence. According to the most recent and highest quality study 1, lithium, valproate, or carbamazepine should be offered to individuals with bipolar mania. The study also recommends that lithium or valproate should be used for the maintenance treatment of bipolar disorder, and maintenance treatment should continue for at least 2 years after the last episode of bipolar disorder.
Key Indications
- Bipolar disorder, particularly for managing acute manic episodes and preventing mood episode recurrence
- Treatment-resistant depression
- Impulse control disorders
- Aggression in various psychiatric conditions
- Certain types of chronic pain
Medication Specifics
- Lithium: considered first-line treatment for classic bipolar I disorder with euphoric mania, especially effective for preventing suicidality, typical dosing ranges from 600-1200 mg daily, with target blood levels of 0.6-1.2 mEq/L
- Valproate: particularly useful for rapid cycling bipolar disorder, mixed episodes, and patients with comorbid substance use, typically dosed at 750-2000 mg daily
- Carbamazepine: often used when patients don't respond to lithium or valproate, or have atypical presentations, usual dose 400-1200 mg daily
Monitoring and Side Effects
Regular monitoring is essential when using these medications, including blood levels, liver function, kidney function, electrolytes, and complete blood counts, as they can cause significant side effects including tremor, weight gain, sedation, and potentially serious organ toxicity. Baseline laboratory assessment and periodic monitoring are recommended for each medication, as outlined in 1.
From the FDA Drug Label
INDICATIONS AND USAGE Lithium is indicated in the treatment of manic episodes of Bipolar Disorder. Bipolar Disorder, Manic (DSM-III) is equivalent to Manic Depressive illness, Manic, in the older DSM-II terminology. Lithium is also indicated as a maintenance treatment for individuals with a diagnosis of Bipolar Disorder.
The indications for mood stabilizers, such as lithium, are:
- Treatment of manic episodes of Bipolar Disorder
- Maintenance treatment for individuals with a diagnosis of Bipolar Disorder to reduce the frequency of manic episodes and diminish their intensity 2
From the Research
Indications for Mood Stabilizers
Mood stabilizers, such as lithium, valproate, and carbamazepine, are used to treat bipolar disorder. The indications for these medications include:
- Treatment of acute manic episodes
- Prevention of recurrences of bipolar disorder
- Treatment of depressive episodes in bipolar disorder
Specific Indications for Each Medication
- Lithium: considered a first-line treatment option for acute mania and has the strongest evidence of efficacy in the prophylaxis of manic episodes 3, 4
- Valproate: considered a first-line treatment option for acute mania, effective in decreasing the frequency or severity of manic episodes, but has no indication for long-term treatment of bipolar disorder 3, 5, 4
- Carbamazepine: effective in acute manic episodes, but evidence is insufficient to consider it as a first-line agent, and has no indication for long-term treatment of bipolar disorder 3, 5, 4
- Lamotrigine: effective in the prevention of depressive episodes, particularly in rapid cycling bipolar disorder, and has a stronger effect in the prevention of depression 5, 4, 6
Treatment Guidelines
- Patients who fail to respond to first-line treatments may benefit from the adjunct of an atypical antipsychotic such as olanzapine, quetiapine, risperidone, or aripiprazole 3, 4
- Combinations of an antipsychotic and a mood stabilizer may yield greater improvement than does continuation of the mood stabilizer alone for patients who develop mania while taking a mood stabilizer 6
- Maintenance-treatment studies support the efficacy of lithium, valproate, and lamotrigine, although with a different spectrum of benefits and limitations for each 6