What medications are used to treat mood swings?

Medications for Mood Swings

The primary medications for treating mood swings include mood stabilizers (lithium, valproate, lamotrigine), atypical antipsychotics (risperidone, olanzapine, quetiapine), and in certain cases, benzodiazepines for acute management. 1

First-Line Medications

Mood Stabilizers

• Lithium: FDA-approved down to age 12 for acute mania and maintenance therapy. Often considered first-line for bipolar disorder with classic presentations. 1
• Valproate (Depakote): Start at 125 mg twice daily, titrate to therapeutic blood level (40-90 mcg/mL). Generally better tolerated than other mood stabilizers. 1
• Lamotrigine: Particularly effective for bipolar depression and prevention of depressive episodes. 2

Atypical Antipsychotics

• Risperidone (Risperdal): Initial dosage 0.25 mg/day at bedtime; maximum 2-3 mg/day. Research supports use of low dosages. 1
• Olanzapine (Zyprexa): Initial dosage 2.5 mg/day at bedtime; maximum 10 mg/day. Generally well tolerated and FDA-approved for bipolar mania. 1, 3
• Quetiapine (Seroquel): Initial dosage 12.5 mg twice daily; maximum 200 mg twice daily. More sedating; monitor for orthostasis. 1

Treatment Selection Algorithm

1. Determine the pattern of mood swings:

   • For bipolar-type mood swings with mania/hypomania: Lithium or valproate as first-line 1
   • For rapid cycling mood swings: Valproate often preferred 1
   • For mood swings with psychotic features: Atypical antipsychotic (risperidone, olanzapine, quetiapine) 1
   • For predominantly depressive mood swings: Lamotrigine 2

2. Consider comorbidities:

   • With anxiety: Quetiapine or valproate may be particularly helpful 1
   • With sleep disturbance: More sedating options like quetiapine 1
   • With agitation: Combination of a benzodiazepine and antipsychotic for acute management 1

3. For acute severe agitation with mood swings:

   • Combination of a benzodiazepine (lorazepam) and an antipsychotic is frequently recommended 1
   • Lorazepam has fast onset of action, rapid absorption, and no active metabolites 1

Important Considerations

• Avoid antidepressants alone: Antidepressants should only be used as adjuncts for depression when the patient is also taking at least one mood stabilizer, as they may trigger manic episodes. 1, 2

• Medication combinations: Although multiple agents are often required for optimal control of mood swings, care should be taken to avoid unnecessary polypharmacy. 1

• Monitoring requirements:

  • Lithium: Regular blood level monitoring (therapeutic range: 0.6-1.2 mEq/L)
  • Valproate: Monitor liver enzymes, platelets, and blood levels
  • Atypical antipsychotics: Monitor for metabolic side effects (weight gain, lipid abnormalities)

• Common pitfalls:

  1. Using antidepressants without mood stabilizers can worsen mood swings or trigger mania 1, 2
  2. Inadequate dosing of mood stabilizers leading to suboptimal response
  3. Failure to monitor for side effects, particularly with lithium and valproate
  4. Premature discontinuation of treatment, which can lead to relapse 4

Special Populations

• Children and adolescents: Lithium is FDA-approved down to age 12 years. The safety profile of other agents in young children has not been well established. 1

• Neurological comorbidities: In patients with neurological illness and mood disorders, mood stabilizers like lithium, divalproex sodium, or carbamazepine are typically required. 5

Remember that medication choice should be based on evidence of efficacy, phase of illness, presence of confounding presentations (e.g., rapid cycling, psychotic symptoms), side effect profile, patient's history of medication response, and medication safety profile. 1