Is oxcarbazepine (anticonvulsant medication) indicated for any psychiatric disorders?

Oxcarbazepine in Psychiatric Disorders

Oxcarbazepine is not FDA-approved for any psychiatric disorder, though it has been used off-label in bipolar disorder as an alternative to carbamazepine with some limited evidence supporting its use in refractory cases. 1, 2

Current Status in Treatment Guidelines

• Oxcarbazepine is not included in major treatment guidelines for bipolar disorder as a first-line or standard treatment option 3
• For bipolar disorder, guidelines recommend lithium, valproate, carbamazepine, or atypical antipsychotics as primary treatment options, with no mention of oxcarbazepine 3, 4
• The American Academy of Child and Adolescent Psychiatry specifically recommends starting with FDA-approved agents for bipolar disorder, which include lithium (approved down to age 12), valproate, and atypical antipsychotics 3
• WHO guidelines for mental disorders in low and middle-income countries recommend lithium, valproate, or carbamazepine for bipolar mania, with no mention of oxcarbazepine 3

Evidence for Off-Label Use

Bipolar Disorder

• Small, open-label studies suggest potential benefit of oxcarbazepine as add-on therapy in treatment-resistant bipolar disorder 5, 6
• In one study of 15 patients with refractory bipolar disorder, oxcarbazepine add-on led to significant symptom reduction at 1-2 months of treatment 6
• A review of hospitalized psychiatric patients found oxcarbazepine was used in patients with depression, mania, or psychosis, with relatively good tolerability compared to carbamazepine 5
• Critical reviews note the lack of double-blind, placebo-controlled studies to establish efficacy in bipolar disorder 2, 7

Borderline Personality Disorder

• A small pilot study (n=17) showed some efficacy for oxcarbazepine in borderline personality disorder, particularly for impulsivity, affective instability, and interpersonal relationships 8
• However, this remains an experimental use with insufficient evidence for clinical recommendation 8

Safety Considerations

• Oxcarbazepine carries an FDA warning for increased risk of suicidal thoughts or behavior, similar to other antiepileptic drugs 1
• The risk of suicidal thoughts or behavior was approximately twice that of placebo in pooled analyses of antiepileptic drugs 1
• Common adverse effects include asthenia, headache, dizziness, somnolence, nausea, diplopia, and skin rash 2
• Serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported 1
• Hyponatremia is a significant concern, with isolated cases of hyponatremic coma reported 2, 6

Clinical Implications

• If considering oxcarbazepine for psychiatric indications, it should only be used after failure of standard, evidence-based treatments 2, 7
• Monitoring should include serum sodium levels, particularly in the initial treatment period 2, 6
• Patients should be monitored for emergence or worsening of depression, suicidal thoughts or behavior, and unusual changes in mood 1
• Cognitive symptoms, somnolence, and coordination abnormalities are potential neuropsychiatric adverse effects that require monitoring 1

Conclusion

• While oxcarbazepine has structural similarity to carbamazepine and may have a more favorable side effect profile, there is insufficient evidence to recommend it as a standard treatment for any psychiatric disorder 2, 7
• Established treatments with stronger evidence bases should be prioritized for psychiatric conditions, particularly bipolar disorder 3, 4, 9