What mood stabilizer can I take?

Mood Stabilizer Selection for Bipolar Disorder

For bipolar disorder, lithium is the gold standard first-line mood stabilizer, with the strongest evidence for treating acute mania, acute depression, and preventing both manic and depressive episodes. 1, 2

Primary Mood Stabilizer Options

Lithium (First-Line Choice)

• Lithium is the only FDA-approved mood stabilizer for bipolar disorder in patients age 12 and older and the only agent that meets strict criteria for efficacy across all phases of bipolar disorder (acute mania, acute depression, and prophylaxis of both). 1, 2
• Lithium demonstrates superior long-term efficacy compared to other mood stabilizers, with evidence showing it reduces suicide attempts 8.6-fold and completed suicides 9-fold. 1
• Response rates for lithium in acute mania range from 38-62%. 1
• Lithium is NOT associated with significant sedation, though it does carry weight gain risk. 1

Monitoring requirements for lithium: Baseline complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females, with ongoing monitoring of lithium levels, renal and thyroid function every 3-6 months. 1

Valproate/Divalproex (Alternative First-Line)

• Valproate shows higher response rates (53%) compared to lithium (38%) in children and adolescents with mania and mixed episodes. 1
• Divalproex sodium is generally better tolerated than other mood stabilizers, with initial dosing of 125 mg twice daily, titrated to therapeutic blood level (40-90 mcg/mL). 3
• Valproate is as effective as lithium for maintenance therapy in bipolar disorder. 1

Monitoring requirements for valproate: Baseline liver function tests, complete blood count, and pregnancy test, with periodic monitoring (every 3-6 months) of serum drug levels, hepatic function, and hematological indices. 3, 1

Important caveat: Valproate is associated with polycystic ovary disease in females and carries more sedation risk than lithium. 1

Lamotrigine (Maintenance Therapy, Especially for Depression Prevention)

• Lamotrigine is particularly effective for preventing depressive episodes in bipolar disorder and is recommended for maintenance therapy in adults. 1, 4
• Lamotrigine significantly delays time to intervention for any mood episode compared to placebo. 1
• In moderate to severe bipolar depression, lamotrigine may be used with an antidepressant, but the antidepressant must always be combined with a mood stabilizer to prevent switching to mania. 4

Critical safety consideration: Lamotrigine must be titrated slowly to minimize risk of serious rash including Stevens-Johnson syndrome; if discontinued for more than 5 days, restart with full titration schedule rather than resuming previous dose. 1

Carbamazepine (Third-Line Option)

• Carbamazepine shows only 38% response rates in pediatric studies and has problematic side effects. 3, 1
• Initial dosage: 100 mg twice daily, titrated to therapeutic blood level (4-8 mcg/mL). 3
• Requires monitoring of complete blood cell count and liver enzyme levels regularly due to significant drug interactions and side effect profile. 3

Atypical Antipsychotics as Mood Stabilizers

When to Consider Atypical Antipsychotics

• Atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone) are recommended for acute mania/mixed episodes and may provide more rapid symptom control than mood stabilizers alone. 1
• Combination therapy with lithium or valproate plus an atypical antipsychotic is recommended for severe presentations. 1

Specific Agents

• Aripiprazole combined with lithium or valproate is the best long-term maintenance option when psychosis is present, prioritizing metabolic safety. 1
• Quetiapine plus valproate is more effective than valproate alone for adolescent mania. 1
• Olanzapine-fluoxetine combination is recommended as first-line for bipolar depression. 1

Metabolic monitoring for atypical antipsychotics: Baseline BMI, waist circumference, blood pressure, fasting glucose, and fasting lipid panel, with BMI monthly for 3 months then quarterly, and blood pressure, glucose, lipids at 3 months then yearly. 1

Treatment Algorithm by Clinical Presentation

For Acute Mania

1. Start with lithium, valproate, or an atypical antipsychotic. 1
2. For severe presentations, use combination therapy (lithium or valproate plus atypical antipsychotic). 1
3. Conduct 6-8 week trial at adequate doses before concluding ineffectiveness. 1

For Maintenance/Prophylaxis

1. Continue the regimen that effectively treated the acute episode for at least 12-24 months. 1
2. Lithium shows superior evidence for prevention of both manic and depressive episodes. 1
3. Lamotrigine is particularly effective for preventing depressive episodes. 1, 4

For Bipolar Depression

1. Olanzapine-fluoxetine combination as first-line. 1
2. Lamotrigine for maintenance, especially when depressive episodes predominate. 4
3. Never use antidepressant monotherapy—always combine with a mood stabilizer to prevent mood destabilization. 1, 4

Critical Pitfalls to Avoid

• Antidepressant monotherapy can trigger manic episodes or rapid cycling—always use with a mood stabilizer. 1
• Inadequate duration of maintenance therapy leads to relapse rates exceeding 90% in noncompliant patients versus 37.5% in compliant patients. 1
• Withdrawal of maintenance lithium therapy dramatically increases relapse risk, especially within 6 months following discontinuation. 1
• Premature discontinuation before completing 6-8 week trials at adequate doses. 1
• Failure to monitor metabolic side effects of atypical antipsychotics, particularly weight gain and metabolic syndrome. 1

Medications to Avoid or Use with Caution

• Mood stabilizers like gabapentin, valproic acid, and topiramate, and atypical antipsychotics like quetiapine and olanzapine for pain management in IBD have not been studied in patients with IBD and should only be considered with psychiatric consultation. 3
• Typical antipsychotics should be avoided as first-line due to inferior tolerability and higher extrapyramidal symptoms risk. 1
• Oxcarbazepine has substantially weaker evidence than other mood stabilizers, with no controlled trials for acute mania. 1